have to report themselves or their colleagues as abusers, which may well have affected ascertainment of occurrence of elder mistreatment.
A number of other potential risk factors can be derived from the more general literature on quality of care in nursing homes. Pillemer (1988) proposed four sets of variables that may be related to maltreatment: exogenous factors (including the availability of nursing home beds and the unemployment rate in an area); characteristics of the nursing home environment (such as size, reimbursement rates, ownership status, staff-resident ratio, and turnover rate); staff characteristics (including age, gender, education level, and burnout), and resident characteristics (health and functional status, social isolation, and gender). A full-scale test of this model remains to be conducted.
In her background paper for this panel, Hawes suggests risk factors derived from surveys of stakeholders in long-term care. She proposes three risk factors from these studies: stressful working conditions, particularly resulting from staff shortages; staff burnout; and the joint effects of resident aggression and poor training of staff in management of challenging behaviors. Pillemer (2001) combined insights derived from long-term care practice with the limited data on nursing home mistreatment to suggest four key factors: poor hiring and staff screening practices; chronic staffing problems; lack of administrative and supervisory oversight; and inadequate training. Taken together, these approaches suggest a number of avenues for studies of risk factors, at both the structural and the individual levels.
Although risk factors at times are causes of mistreatment, this is not always the case. Some risk factors (preferably called “risk indicators”) may be “markers” for unmeasured/unobserved causes (confounders); or risk factors may modify the relationship between causal factors and elder mistreatment (effect modifiers). For example, depression in a caregiver may be a causal risk factor in that a depressed caregiver may be more likely to neglect the care of an elder by virtue of the fatigue, social withdrawal, and uninterest associated with depression. Living with others has been associated with an increased probability of mistreatment. However, this may not be a direct causal relationship, because living with others is a contextual factor in which mistreatment is more likely to occur; it would be possible to reduce the risk of mistreatment by modifying other factors associated with living with others and not changing the living circumstances of the older person (which is often difficult and disruptive). To provide another example, frailty—a form of vulnerability—may be an effect modifier, such as at very high levels of frailty the probability of mistreatment may be much