Work Environment and Elderly Abuse in Nursing Homes: The Mediating Role of Burnout

Abstract

The present study focuses on elderly abuse committed by nurses and nurses’ aides in nursing homes. Elderly abuse includes neglect and abusive behaviors deleterious to the health and welfare of the elderly. The study aimed at a better understanding of neglect and abusive behaviors by considering caregiver burnout and the work context of these professionals. To achieve this goal, direct effects of job demands (workload and emotional demands) and organizational resources (quality of relationships with colleagues and with the supervisor) on elderly abuse were analyzed. Moreover, the mediating role of caregiver burnout was explored by suggesting that job demands and lack of organizational resources were related to neglect and abusive behaviors through burnout. The study was conducted among 481 nurses and health care assistants from different French nursing homes. Correlations, multiple regressions, and mediation analyses were performed. Results globally confirmed our hypotheses. Emotional demands and poor quality relationships with colleagues and the team supervisor were the most predictive variables for caregiver burnout, neglect, and abusive behaviors toward the elderly. Moreover, the results contributed to the literature by highlighting the mediating effect of burnout and give rise to potential implications in preventing elderly abuse in nursing homes.

Keywords

elderly abuse nursing homes burnout job stressors organizational resources

Introduction

In Western countries, advances in health care have led to an increase in the aging population. This progression results in more and more people older than 85 years, who are more susceptible to chronic and disabling diseases, cognitive impairment, and even more dependent with greater needs of long-term care and institutional care (Bužgová & Ivanová, 2009; McDonald et al., 2012; Schiamberg et al., 2011). By the nature of their clinical and social circumstances, the elderly in the last stage of human life are more vulnerable and constitute a significant part of the population exposed to the risk of abuse (Sethi et al., 2011). Although high-quality patient care is a fundamental expectation of an effective health care system, the 2011 World Health Organization (WHO) report emphasized that elderly abuse is a phenomenon much more common than the limited data available suggest. According to the WHO, elder maltreatment is “a single or repeated act or lack of appropriate action, occurring within any relationship in which there is an expectation of trust, that causes harm or distress to older people” (Sethi et al., 2011). In 1987, the American Medical Association’s guidelines on elder mistreatment defined elder abuse as

acts of commission or omission that result in harm or threaten the health or welfare of an older adult. Mistreatment of the elderly person may include physical, psychological, or financial abuse or neglect, and it may be intentional or unintentional. (Council on Scientific Affairs, 1987)

Thus, elderly abuse consists of two components: neglect and abusive behaviors. Neglect consists in the withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person (Jayawardena & Liao, 2006). Neglect can be intentional and unintentional. Unintentional neglect may stem from either ignorance or from the genuine inability to provide care (Jones, Veenstra, Seamon, & Krohmer, 1997). Intentional neglect occurs when a caregiver deliberately fails to fulfill caretaking responsibilities, causing harm to the elderly person (Lachs & Pillemer, 1995). Abusive behaviors include physical and psychological abuse. Physical abuse includes pushing, striking, or causing bodily injury, force feeding, or improper use of physical restraints (Aravanis et al., 1993). Psychological or emotional abuse includes verbal or nonverbal insults, humiliation, infantilization, or threats (Anetzberger et al., 1993).

Despite the well-studied familial abuse, institutional abuse still lacks proper analysis of its risk factors (Burns, Hyde, & Killet, 2013; Bužgová & Ivanová, 2009; Cohen, Levin, Gagin, & Friedman, 2007; McDonald et al., 2012; Schiamberg et al., 2011). However, identifying risk factors for abuse is important to intervene at an early stage to prevent or stop abuse (McDonald et al., 2012). Although elder abuse is the outcome of a complex situation in which a wide range of medical, psychosocial, economic, and interpersonal factors converge, caregiver stress has been pointed out as the main risk factor for abuse (Jayawardena & Liao, 2006). However, the process relating caregiver stress or caregiver burnout to their work context and the risk of elder abuse remains unclear. Employee burnout is a progressive psychological response to chronic work stress involving emotional exhaustion, depersonalization, and feelings of reduced personal accomplishment (Maslach & Jackson, 1981). Therefore, the present study proposes to consider caregiver burnout and its determinants in nursing homes to better understand how these factors contribute to elder abuse. Thus, the first aim of the study was to analyze the relationship between caregivers’ burnout and the risk of neglect and abuse toward the elderly in nursing homes. Secondly, the study aimed at a better understanding of the relationships between caregiver burnout and various job demands (workload and emotional demands) and organizational resources (quality of the relationships with the team colleagues and the team supervisor). Moreover, to get more insight concerning the relationship among these variables, our third aim was to explore the mediating ole of burnout between job demands, organizational resources, and the two components of elderly abuse: neglect and abusive behaviors.

Burnout and Elderly Abuse Nursing Homes

Burnout is defined as a psychological syndrome in response to chronic stressors on the job and is characterized by emotional exhaustion, depersonalization, and reduced sense of personal accomplishment (Maslach & Jackson, 1981). Emotional exhaustion refers to the depletion of mental and emotional resources, feeling of strain, and chronic fatigue. Emotionally exhausted workers lack adaptive resources. They cannot give anymore to their job. Depersonalization refers to indifference or a distant attitude toward one’s job and one’s patients. Lack of professional accomplishment refers to the tendency to evaluate one’s work performance negatively. High degrees of burnout were found among nurses’ aides working in nursing homes (Novak & Chappell, 1994). In fact, empirical studies have reported that higher levels of burnout were associated with higher risk of elder abuse (Shinan-Altman & Cohen, 2009) or with lower self-reported quality of care (Bowers, Esmond, & Jacobson, 2000; Salyers et al., 2015; Shanafelt, Bradley, Wipf, & Back, 2002; Van Bogaert, Kowalski, Weeks, Van heusden, & Clarke, 2013). Based on these previous findings, we suggest that a stressed caregiver may become abusive when overwhelmed or exhausted. Indeed, burnout can be related to the risk of neglect and abusive behaviors for a number of different reasons. Burnout has, for example, been associated with cognitive impairments, including decreased attention (Van Der Linden, Keijsers, Eling, & Van Schaijk, 2005), which can lead to errors and less engagement. Burnout has been associated with decreased empathy (Åström, Nilsson, Norberg, Sandman, & Winblad, 1991):

Hypothesis 1: Higher levels of burnout are positively related to neglect and abusive behaviors.

The Effects of Job Stressors and Organizational Resources on Burnout and the Risk of Elderly Abuse

According to the Job Demands–Resources model (Bakker & Demerouti, 2007), burnout can develop from a combination of high job demands that require sustained effort over time and lack of job resources. Specifically, job demands are posited to result in psychological and physiological costs to the staff person (e.g., emotional exhaustion), whereas lack of job resources contributes to difficulty meeting job demands, which leads employees to disengage or withdraw from their work. Whereas caregivers become exhausted and disengaged, they likely conserve resources and pull back. This attitude leads to depersonalization and ultimately reduced quality of care. Based on this model, we propose to consider specific job demands and job resources of caregivers working in nursing homes to better understand their relationship with burnout and elderly abuse. Contextualized job demands and organizational resources from these professionals were taken into account including workload, emotional demands, and high-quality relationships with colleagues and the team supervisor.

Workload

During the last years, many French nursing homes have experienced budget cuts or stagnant financial support. Consequently, they have been forced to cut staff and reduce budgeted staff hours. Some evidence suggests that health care professionals are working longer hours to overcome staff shortages (Cleary, Horsfall, Muthulakshmi, Happell, & Hunt, 2013; Rogers, Hwang, Scott, Aiken, & Dinges, 2004). As a result, professionals working in gerontology units are often experiencing time pressure. Among caregivers, it has been reported that time pressure or high workload was associated with burnout (Greenglass, Burke, & Fiksenbaum, 2001) and reduced quality of care, reduced patient safety and satisfaction (Stimpfel & Aiken, 2013; Stimpfel, Sloane, & Aiken, 2012) This lack of time leads to damaging attitudes or behaviors toward the care recipients. Indeed, in such situations, lack of time may lead professionals to neglect the relational needs of the elderly (e.g., comforting him or her professional, listening, talking) and to restrict their activity to the technical aspects of care. Worse, with lack of time, the fact that the patients are dependent and need time for every action of their daily life is not taken into account and can give way to abusive behaviors (Amyot, 2010).

Emotional Demands

In addition to workload, occupations in nursing homes are characterized by high emotional demands related to the aggressiveness of the patients, the management of unpleasant patients (due to certain pathologies), the handling of the suffering, the psychological or physical pain of patients, and the death of patients. Indeed, caregivers in nursing homes are working with elderly persons who are weak, vulnerable, and presenting a loss of psychological and physical independence (Amyot, 2010). Dementia and its consequences (aggressiveness, agitation, roaming, etc.), for example, has been pointed out as an important predictor of caregiver burnout (Barber & Iwai, 1996). Moreover it was considered as the main factor of elderly abuse (Bužgová & Ivanová, 2011; Joshi & Flaherty, 2005; Lindbloom, Brandt, Hough, & Meadows, 2007). According to Joshi and Flaherty (2005), the behaviors of patients suffering from dementia can be experienced as perturbation and provocation toward the personnel that can then respond in a violent way. The aggressiveness of patients can bring about in professionals the feeling of being disarmed. Facing to their own distress and anxiety, they can then respond with aggressiveness (Bužgová & Ivanová, 2011; Lindbloom et al., 2007). The physical and psychological dependence of the patient is also considered to put them at risk of abuse (Baker & Heitkemper, 2005; Bužgová & Ivanová, 2011; Joshi & Flaherty, 2005; McGarry & Simpson, 2008). Indeed, the patient suffering from a physical disability cannot accomplish their daily life acts (nutrition, getting washed, etc.) alone. This total dependence results in a workload peaks that can lead to the rejection and isolation of the patients (Joshi & Flaherty, 2005). Based on the previous findings, we assumed that these specific emotional demands in nursing homes can lead to a feeling of helplessness in the health care personnel. When this feeling of distress becomes too prominent, the personnel can then reluctantly act in a mistreating or neglecting way (e.g., by avoiding the patient’s gaze or using applications of restraints by the facility, etc.).

Based on the Job Demands–Resources model and on previous findings, we suggest the following hypothesis:

Hypothesis 2: Workload, emotional demands, and lack of recognition are positively related to burnout, neglect, and abusive behaviors.

High Quality Relationships With Colleagues and the Team Supervisor

According to the Job Demands–Resources model (Bakker & Demerouti, 2007), social support represents an important job resource, reducing job strain, and burnout. In fact, supportive colleagues and proper feedback from one’s superior increase the likelihood of being successful in achieving one’s work goals and in satisfying the need to belong (Bakker, Demerouti, & Euwema, 2005). In nursing homes, the high quality of the professional relationship among team colleagues is particularly essential. Indeed, efficient team collaboration facilitates the transmission of information concerning patients and their state of health and of eventually encountered difficulties. It also promotes support among professionals and enables, for example, the possibility of handing over to or calling on a colleague when the situation with a patient puts the professional in a difficult situation (Amyot, 2010). In fact, support from colleagues is considered as a key job resource for coping with job demands (van Emmerik, Euwema, & Bakker, 2007). The team supervisor plays an essential role in the team as he or she is responsible for the good collaboration among the team members. The team supervisor can dispense instrumental support by providing work-related information and feed back (Reblin & Uchino, 2008). Moreover, he or she can also provide an emotional support by providing sympathy, caring, comfort, and encouragement toward his or her team (Reblin & Uchino, 2008). A high-quality relationship with the team supervisor can be an important resource. When these job resources fail, results suggest that team collaboration problems (such as the lack of communication and collaboration among the team) are related with caregivers’ burnout (Andela & Truchot, 2017) and elderly abuse (Roulet Schwab & Christen-Gueissaz, 2006). Besides, conflicts between the team and the administrative hierarchy were also related to patients’ abuse (Payne & Fletcher, 2005). We thus propose the following hypothesis:

Hypothesis 3: High quality relationships among the team members and with the team supervisor are negatively related to burnout, neglect, and abusive behaviors.

The Mediating Role of Burnout

Theoretical models and previous findings suggested positive relationships between job stressors, lack of organizational resources, and burnout as well as elderly abuse. However, the role of caregiver burnout on elderly abuse in the broader context of job stressors and organizational resources in nursing homes is not clear. Thus, exploring the nature of the relationship between job demands–organizational resources, burnout, and elderly abuse is of special interest. One study found that burnout mediated the relationship between number of work hours and poor self-reported quality of care in physicians (Shirom, Nirel, & Vinokur, 2006), whereas another reported that burnout partially mediated the relationship between work stressors (work overload, role ambiguity, and role conflict) and elder abuse (Shinan-Altman & Cohen, 2009). Based on these findings, we suggest that burnout will mediate the relationships between job demands, organizational resources, and elderly abuse. A work environment characterized by work overload, high emotional demands, and low quality relationships with colleagues and the team supervisor may induce burnout, which will contribute to the risk of neglect and abusive behaviors:

Hypothesis 4: Caregivers’ burnout mediates the relationships between job demands, job resources, and elderly abuse.

Method

Procedure and Participants

The present study focused on nurses and health care assistants from French nursing homes. All nursing homes from one region in the east of France were selected. Thus in total, 1500 questionnaires were sent to 109 nursing homes. Depending on the nursing home size and the number of health care worker working there, the envelopes contained 15 to 50 questionnaires. The envelopes containing the questionnaires were accompanied by a letter addressed to the director and the team supervisors explaining the aim of our study. The study was presented as a research project concerning the work difficulties that health care professionals have to face daily and how they deal with them. It was presented as a voluntary study to which they could participate by answering the questionnaires. Team supervisors distributed them to their teams. The health care professionals were asked to return the questionnaires within the following 3 weeks. To ensure anonymity, we included stamped envelopes with the questionnaires so that the participants could return their responses directly to us. A telephone number and an email address were also indicated on the questionnaire. Thus, participants could contact us for more information.

Measures

To test our hypotheses, we selected validated measures that were adapted or contextualized to the French nursing home environment.

Burnout was measured with the French validation of the Maslach Burnout Inventory Human Services Survey (MBI-HSS; Dion & Tessier, 1994). Participants were asked to rate, from 0 (never) to 6 (daily), how often they experienced feelings like those described in each of the 22 items corresponding to emotional exhaustion (nine items), depersonalization (eight items), and personal accomplishment (five items). The Cronbach’s alpha reliability estimates were as follows: .87 for emotional exhaustion, .66 for depersonalization, and .75 for personal accomplishment.

Specific nursing home job stressors and job resources were measured with different subscales of the scale developed by Huguenotte, Andela, and Truchot (2016). This scale was developed to assess the work stressors and the organizational resources for nurses and nurses’ assistants working in French nursing homes. For this study, we used this scale by including two job demands (workload and emotional demands) and two organizational resources (the quality of the relationships with colleagues and the quality of the relationship with the team supervisor). Workload was measured with nine items including “having too many patients to look after” and “having not enough time for patients care.” Emotional demands were evaluated with nine items such as “facing the patients’ aggressiveness” and “facing patients’ suffering.” The quality of the relationship with the team supervisor was evaluated with eight items including “having regular feed backs on ones work with the team supervisor” and “being listened by my health manager when I experience difficult moments.” The quality of relationships with colleagues was evaluated with 11 items including “trusting my colleagues” and “being supported by my colleagues for practical help.” Participants were asked to rate, from 1 (strongly disagree) to 4 (strongly agree) to which extent each situation corresponds to their daily work. The Cronbach’s alpha reliability estimates were as follows: .84 for workload, .78 emotional demands, .77 for lack of recognition, .84 for the quality of the relationships with the colleagues, and .82 for the quality of the relationships with the team manager.

Elderly abuse was evaluated with the scale developed by Huguenotte (2012). This scale was developed using both qualitative and quantitative methodologies to assess abusive behaviors and negligence of health care professionals toward elderly patients in the nursing home context. The scale consisted in two subscales: neglect and abusive behaviors. Neglect was evaluated with 11 items including “sometimes I don’t provide the patients water when they asked for it because I am too busy,” “sometimes I don’t provide a patient enough food when he or she takes too much time to open his or her mouth and to swallow,” and “I don’t bring the dependent patients to the toilet even if they are continent, because to save time they systematically have incontinence diapers.” Abusive behaviors were evaluated with eight items including “sometimes I hurt patients when accomplishing technical nursing practices because I haven’t got the time anymore to be careful,” “sometimes I provide food to patients that cant’s eat alone without respecting their rhythm because I’m in a hurry,” and “sometimes I threaten patients when they waste my time and when I’m overwhelmed.” Employees were asked to indicate the frequency with which they experienced the following situation by using a frequency rating with a 5-point scale (0 = never; 5 = every day). The Cronbach’s alpha reliability was satisfactory for abusive behaviors (α = .75) and negligence (α = .81).

Data Analysis

Bivariate correlations and multiple regressions analyses were performed to test Hypotheses 1, 2, and 3. The three components of burnout (emotional exhaustion, depersonalization, and personal accomplishment) were entered in the first step of the regression. Workload, emotional demands, and lack of recognition were entered in the second step. The quality of the relationships with colleagues and the team supervisor were then entered in the third step of the regression. All variables were centered before entering them into the regression analysis. With regard to mediation analysis, current methods have moved beyond the causal steps approach (multistep regression model) popularized by Baron and Kenny (1986), to a more robust approach that can quantify rather than simply infer the indirect effect (Hayes et al., 2009). Thus, to adequately test the mediating role of burnout (Hypothesis 4), we used the SPSS macro PROCESS (version 3) developed by Hayes and Preacher. Mediation analysis tests whether the effects of an independent variable on an outcome variable can be accounted for by its effect on a mediator variable, which in turn affects the outcome.

Results

The participation rate was satisfactory as 481 questionnaires were filled out and returned, yielding a 32% participation rate. This sample consisted of 28% nurses and 72% health care assistants. The average age of participants was 39 years (SD = 10), and 96% of the employees were women.

Burnout, Neglect, and Abusive Behaviors

We first hypothesized that caregiver’s burnout was associated with neglect and abusive behaviors as burnout can be associated with cognitive impairments, including decreased attention and decreased empathy, which can lead to errors and less engagement. Correlations results (see Table 1) indicated that emotional exhaustion and depersonalization were positively related to the risk of neglect and abusive behaviors, whereas personal accomplishment was negatively associated with these two components of elder abuse. Thus, results were in line with the first hypothesis.

Table 1.

Bivariate Correlations, Ms, and SD.

	M	SD	1	2	3	4	5	6	7	8	9
1. Neglect	5.77	5.42	1
2. Abuse	6.20	5.01	.69**	1
3. Emotional exhaustion	19.44	10.10	.37**	.45**	1
4. Depersonalization	12.00	3.23	.24**	.29**	.35**	1
5. Personal accomplishment	20.27	4.72	−.25**	−.24**	−.06	−.19**	1
6. Workload	32.12	6.08	.26**	.29**	.39**	.20**	−.15**	1
7. Emotional demands	35.65	5.89	.26**	.32**	.29**	.21**	−.16**	.42**	1
8. Colleague relationships	37.90	6.18	−.30**	−.30**	−.28**	−.22**	−.14**	−.23**	−.03	1
9. Supervisor relationships	19.69	5.11	−.37**	−.38**	−.31**	−.19**	.25**	−.30**	−.17**	.37**	1

p < .01. **p < .05.

Job Demands, Burnout, and Elder Abuse

It was suggested that workload and specific nursing homes’ emotional demands can induce in caregivers the feeling of helplessness and lead the personnel to act in a mistreating or neglecting way, for example, by avoiding the patients’ gaze or by using restraint application by the facility and so on. Thus, Hypothesis 2 suggested that workload and emotional demands were related to burnout as well as to higher risk of neglect and abusive behaviors. Correlations indicated that higher scores of workload and emotional demands were associated with higher scores of emotional exhaustion and depersonalization and with lower levels of personal accomplishment (see Table 1). Results also indicated that both job demands were related to a higher risk of neglect and abusive behaviors. Results were thus in line with Hypothesis 2.

Organizational Resources, Burnout, and Elder Abuse

Support from colleagues and team supervisors were considered as key job resources for coping with job demands. Hypothesis 3 proposed that high-quality relationships with colleagues and with the team supervisor were related to lower levels of burnout and lower risk of elder abuse. Results revealed that high-quality relationships with colleagues and with the team supervisor were associated with lower levels of emotional exhaustion, depersonalization, and higher scores of personal accomplishment. Besides, the quality of these relationships was negatively related to neglect and abusive behaviors. Results were thus in line with our third hypothesis.

Relative Importance of Job Demands and Organizational Resources

In addition to the correlation analysis, regression analyses (see table 2) were performed to evaluate the relative importance of the three job demands and the two organizational resources for burnout (emotional exhaustion, depersonalization, and personal accomplishment) and for elder abuse (neglect and abusive behaviors).

Table 2.

Regression Analysis.

	Neglect	Abuse	Emotional Exhaustion	Depersonalization	Personal Accomplishment
Step 1
Workload	.00	.05	.13*	.06	−.09
Emotional demands	.16*	.22**	.11*	.15*	−.10
R²	.10**	.14**	.26**	.06**	.01
Step 2
Colleague relationships	−.20**	−.20**	−.14**	−.19**	.04
Team supervisor relationships	−.21**	−.20**	−.03	−.07	.25**
R²	.18**	.22**	.28**	.10**	.05*

Note. * = p < .05, ** = p < .01.

Both job demands were entered in the first step of the regression analysis, whereas the two organizational resources were introduced in the second step of the analysis. The model was statistically significant and accounted for 28% of the variance for emotional exhaustion, 10% of the variance for depersonalization, 5% of the variance for personal accomplishment, and 18% of the variance for neglect, and 22% of the variance for abusive behaviors. Concerning neglect and abusive behaviors, the coefficients associated with workload and lack of recognition were not significant (respectively β = .00, p >.05 and β = .05, p >.05 for neglect; respectively β = .05, p >.05 and β = .05, p >.05 for abusive behaviors). In contrast, higher emotional demands were associated with higher levels for the risk of neglect or abusive behaviors (respectively β = .16, p < .05 and β = .22, p < .01). In addition to emotional demands, high-quality relationships with colleagues and with the team supervisor were negatively related with neglect (respectively β = −.20, p < .01 and β = −.21, p < .01) and abusive behaviors (respectively β = −.21, p < .01 and β = .20, p < .01).

The Mediating Role of Burnout

Based on the job demand–resources model and previous findings, Hypothesis 4 proposed to explore the mediating role of caregiver burnout between job demands, job resources, and elder abuse. As the job demands and the organizational resources only predicted 5% of the variance of personal accomplishment and as only high-quality relationship with the supervisor was correlated with it, mediation analyses were not performed for personal accomplishment and were only performed for emotional exhaustion and depersonalization.

Correlations established that the four predictor variables (workload, emotional demands, quality of relationships with colleagues, and quality of relationships with the team supervisor) as well as emotional exhaustion and depersonalization were associated with neglect and abusive behaviors. So, all the criteria for proceeding with the mediation analyses were met. Table 3 shows the direct and indirect effects output for neglect and abusive behaviors, with and without emotional exhaustion and depersonalization as mediator variables. The output provides the 95% bias-corrected bootstrapped confidence interval. Here, we are looking to see if zero (0) lies within the interval range. Note that LL = lower limit (or the lower boundary) and UL = upper limit (or upper boundary) of the confidence interval (CI). Essentially, we are asking whether it is possible (with 95% CI) that the true indirect effect would be zero (basically, no mediation). If zero does not fall between LL and UL, then we can conclude that the indirect effect for this mediator is significant. More specifically, depersonalization totally mediates the relationships between workload, emotional demands, poor quality relationships with colleagues and the team supervisor, and both components of elder abuse: neglect and abusive behaviors. Concerning the mediating role of emotional exhaustion results revealed that this burnout dimension partially mediates the relationships between workload, emotional demands, poor quality relationships with colleagues and the supervisor, and both components of elderly abuse: neglect and abusive behaviors. Thus, Hypothesis 4 was not totally, but strongly supported.

Table 3.

Indirect Effects of Job-Demands-Resources-Fit Indices Though Emotional Exhaustion and Depersonalization.

	Job Demands–Resources and Neglect Through Emotional Exhaustion				Job Demands–Resources and Neglect Through Depersonalization				Job Demands–Resources and Abusive Behaviors Through Emotional Exhaustion				Job Demands–Resources and Abusive Behaviors Through Depersonalization
	Direct Effect	Indirect Effect	LL CI	UL CI	Direct Effect	Indirect Effect	LL CI	UL CI	Direct Effect	Indirect Effect	LL CI	UL CI	Direct Effect	Indirect Effect	LL CI	UL CI
Workload	0.17	0.14	0.07	0.21	0.19	0.04	0.01	0.08	0.17	0.12	0.10	0.25	0.23	0.06	0.03	0.11
Emotional demands	0.14	0.10	0.05	0.15	0.19	0.03	0.01	0.07	0.19	0.13	0.07	0.19	0.26	0.05	0.01	0.09
Relationships with colleagues	−0.18	−0.08	−0.13	−0.03	−0.19	−0.04	−0.08	−0.01	−0.17	−0.13	−0.16	−0.04	−0.21	−0.06	−0.11	−0.03
Relationships with supervisor	−0.27	−0.09	−0.15	−0.04	−0.29	−0.03	−0.06	−0.01	−0.21	−0.14	−0.33	−0.09	−0.33	−0.04	−0.08	−0.01

Note. LL CI = lower limit confidence interval; UL CI = upper limit confidence interval.

Discussion

Elder abuse in institutions constitutes a serious public health problem as it has negative consequences for both the abused and the abuser (Giurani & Hasan, 2000). The aim of the present study was to better understand neglect and abusive behaviors toward the elderly in institutions by focusing on the caregivers’ work context and their levels of burnout. The study was conducted in a French context among French nursing homes. During the last few years, French nursing homes have been beset by budget cuts or stagnant financial support. Consequently, nursing homes have been forced to cut staff and reduce budgeted staff hours. This economical context is not without consequences on the organizational context of caregivers. Although a very small part of the literature about elderly care emerges from a French context, the findings from the present study add interesting information to the international literature.

Based on previous findings and the Job Demands–Resources model (Bakker & Demerouti, 2007), we suggested that workload, emotional demands, and low quality relationships with colleagues and the team supervisor were related to caregiver burnout as well as to higher risk of neglect and abusive behaviors toward the elderly. Moreover, we suggested that job demands and lack of organizational resources were related to elderly abuse through burnout. The study was conducted on a large sample of nurses and nurses’ assistants working in French nursing homes. Overall, results were in line with the hypotheses and contribute to the literature in several ways.

First, correlation indicated that both job demands (workload and emotional demands) were positively associated with burnout, whereas both organizational resources (quality of the relationships with the colleagues and the team supervisor) were negatively related with burnout. Moreover, correlations indicated that high job demands and lack of both types of organizational resources were associated with higher risk of neglect and abusive behaviors. Regression refined the analysis by indicating the relative importance of each predictor variable for the three burnout dimensions and the two components of elder abuse. Indeed, results showed that both job demands and lack of organizational resources accounted for an important percentage of the variance of emotional exhaustion, depersonalization, neglect, and abusive behavior. In fact, emotional demands and poor quality relationships with colleagues were particularly involved in the process of emotional exhaustion, depersonalization, neglect, and abusive behaviors. Although workload was also an important predictor of emotional exhaustion, poor quality relationships with the team supervisor were an important predictor for neglect and abusive behaviors. Results were in line with previous findings reporting that workload is one of the most significant stressors among health care professionals (Garrosa, Rainho, Moreno-Jiménez, & Monteiro, 2010; Patrick & Lavery, 2007). Results also confimed that team collaboration problems in nursing occupations (Andela, Truchot, & van der Doef, 2016) and dealing with difficult patients’ and relatives’ requirements and hostility are strong predictors of emotional exhaustion (Bakker & Heuven, 2006). Whereas elder abuse is the outcome of a complex situation, our results highlight the impact of the emotional demands and the working context of caregivers, and especially the relationships between health care professionals.

Second, the present study confirmed the predominant relationship between caregivers’ burnout and neglect and abusive behaviors toward elderly in institutions. This result is in line with the literature pointing out caregivers’ stress as the main risk factor for abuse (Jayawardena & Liao, 2006). Caregivers who are overwhelmed, exhausted, and adopt an indifferent or a distant attitude toward their job and their patients are more likely to neglect or behave in an abusive way.

The third aim of the study was to gain more insight regarding the process connecting job demands and organizational resources to turnover intention, examining the potentially mediating effect of burnout. The present study found evidence for indirect effects of both job demands and both organizational resources on neglect and abusive behaviors through emotional exhaustion and depersonalization. Depersonalization was found to be a total mediator of the effects of workload, emotional demands, and poor quality relationships with the colleagues and the supervisor on neglect and abusive behaviors. Moreover, emotional exhaustion partially mediated the relationships between both job demands and both organizational resources and elder abuse (neglect and abusive behaviors). As such, the process seems to be that high workload and emotional demands as well as poor relationships with colleagues and the team supervisor predicted neglect and abusive behaviors through emotional exhaustion and depersonalization. To conclude, the findings of the current study highlight the importance of caregiver burnout in the elder abuse process. Concerning practical implications, nursing homes would benefit from integrating this insight in the prevention of elderly abuse in institution. As emotional demands in nursing homes appear to be strongly related to burnout and elder abuse, institutions could benefit from specific courses and concrete training related to the various elder pathologies and how to deal with them. Moreover, to provide high-quality care and prevent elder abuse, organizations would benefit from preventing caregivers from burnout. As health care work in nursing homes has intrinsic stressors such as workload and high emotional demands that may not be easily reduced, our results suggest that one possible way to prevent caregivers burnout is to increase the quality of relationships among colleagues and with the team supervisor. The results shed light on one social factor that could be involved in the prevention of caregiver burnout. This finding indicates the relevance of recommending formal teamwork training and the development of strategies that facilitate effective collaboration among health care professionals. Team reflexivity could for example be encouraged as team reflexivity has been shown to moderate the effects of job stressors on caregiver burnout in a general hospital setting (Andela & Truchot, 2017). Moreover, in the prevention of caregiver burnout, team supervisors appear to be a key resource. Thus, organizations would benefit from boosting their team supervisors and encouraging training, aiming at developing their team supervisor competencies.

In summary, this study highlights the importance of high-quality relationships among the different health care professionals in nursing home in the prevention of caregivers’ burnout and elderly abuse in institutions. However, our study presents several limitations. As we used a cross-sectional design, we cannot confirm the causal direction of the relationship between job demands, organizational resources burnout, and elderly abuse. Whereas the idea that job demands and organizational resources lead to work-related outcomes such as burnout and quality of care are based on established theory (job demands resources model) and strong previous findings, the next step for future research would be to replicate our study with a longitudinal design. Future longitudinal research, such as daily diary studies, as well as the use of critical incident techniques or introspection, may help capture this complexity.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Marie Andela completed a PhD in work and organizational psychology in 2014. She is now working as an associate professor at the University of Bordeaux. She is involved in teaching in the bachelor program of psychology and the work and organizational psychology master’s program. Her research mainly focuses on occupational health-related topics such as emotion regulation and the role of the organizational context for employee health and well-being.

Didier Truchot is a professor at the University of Franche-Comté with an expertise in social and organizational psychology. He has notably written a book about the burnout syndrome: Epuisement professionnel et burnout.

Virginie Huguenotte completed a master thesis at the university of Franche-Comté. She is actually working in a plubic institution in wish she gives trainings for caregivers in order to prevent mistreatment and neglect toward elederly in nursing homes.

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