Use of Force in Aged-Care


Published: 31 July 2019

Consider the following scenario:

Mary is a physically agile 85-year-old with second stage dementia. She has always been an early riser, so it’s not unusual for morning staff on their hygiene cares rounds to find Mary already up and ‘showered’ and fully dressed.

However, the staff find the shower room dry, the towels dry and Mary declines their suggestion to have another shower or ‘… a nice wash… ’. As the staff have several resident hygiene cares to attend to, they decide to move on and to try again tomorrow.

Four days later, Mary now has a very strong odour. Her hair is greasy, her eyes are sticky, her ears are dirty and she smells of dried urine. By this point, other residents have complained about her in the dining room at meal times.

It has reached the stage that Mary will be showered/bathed/washed whether she likes it or not, as no amount of reasoning such as ‘Mary, it’s not nice to smell … or … Mary you’ll look lovely with your hair washed and blow dried…’, has worked to convince her that she was in need of attention.

Mary fights all the way through the undressing, washing, drying and redressing. One nurse has to hold her arms back to prevent the hits from making contact (a nurse’s glasses have previously been broken) or restrain her kicking legs while the other nurse quickly washes her.

The screaming and physical resistive behaviours are as distressing to the nurses and other residents within ear-shot as they are to Mary.

Once the hygiene care is over, Mary quickly settles, returns to her smiling pleasant self and is possibly unaware of the preceding events. However, Mary has already started to bruise on both wrists.

Aged-care residents have fragile skin and a bruise can be acquired when any nurse or staff member assists a compliant resident with their cares that require physical contact. Therefore, such a bruise cannot be claimed as evidence of the unreasonable use of force. But what of Mary’s case?

Mary was screaming ‘… no, I don’t want a shower …’ – a verbal refusal.

Mary sustained bruises – she was deliberately restrained by a nurse using ‘force’.

Is the above scenario (one not uncommon in residential care) an example of an unreasonable use of force and therefore requiring mandatory reporting to the relevant bodies?

If so,

  • What of the well-intentioned nurses who would then be under investigation and possibly relocated/stood down with pay/no pay;
  • What of the reputation of the facility, that has yet another ‘alleged’ abuse claim added to the reporting agencies register;
  • Is a chemical restraint required or even warranted for this one ADL as at all other times during the day Mary is quiet and cooperative;
  • Should we restrict Mary to her room where her smell will not offend others – socially isolating her would be another form of elder abuse, as would also be the intentional neglect of not washing her;
  • Is the documentation of the facility sufficient to demonstrate that all bases have been covered?
    • Mary has been behaviour monitored ad infinitum;
    • Care plans have been evaluated and re planning;
    • The GP has noted that the provision of hygiene care is a nursing issue and a chemical restraint is not the answer;
    • All resident injuries have been recorded in the clinical notes and electronically logged; and
    • The family have been previously contacted and are aware of Mary’s ‘aversion’ to a daily wash.

Incidentally, the family had advised staff that Mary spent most of her childhood and married life on a remote property where water was often scarce. It was therefore the norm during lengthy dry spells to bathe once per week and have daily washdowns from the handbasin on all other days – could this memory have re-surfaced to the forefront of Mary’s mind?

If this is the case, how should this be accommodated?

Management may decide that this case is not an example of the unreasonable use of force and so not report the incident, but is it enough to say the use of force was well intentioned, and not a deliberate attempt to deny Mary her right to refuse a shower and to cause pain and bruising?

Also note, others can report directly to the relevant body if they suspect the rough handling of a resident – another visitor hearing the commotion and screams of protestation, or a passing cleaner or a visiting trades-person, and they aren’t required to tell Management of their intentions.

Situations such as this are complex, and there may not be a clear answer or method to handling them. As long as you are guided by a core intention of providing exceptional patient care you will be able to rely on your capability to consider, negotiate and navigate these scenarios as they arise.