Elder Abuse in Nursing Homes – A Wicked Problem?

In this study, polyvictimization was not specifically measured, but considering the high prevalence, the knowledge that exposure to one type of abuse may exacerbate the risk of

67 experiencing other types, and that the same risk factors are often associated with several types of abuse (Teaster, 2017), it is not imprudent to consider polyvictimization an issue of concern in Norwegian nursing homes. In 2017, Teaster illustrated this complexity of elder abuse as in looking into a kaleidoscope, where at first glance a situation of abuse, such as neglect and the associated risk factors, may be observed, but as the lens is turned, myriad various types of abuse and factors may also be revealed. Scholars and practitioners tend to isolate these situations and develop specific intervention strategies, but Teaster (2017) argues that this is only an artificial distinction and that the problem is more wicked, with issues running the gamut from the micro to macro level, requiring a “committed, interdisciplinary approach engaging the brightest minds possible” (Teaster, 2017, p. 289).

The concept of a wicked problem dates back to the system theory and policy planning literature in the 1960s, where the first definition of a wicked problem was issued as “a class of social system problems which are ill-formulated, where the information is confusing, where many clients and decision-makers hold conflicting values, and where the ramifications in the whole system are thoroughly confusing” (Churchman, 1967, p. B-141). The subsequent paper by Rittel and Webber (1973) described emerging policy problems as wicked and elaborated its notion as “no solutions in the sense of definitive and objective answers” (p.

155). Since then, the existence of wicked problems has been rooted in many fields, including public administration, education, mental healthcare, climate change, terrorism, aging populations (Termeer et al., 2019), child abuse (Devaney & Spratt, 2009), and more recently the COVID-19 pandemic (Auld et al., 2020). Characteristics of a wicked problem include a) difficulty in defining and a lack of definitive formulation; b) no clear stopping point; c) solutions being not true-or-false but good or bad; d) no immediate or ultimate test for solutions existing; e) all attempts to solutions having effects that may not be reversible; f) having no clear solution; g) every problem being essentially unique; h) every problem potentially being a symptom of another problem; i) multiple explanations for the problem existing, and j) the planner having no right or wrong answer (Peters, 2017). In contrast, a tame problem is characterized as a) being relatively well-defined and stable; b) having a definite stopping point where the problem is solved; c) containing solutions that may be evaluated as right or wrong; d) belonging to a class of similar problems that may be solved similarly; and e) having solutions that can be tried and abandoned (Rittel & Webber, 1973).

Since Rittel and Webber’s influential work on wicked problems, the underlying understanding has advanced, and several papers have disentangled the concept and

68 transcended the dichotomous framing of tame versus wicked (Termeer et al., 2019), for example, arguing that wickedness could be a matter of degree (Head & Alford, 2015).

Elder abuse in institutional settings has for many decades been considered multifaceted, complex, and difficult to define since different stakeholders perceive the problem differently, the problem has no definitive solution, a wide range of risk factors exist representing unique problems that may have several solutions, attempts to deal with one problem may result in the appearance of other unexpected problems, and the researchers or practitioners have no right or wrong answer to the phenomenon. At the same time, some problems related to the quality of care in nursing homes may be easily solved with no subsequent enhancement of other problems, and some nursing homes are very well organized and may not recognize themselves through a lens of wickedness.

Burns et al. (2013) used a wicked problem analysis to explore elder abuse in a residential care home for older persons referred to as Honeysuckle Place. Honeysuckle Place had taken part in a local-authority supported project to improve residents’ mealtimes and enhance nutrition needs, and structural and cosmetic changes were made to the dining room to resemble a commercial restaurant. Consequently, all residents could see the menu, all meals were freshly prepared, serving time was extended, and staff helped with feeding as needed. Overall, the person-centered meal improved residents’ nutrition but also created a better work

environment for staff. However, these changes in arrangements led to other problems. The dining room was on a different floor, and it was time-consuming for staff to move all residents. The dining area had fewer toilet facilities, resulting in residents rushing mealtimes to get in the queue for the toilet, and delays often resulted in soiling, with residents needing to wait to be changed. This toilet problem was, however, perceived differently by staff,

managers, and residents, and although the managers tried different structural arrangements to solve the problem, they reached no consensus, and instead, conflicting views escalated. The monitoring of residents’ nutrition and the provision of menus and well-presented meals were, however, all practices given a positive value in the local-authorities’ inspection process, and as a standalone issue, this restaurant-service provided a visible representation of good quality care, even though it had created a secondary problem regarding accessing toilets (Burns et al., 2013). This study shows that rather than being intentionally wicked, nursing home staff may work hard to improve care in one area but fail to provide adequate care in others (Burns et al., 2013).

69 Burns et al. (2013) argue that when faced with wicked problems in nursing homes,

practitioners, researchers, and decision-makers tempt to solve problems as if they were tame because each facet appears reducible to a certain issue or solution but that reducing such complex issues into smaller fragmented elements may only diminish the larger scope of the problems (Rittel & Webber, 1973). Moreover, Burns et al. (2013) argue that framing abuse as a wicked problem could draw more attention to how organizational factors and recurrent problems interconnect in the provision of care; a wicked problem formulation demands a collaborative approach, where stakeholders, researchers, and decision-makers are more involved when the problem is identified and solutions developed, which requires continuous improvements that involve actively seeking related problems and considering the totality of care, even when dealing with isolated problems (Burns et al., 2013). However, one may argue that when defining elder abuse as a wicked and unresolvable problem, one may enhance the discouraging and frustrating conditions many health professionals already experience in nursing homes. One may instead argue that elder abuse in nursing homes has some wicked characteristics (Burns et al., 201). Noordegraf et al. (2019) note that this wickedness theory does not contribute to the ability to manage wicked problems in the field, because many discussions of wickedness only favor the holistic or systemic approach, and this view may contribute to a larger, not a smaller, problem. Also, a wicked problem itself, as a buzzword, remains quite abstract in terms of implications, since this may identify a problem but not how and by whom it should be solved (Noordegraf et al., 2019).