Managing reports of trouble: designated officials’ responses to reports of mistreatments initiated by service users and relatives

ABSTRACT

Mandatory reporting of elder abuse aims to detect and prevent mistreatment and improve services. Service users and their relatives can raise concerns, but only staff can file mandatory reports. This article examines how the concerns of service users and relatives were managed by designated officials in reports of mistreatments in care for older adults in Sweden. We lean on sociological theories of “interpersonal trouble” and organizational “disputes domains.” The thematic analysis is based on 28 incident reports initiated by service users or their relatives. The analysis shows that the reports were managed in one of three ways: asymmetrically, by 1) dismissing or 2) supporting the complainant’s position, or symmetrically, by 3) treating complainants’ accounts as credible but minimizing their seriousness. There were differences between reports initiated by service users and relatives. Dismissing concerns about abuse, mainly those made by relatives, risks support for service users failing.

KEYWORDS:

• Complaints
• elder abuse
• family members
• mandatory reporting
• relatives

Introduction

Elder abuse is a significant problem (Hirt et al., 2022, Moore, 2016, Yon et al., 2019) and has serious negative impacts on the physical and mental health of victims, such as premature death, injuries, anxiety, depression, suicidal thoughts, and sleeping problems (Lachs et al. 2015, Yunus et al., 2019). There is no standard definition of elder abuse, and recognition of the phenomenon varies between countries and contexts. However, there is a growing consensus of a common definition of elder abuse, including physical and sexual abuse, financial exploitation, and neglect, defined as a failure of caregivers to provide the basic needs of dependent older persons (Emerson, 2015); the definition provided by the World Health Organization (2022) also includes “violation of human rights” and “serious loss of dignity and respect.” According to these definitions, elder abuse can include what is usually defined as intimate partner violence (Penhale, 2018), as well as abuse that is committed by carers in care settings for older adults (Schiamberg et al., 2012). The latter, staff-to-resident abuse, is the focus of this article. When older persons described their experiences of violence and abuse, they included the feeling of being treated like an object and controlling behavior by staff, similar to the control often linked to cases of intimate partner violence (Ludvigsson et al., 2022).

Mandatory reporting of elder abuse is an intrinsic part of adult protection services, and the reporting of incidents aims to detect and prevent further mistreatment and improve services. In Sweden, all staff working within care for older adults have a duty to report mistreatment, including all types of abuse. The obligation to report mistreatment is regulated in the Social Services Act and applies to everyone who works within care for older adults. Designated officials investigate reports and make a judgment on reported incidents based on gathered information. All cases judged as serious mistreatment are passed on to the Health and Social Care Inspectorate (HSCI), which assesses the quality of the investigation and actions. Care for older adults in Sweden includes nursing homes (some specialized in care for people diagnosed with dementia), home care, and other services such as safety alarms. Care for older adults is mainly the responsibility of municipalities. Home health care and medical services are provided regionally. The mandatory reports analyzed in this study concern nursing homes and home care; in both settings we use the term “service user” to refer to older persons receiving care.

Only staff can file mandatory reports of mistreatment and, according to legislation, the care facilities are obliged to investigate all reports from staff. However, service users and their relatives can make complaints or raise concerns with staff (managerial or caring); they can also file complaints directly to the HSCI or the National Board of Health and Welfare. Complaints from service users and relatives are not mandatory for the care facility or the HSCI to investigate. Staff can choose to file a report based on complaints from service users or relatives (Kjellberg et al., 2023). In other words, there is no requirement for complaints raised by relatives and service users to be investigated in the Swedish context, unlike mistreatment reports filed by staff. What happens to complaints filed by relatives and service users through the mandatory reporting system is unknown.

The aim of this article is to analyze how the concerns of service users and their relatives are managed by designated officials in mandatory reports of mistreatment in care for older adults in Sweden. All the mandatory reports in the study sample were filed by staff, initiated by complaints from a service user or relative. Relatives include family members (children, partners, other related people) friends, or any person who plays a significant role in the life of the service user.

Previous research

A few studies have explored the management of safeguarding reports. For instance, Trainor (2015) found that several factors influence the decisions of Designated Officials in threshold cases, including the type of abuse and whether the affected service user agrees to continue proceedings. It has been reported that the threshold for seriousness is poorly defined (Manthorpe & Martineau, 2011) and that designated officials use different approaches to judge the seriousness of abuse and neglect (Berg & Kjellberg, 2022).

Moreover, research shows that elder abuse is highly underreported for a number of reasons, including care managers’ inability to recognize abuse (Myhre et al., 2020), loyalty amongst staff, fear of conflict with colleagues, and fear of sanctions (Hirt et al., 2022, Lund et al., 2023). In one study, directors and care staff described the involvement of authorities in a hearing as “quasi-judicial,” “intimidating,” and “an awful experience,” arguing that there was an assumption of guilt from the outset of the proceedings (Moore, 2016, pp. 312–313). Thus, despite staff being generally positive toward the reporting of mistreatment, the barriers mentioned above contribute to neglect and abuse being concealed rather than exposed and dealt with (Lund et al., 2023). In addition, some research points to reporter bias in clinical care; incident reporting has been used to deflect blame in adult patient transfers (“defensive reporting”) and harm is frequently underreported (Scott et al., 2021). Scott et al. (2021) suggest that involving service users and family members in the reporting process may be one way of improving the understanding of harm and its underlying causes.

Research on complaints of mistreatment, abuse, and neglect by service users is limited. Verbal and psychological abuse was the most frequent complaint made by service users in an assisted living setting in the US (Magruder et al. 2019). Researchers have also pointed out several possible barriers to older people disclosing abuse, including cognitive impairment, lack of ability to communicate, lack of detailed memory and hence ability to describe an event in detail, lack of knowledge of official reporting channels, embarrassment, and dependency on staff about whom they want to make a complaint (Persson & Berg, 2008, Payne & Fletcher, 2005). As Persson and Berg (2008) highlight, older people may be restricted in their ability to leave a residential care unit, which makes having proper reporting channels even more important. In addition, interviews with care staff have shown that older people’s complaints in nursing homes are often trivialized and not taken seriously (Persson & Wästerfors, 2007). An alternative way for older people to make a complaint is through relatives.

Research suggests that relatives can be very active in a care context and in raising concerns about mistreatment and failures in care (Baumbusch et al., 2018, Harnett and Jönson, 2010, Kangasniemi et al., 2022). A qualitative study in Norway showed that relatives see themselves as voices for voiceless family members (Saga et al., 2021). Complaints from relatives concern many different types of mistreatments: neglect of hygiene needs, clinical/medical care, nutrition, social needs, physical movement, autonomy, and dignity (Kangasniemi et al., 2022), as well as physical and psychological abuse (e.g., rough treatment, yelling, ridiculing, disrespect for belongings). Relatives of older adults in nursing homes in Sweden also defined “identity subversion” as a form of abuse (Harnett and Jönson, 2010). Engagement from relatives to protect a family member’s personhood, i.e., their personality and habits, can be a source of support, but it can also present problems if they cannot accept that the family member may have changed.

Another theme in research on relatives’ experiences of raising concerns is that they often feel ignored and misunderstood. Barriers to relatives complaining include a fear of not being taken seriously and staff retaliation against a family member (Payne & Fletcher, 2005, Saga et al., 2021). Some relatives reported retaliatory behavior by staff after making a complaint (Saga et al., 2021).

Theory and analytic framework

To explain the broader meaning and functions of investigators’ management of reports initiated by relatives, we lean on the sociological theory of “interpersonal trouble” (Emerson, 2015) and the management of disputes in an organizational context (Miller & Holstein, 1995). Emerson (2015) defines “trouble” as dissatisfaction, irritation, or anger directed toward another person, a feeling that something is wrong and that something needs to be done about it. When this feeling is communicated to an informal or official person, a “trouble account” is constructed. Trouble accounts are by their nature reactive to the context and history of events, retrospective, and partial. In other words, they are narrated with the purpose of conveying a specific understanding of an event. In turn, such accounts may trigger contrasting accounts from people involved. The complaints in this study were communicated to members of staff as accusations of wrongdoing by one or multiple members of staff. We understand and refer to these complaints as “trouble accounts” made to highlight a service users’ position. In turn, interviews with staff either confirmed the complaints or triggered contrasting accounts with respect to the victims, perpetrators, and/or underlaying causes. These are referred to as “defense accounts” in our analysis.

Emerson and Messinger’s (1977) concept of how third parties transform a trouble account is used to explain the role of investigators in the management of complaints. Official troubleshooters, such as designated officials, are consulted to scrutinize trouble accounts and apply a specific theory of wrongdoing. In social care, definitions of mistreatment and abuse are likely to guide the judgment of a complaint of mistreatment. Accordingly, troubleshooters have the authority to transform a complaint by labeling it as, for example, a minor deviation or serious abuse. Defining trouble may also involve aligning with one aspect of a dispute (Emerson & Messinger, 1977). Troubleshooters can manage a trouble account asymmetrically, by orientating themselves toward a specific side and identifying a victim and a perpetrator. They can also choose a more symmetrical intervention and avoid siding with either party. This means that the troubleshooter takes “a third position” that does not entirely support either side of the dispute. Symmetrical intervention involves validating and rejecting some aspects of both versions of events.

In the process of investigating a report, external parties may be invited to give information, changing the reported picture of the event, i.e., relatives and staff. An investigator’s task is to make an informed judgment of a reported incident and, based on the available information and facts, determine what occurred and the seriousness of the occurrence. In line with Potter (1996), we regard “facts” to be assertions made with the support of credible descriptions. Versions of an event can be made “factual” using several narrative techniques (Potter, 1996, Smith, 1978). The focus of this analysis is how investigators construct credibility within their judgments of different accounts of an incident. The use of “witness testimonies” is one way of corroborating an account of an incident, as well as to give a picture of the character and morality of the people involved. Supporting documentation and written statements are also used as evidence.

Troubleshooters are restricted by organizational ideologies, power relations, and organizational resources (Emerson & Messinger, 1977). Miller and Holstein (1995) present the concept of “dispute domains” to explain the impact of an organizational context when processing disputes through the use of discursive resources. In care for older adults, ethical principles, organizational measurements of quality, and living standards may shape the understanding of trouble. Miller and Holstein (1995) also underline the power dimensions of the dispute domain. Involved actors are positioned according to their interests, acts, and blameworthiness, which are evaluated and judged according to procedure. However, actors in a dispute are not always equally equipped with respect to available resources. This means that a complaint brought forward by a relative or service user may be processed in a dispute domain that requires resources to which they do not have access. Importantly, the organizational context should never be treated as deterministic. Individual skills, relationships, and local practices may influence the strategies a troubleshooter applies (Miller & Holstein, 1995).

Accordingly, we understand mandatory reporting as an organizational “dispute domain,” in which various statements of alleged abuse are processed, transformed, and defined through specific organizational resources. Staff (managerial or caring) who decide to report a complaint from a service user or relative concerning mistreatment is from this theoretical perspective moving everyday trouble into the formal dispute domain, an investigative process that presents the possibility of organizational-change remedies.

Methods

This analysis is part of a larger study on mandatory reporting by staff working in care for older adults, disability services, and individual and family care in Sweden (anonymized). The larger data set consists of all reports (n = 1105) by staff within these three areas in the region of Västra Götaland over one year (2019). The analysis presented in the following paper is based on 28 incident reports in care for older adults that were initiated by a service user or their relative(s).

The reports

The initial complaints from service users or relatives concerned failure of care, abuse, mistreatment, and neglect that were communicated (usually verbally) with the manager of the care unit or other care staff who decided to report the incidents. The investigations conducted by the designated officials contained detailed descriptions of what the service users or relatives had communicated to staff, but their verbatim accounts were not available for us to analyze. When referring to service users’ and relatives’ “trouble accounts,” we refer to the text-based descriptions and summaries of the complaints as reported by staff; accordingly, they may not constitute exact descriptions. However, our focus was on analyzing investigators’ ways of managing the central points and messages of the cases (i.e., what happened and who was to blame) as reported by relatives and service users, which we found to be possible given the data available. The reports included details and descriptions from interviews with the involved parties, references to documents such as medical and nurses’ records, and investigators’ judgments of the incident. The reports varied in length from 4 to 13 pages.

The selection process

Initially, there were 88 reports, and these were reduced to 28 following the selection process (see Figure 1). The reports were selected through a multi-step process. First, KB read all the incident reports from care settings for older adults, including nursing homes and home care, initiated by relatives and service users (47 by relatives, 41 by service users), selecting those fitting the following criteria: that it was explicitly stated that the report was filed in response to a complaint by a service user or relative(s) and that the concerns/complaints of the service user and/or relative(s) were clearly described.

Figure 1. The selection process of reports.

Adapted from: Page et al. (2021)

In total, 60 reports were excluded for three different reasons (see Figure 1). Reason 1 included a lack of information about the relative’s or service user’s description of the incident and the investigation leading up to the judgment. In addition, some of these reports were not judged to be mistreatments but deviations. Reason 2 concerned theft, and these reports did not contain a full investigation and were treated as a matter for the police. The third reason for exclusion was technical problems, such as very short investigations about a malfunction of the alarm system and other minor incidents.

The final sample included 28 reports (15 related to complaints by relatives and 13 related to complaints by service users). The relatives were children, siblings, partners, and one friend. In all the analyzed reports, it was staff who were accused of abuse and neglect.

Analysis

The process of choosing the study themes broadly followed the four-step process developed by Vaismoradi et al. (2016). The first two phases, “initialization” (reading, initial coding, and reflective writing) and “construction” (classifying, comparing, labeling), were mostly conducted by KB. The final two phases, “immersion” and “distancing” (relating results to existing knowledge and creating a coherent structure/storyline), were conducted in collaboration between the two authors and through critical discussions.

Both authors had already read and conducted content analysis of 1,105 reports collected during the project to describe their manifested and implicit content (Kjellberg et al., 2023) and conducted a qualitative analysis of all the reports that were deemed serious by investigators (Berg & Kjellberg, 2022). Given our familiarity with the data, in the first phase of the analysis (initialization), we focused on answering questions about each report formulated on the basis of our existing knowledge of the reports: What was the complaint about? How was the complaint managed (confirmed, dismissed, or transformed)? How were the investigators’ final judgment of the incident accounted for?

Accordingly, we analyzed and summarized the most relevant content for each report to answer the questions above. This reading resulted in a first organization of different trouble accounts, staff defense accounts, and different responses by investigators. In the second phase of the analysis, “construction,” a first draft of the themes and subthemes was developed.

In the final two phases of the analysis, the categories and themes were continually revised until both authors agreed on the content and structure. Three broad themes of how investigators managed reported incidents and the nature of their final judgments remained: 1) the investigator sided with the organization and dismissed the trouble account, 2) the investigator sided with the service user by supporting the complainant’s trouble account, and 3) the investigator took a middle ground and integrated the complainant’s position in development and learning (see Table 1).

Table 1. Reports initiated by service users and relatives in three themes.

	Themes
Initiated by:	Siding with organization	Siding with service user	Finding a middle ground	Total
Service users	1	12	0	13
Relatives	4	1	10	15
Total	5	13	10	28

The study was approved by the Swedish Ethical Review Authority, number 2020–05817. All personal identifiers have been removed.

Result

The results are presented according to the three themes and subthemes regarding investigators’ treatment of reports initiated by service users and relatives. Across the different themes, investigators used different sources of evidence to determine the facts of trouble accounts and reach a judgment.

Siding with the organization: dismissing the trouble account

Five of the 28 trouble accounts were completely dismissed by investigators. All but one report was initiated by relatives who gave descriptions of specific incidents of mistreatment and neglect that had occurred between staff and a service user. Some trouble accounts had moral undertones and directly or indirectly accused staff of laziness, carelessness, and/or incompetence, while others pointed to a faulty organization. These investigations were all short and underdeveloped, and their focus was mainly on whether staff had followed routines and regulations. Written documentation and information about service users were treated as “factual,” i.e., the most reliable evidence (Potter, 1996). Investigators dismissed trouble accounts in two ways, either by referring to the lack of evidence or by questioning the service users as victims.

Referring to a lack of evidence

When relatives’ and service users’ claims of wrongdoing and experiences of harm could not be backed up with evidence, they were dismissed: “it is not possible to demonstrate that the described course of events has occurred” (18.158, home care). Little effort was made to investigate the experiences behind complaints or service users’ potential physical and psychological suffering. In addition, investigators sometimes ignored the specific claims of reports, redirecting focus onto what staff had done right to present them favorably. For example, one relative reported that she detected symptoms of a stroke when visiting a service user and notified staff. Her concerns were based on her personal knowledge about the service user’s “normal” behavior. She could see that something was wrong. However, her observations were ignored, which was the basis of the trouble account. Could her friend’s diagnosis have been improved if staff had listened to her and discovered the stroke earlier?

A friend of NN’s comes to visit at lunch time. She notices that NN’s speech is slurred and that NN has a “hanging corner of the mouth.” The friend points out to a staff member that NN is not as usual. Something has happened to NN. The staff then allegedly replies “No, it hasn’t” and do not go in to NN to observe her. Staff observed signs of stroke later in the evening and sent her to hospital. The friend is worried that the service user has not received adequate care in time and that, as the friend perceives, the staff’s nonchalance regarding signals of disease symptoms may have worsened the prognosis. (25.18, nursing home)

The investigator, who was also the manager, responded with a detailed description of documented tasks that staff had completed during the day in question. Times of tasks were noted by the minute, which was presented as evidence of the details being factual:

According to the alarm history, the service user called and received help on three occasions during the morning of April 6, at 08.55, at 09.59, and at 10.44. […] During the lunch service, the service user was still asleep, which is why lunch was saved so that NN could eat when she woke up. At 2 p.m., two caring staff give NN medicine; they don’t see.any sign of a stroke. […] At 2 p.m. when the evening shift arrives, no information is provided about “deviations” that apply to the service user in question. Between 2 p.m. and 5 p.m., the staff visit NN several times without seeing signs of stroke. According to a note in the reserve, the suspected stroke was discovered in the evening at 6 p.m. (25.18, nursing home)

Few of the listed details presented above were relevant to the complaint – the disregard of the friend’s warning. Nevertheless, based on these facts, the investigator concluded that it was not possible to ascertain when the stroke happened or if staff had failed in their duties. According to the investigator, all the evidence pointed to the opposite: “Staff [have] carried out their assignments, during morning, late morning, afternoon, and evening.” Thus, the personal knowledge and observations provided by the friend were lost when examined in the staff member’s daily report.

Questioning the service users as victims of abuse

The service users as victims was also questioned in several ways, which made the reported incidents seem more acceptable. However, the focus was not on whether the service user had suffered, but whether staff acted in good faith and in line with routines and regulations.

One way of questioning the service users as victims, and partly clear staff of blame, was to appeal to service users’ self-determination. For example, a daughter discovered that her mother was living in misery after she was taken to hospital. She described unacceptable failures in home care and indicated major problems in the organization, specifically an intolerable amount of filth (feces on the wall and on the floor, old garbage). Service providers failed to show up on four occasions, and those who did show up worked in haste and left early. However, in their verdict, the investigator pointed to a number of occasions on which the mother declined the services of staff, suggesting that the untidiness was a result of her own choices:

NN has cancelled most of the services herself; this could be one of the reasons why this situation has arisen. The investigator makes the assessment that it is not possible to establish that any mistreatment has occurred. (18.161, home care)

However, the service users’ reasons for canceling home care visits were never explored in these investigations. Another way in which the suffering of service users was questioned was by raising doubts over the complainants’ motives. While investigators often declared sympathy and understanding for relatives’ concerns, they sometimes suggested that relatives had acted out of personal emotion rather than on behalf of the service user. Such statements indicated that claims of risk and suffering were overstated. For instance, a son was indirectly accused of wanting to control his mother’s food intake when complaining about staff not accompanying her for all meals. The mother had recently choked on her food, an incident that required an ambulance to be called (36.13, home care). The next day he found his mother once again left alone with a sandwich. According to the son, his mother had a problem with “chewing,” which he claimed had caused the incident. The ensuing investigation focused on these claims but did not find any written evidence in support of them, revealing only that the woman had problems “swallowing” certain foods, something of which staff were aware. There was also no evidence that the service user did not want food left on the table. Interestingly, the investigator acknowledged that the information about the woman according to her own perspective urgently needed updating: “It is important that investigations, assignments, and implementation plans are clear and up to date” (36.13). Nevertheless, it was concluded that staff had acted in good faith by adhering to the information at hand:

If NN wants to have food available, staff must respect her wishes. The fact that the son does not want her to choke and was worried after the incident with the ambulance is understandable, but it does not mean that his wish for the home care service to limit his mother’s access to food in her home can be fulfilled. […] Since the mother has not expressed a desire not to be left alone with food, there has been no mistreatment. (36.13)

A final example within this theme concerns the only trouble account from a service user regarding rough treatment when receiving home care. The report in question was instigated at the encouragement of the manager, in response to a long series of complaints from the service user. The investigator concluded that mistreatment could not be established due to a lack of recorded evidence of physical injury to support the service user’s claims. However, this investigation stands out because the investigator also indicated that the real victims were staff members, with the service user depicted as a bully: “she has had opinions about their [staff’s] size, age, and ethnicity,” and “punished staff” in various ways (36.22, home care). Detailed examples of how she had mistreated staff raised questions over the motives behind the trouble account and presented the service user as an unlikely victim. The service user was instead referred to the regular complaints channel.

In summary, siding with the organization and dismissing trouble accounts functioned to clear staff from blame, obstructing development and learning. Leaning on written notes as evidence, relatives’ verbal and personal trouble accounts could easily be dismissed, and their accounts were not always treated as trustworthy. Ironically, concern and engagement by relatives undermined their credibility in the eyes of investigators when providing information. The analysis also revealed the high level of trust placed in routines, with the understanding of mistreatment being narrowly defined as staff failure to follow established practice.

Siding with the service user: supporting the complainant’s position

Thirteen of the 28 trouble accounts were supported by the investigators. All but one complaint was initiated by a service user, whose experiences of mistreatment were described in detail. Most commonly, a service user in need of help was neglected or help was delivered in the wrong way or in combination with unfriendliness and/or violence/force. The trouble accounts were not always judged as serious, but they were validated and confirmed as mistreatment. In contrast to cases grouped under the previous theme, these reports concentrated on the verification of service users as victims of abuse and often entailed the accusation of a specific member of staff. The process of evaluating different accounts shared similarities with court trials, with trouble accounts and defense accounts from interviews with staff compared and scrutinized. Investigators leaned on documentation as well as witness testimonies to determine the most credible trouble account and make it “factual” (Potter, 1996, Smith, 1978). Showing compassion for the position of service users is a core ethical value in social work (Reamer, 2018). Another way of supporting complainants’ accounts was to appeal to the importance of listening to service users’ perspectives and experiences.

Corroboration of a credible victim

A frequent key witness was the manager of the care unit, sometimes also the official author of the report. Other witnesses included staff members or relatives who had observed an incident, experienced a service user’s lack of wellbeing, or to whom a service user had disclosed mistreatment. Both documentation and witness testimonies were used by investigators to present a credible victim.

For instance, investigators presented witness statements of service users’ displays of emotions, which served to support service users’ claims of suffering: “staff has noticed on two occasions that the service user cried and was upset” (18.140 nursing home). In addition, managers’ statements corroborated service users as truthful. For example, one report described a service user as “trustworthy in conversation,” and stated that their “statement had been clear and coherent and that there was no reason to question it according to the manager” (18.24, nursing home). In another case of suspected physical violence against a woman receiving home care, a manager provided documented evidence of the service user’s mood at the time at which an accused member of staff had been in duty. It was concluded that “they could establish a pattern in which the service user had been worried, or in other ways acted abnormally linked to when the temporary employee had been on duty” (18.51, home care). Generally, the suffering of service users was highlighted even if staff could not be proven guilty:

What can be said with certainty is that NN has suffered a bruise on the face, which is documented in a photo, and that she previously expressed fear of the now alleged member of staff… The fact that the above described has transpired while under the responsibility of the caregiver means that NN has been the victim of mistreatment. (18.51, home care)

The investigator also scrutinized staffs’ defense accounts and motives. Witness statements added to the narrative that care staff were negligent or had behaved aggressively: “Staff member 2 had seen staff member 1 on three occasions sitting and studying instead of working” (18.24, nursing home); “The interviewed employee witnessed how the staff in question confronted the user. This was done in a loud and harsh manner. She stood up and leaned over the service user” (18.140, nursing home). One manager spoke partly in favor of an accused staff member, which further complicated the evaluation of their behavior: “the staff member is calm, reliable, and never had any complaints from service users before” (40.2, nursing home). However, the manager also added that the staff member had been described as “unfriendly and harsh by colleagues.” In addition, if staff defense accounts could not be verified in documented files, this was used as evidence: “The investigator cannot deduce from the nurse’s documentation that contact has been made to provide pain relief. The employee has not documented anything that can support the above” (40.8, home care).

Moreover, the process of finding the most reliable account could transform potentially complicated incidents involving conflicting testimonies into a one-sided event. For example, one service user who received home care complained that a member of staff had behaved in a “military way,” and that she made him feel “uncomfortable and scared.” When he asked for help because of his reduced eyesight, the staff member responded “you see what you want to see” in a belittling way. “The service user felt that his need of support was questioned despite his reduced eyesight” (18.12, home care). The accused staff member presented a different version of events, stating that the service user had made her feel uncomfortable by being “difficult to please” and “intrusive.” She also implicitly questioned his morals (“lacks will,” “drinks”):

The employee tells us that the service user can be difficult to accommodate. He hears poorly but reacts by yelling at the employee if she talks too loudly or too quietly. The employee says it’s hard to know how to do it, and states that it is difficult to get the service user to do what he can do on his own. He also would like to talk privately with her, which she tries to avoid. The service user also wants the employee to hug, which she has said no to. She experiences the service user as close in a sometimes unpleasant way. She says that the service user likes to drink alcohol and take tablets. There are other staff members who also have felt discomfort when visiting the man.

In the detailed defense account above, the service user is presented as the problem, not only for the accused employee but also her colleagues. Her defense account was dismissed by the manager who referred to a lack of evidence: “the manager has not received any complaints from other staff about the service user.” The manager had, however, also received an additional complaint from a second service user about the same staff member. Two independent witnesses were deemed to provide sufficient credibility to support the service user’s trouble account in this report.

Appealing to service users’ perspectives as a higher order principle

A typical response to conflicting testimony was to quote the importance of service users’ own perspectives and experiences: “Different sides of the described events emerge and the responsible investigator cannot confirm exactly what happened. However, the most important thing to consider is what the service user himself has stated regarding his experience of being mistreated” (18.140, nursing home). In one report, the service user had frontal-cortex dementia and a history of “making things up,” however the investigator still supported his position:

Because the service user has dementia, there are certain difficulties in fully trusting what he says. There is also a previous history in which he embellished his own involvement, in which he was clearly disproved. However, adequate labor law measures have been taken based on the fact that whatever he says are serious accusations. […] It is important to treat our service users based on their experiences and that our staff behave professionally in their treatment. The people we care for are here for a reason and we must provide our service users with safe and secure care, and in this case, we cannot guarantee that. (50.27, nursing home)

Thus, the service user’s experience was treated as important despite conflicting or insufficient evidence, independent of whether mistreatment could be linked to a member of staff. In other words, trust in a service user’s perspective was treated as a higher order principle.

In summary, the service user’s experiences were prioritized in the judgment of the incident. The investigator argued that the service user was a credible victim and demonstrated trust in his perspective. However, comparing two contrasting accounts could also result in a one-sided analysis in which staff perspectives appeared to be invalidated. Some defense accounts that highlighted issues with the work environment were dismissed. Thus, while service users’ positions are supported, this way of managing complaints may risk overlooking the full picture of a problem.

Finding a middle ground: integrating complainants’ positions in development and learning

Ten of the 28 trouble accounts were treated as credible information. All the complaints were made by relatives and were relatively serious, such as faulty care and severe neglect resulting in death or suffering. In addition, all the reports except one (18:177, nursing home) referred to major problems in the organization that had been previously acknowledged, and the trouble accounts were described as one of many. These investigations commonly balanced the acknowledgment of serious wrongdoing alongside validating staff’s explanations by promoting development and learning. The reports described faulty service by a faulty organization, and investigators used techniques of minimization (Potter, 1996) to downplay claims of wrongdoing and make them less morally charged.

Treating trouble accounts as credible information, but minimizing the worst allegations

In these reports, relatives’ accounts were mostly treated at face value. Mistakes had clearly been made: faulty care, communication, or documentation had or could have caused suffering. Attempts were made to verify relatives’ accounts, but even if evidence could not be found for everything the relatives claimed, their trouble accounts were still treated as credible. In the extract below, the trouble account was treated at face value and became the focus of a final and relatively harsh judgment:

The relative reports what they experience to be deficiencies in hygiene: the resident is wearing dirty clothes that do not seem to have been changed for several days and the incontinence protection has not been changed for a very long time. The relative has previously complained about the above-mentioned shortcomings, which is why a number of routines and support documents have been developed and implemented. Despite this, the shortcomings still exist. The investigation of the incident shows that there is a substantial risk of mistreatment. The service user has not shown any injuries since the incident, but it appears, without any in-depth analysis, that the lack of care was palpable and preceded by negligent conduct. (18.1, home care)

However, relatives’ most serious accusations were minimized in most reports. Claims of mistreatment or neglect causing severe injury, “death,” and “severe pain” were never supported. Shifting responsibility for the most serious claims to something or someone else was one approach used to reduce the moral burden on staff. For example, following the death of a service user due to heart failure, the investigator explicitly cited a medical journal to explain that the incident was not the fault of a staff member. In addition, the investigator concluded that, while faulty care posed a serious risk of harm, the responsibility for death was attributed to a medical judgment prescribing too few caring hours:

Whether the lack of care from the home care service affected the outcome for the individual cannot be determined. Based on the small amount of allocated care, it is not certain that the service user’s deteriorating health situation would have been noticed by the home care service even if the intervention had started as planned. The serious risk is that when planning does not work and efforts are not made, there are significant risks. (18.10, home care)

There were also examples of investigators minimizing the consequences of failures of care for service users. In one case, a service user was left without food and water and unable to use the toilet for a whole day on two separate occasions. However, these consequences were contrasted with what could have happened if the service user had been fragile and sick, or in need of “life supporting medication.” When contrasted with the potential of death as a result of thirst and hunger, the incident was presented as less serious: “If similar mistakes had occurred against someone with more extensive support needs, the consequences could have been serious” (18.183, home care). In one report, the organization was described as having been transformed, with a reported serious incident being presented as an exception in an otherwise positive trend of improvement, a framing that made the incident seem less serious (18.170, home care).

Balancing explanations, responsibility, and requests for development and learning

While not trying to deny accusations of wrongdoing, staff provided explanations and referred to mitigating circumstances to reduce the moral weight of incidents. These related to the work environment and included stress, complicated computerized scheduling systems, a lack of functioning routines, a lack of trained staff, absent leadership and understaffing. Investigators supported staff defense accounts by attributing responsibility for an incident to the group or organizational level rather than singling out a specific member of staff. For example, in one report an investigator states that staff lacked knowledge, professionalism, and the ability to follow routines and take responsibility. However, the investigator also supported their experiences of stress, placing ultimate responsibility on management.

The staff’s experience of stress and workload needs to be taken seriously, and work to reduce stress needs to be done. Ambiguity in routines and organization of daily work also affect the experience of stress. [.] In addition to competence development, establishment and clarification of routines, the investigator perceives that the need in the working group is clearer management and governance, and efforts aimed at increasing personal responsibility, professionalism, and values. (18.154 home care)

The above could be interpreted as a plea to create “a learning organization.” In one report within this theme, staff appeared to deny the accusations made by a relative in full. In this case, the service user’s health had deteriorated quickly in care, eventually leading to death due to heart failure. It became known that the service user was severely dehydrated, for which staff were blamed. Staff were also described as rude and the room as not being properly cleaned and smelling of urine and garbage (18.177, nursing home). However, the manager and staff countered with detailed examples of good care and argued that the uncleanliness was a one-time mistake. Instead of backing one side of the dispute, the investigator supported both perspectives. On the one hand, the warmth and care shown by staff was validated and provided as evidence of high-quality care. On the other, the investigator pointed to an important critique from relatives that staff needed to acknowledge:

Interviews with staff revealed that staff knew the service user well. They could give several examples of what NN appreciated in everyday life and how they used to talk to NN. NN was described with warmth and care [by staff]. However, the relatives also describe that some staff treated NN in a “harsh way” and without understanding of NN’s health. The relative felt that she was not listened to when she conveyed the doctor’s recommendations to staff. It is a delicate task to investigate the issue of treatment as there are often different perspectives and different aspects to consider.

The investigator’s response above suggests the belief that neither perspective was wholly true, and that it would have been impossible to corroborate one side over the other. Thus, the dispute was treated as a conflict with different sides (Emerson, 2015), and the situation was later partly defined as a result of “lacking communication,” a rather neutral phrase. In addition, the investigator supported the importance of relatives in care, stating that staff needed to learn from relatives and use their knowledge as a tool:

Having a family perspective means that the family or other people who are important to the service user are made visible and that the organization collaborates with both the service user and the people who are important to them. Relatives can be involved as a source of knowledge by describing how the user eats/drinks in the home environment. (18.177, nursing home)

In this theme, by balancing the emphasis on mitigating circumstances, explanations, and responsibilities, the different sides of the dispute were managed more symmetrically. The relatives’ complaint was mostly treated as supporting evidence in the investigators’ analysis of the organization. Rather than emphasizing or dismissing the trouble account, the worst allegations were minimized. One interpretation is that minimizing the worst allegations is a way to move beyond blame and guilt and toward development. Responsibility was distributed between different actors, including managers, and staff responsibility was reduced.

Discussion

The aim of this article was to analyze how the concerns and complaints of service users and their relatives were managed by designated officials in mandatory reports of mistreatment in care for older adults in Sweden. Mandatory reports can only be filed by staff, but they are sometimes initiated by complaints made by relatives and service users. The complaints in all the analyzed reports were acknowledged to the extent that staff decided to report them as suspected mistreatment. The analysis shows that reports initiated by relatives and service users were managed in one of three ways: asymmetrically, by 1) dismissing the complaint or 2) supporting the complainant’s position through constructing a credible victim, or symmetrically, by 3) treating complainants’ accounts as credible, but minimizing the worst claims of wrongdoing.

When complaints were managed asymmetrically, mandatory reporting as a dispute domain was processed as a “quasi-legal” hearing, in which documented evidence, facts, and witness testimonies took precedence over personal knowledge (Miller & Holstein, 1995, pp. 52–53). Investigators compared contrasting accounts of potential mistreatments and judged their credibility. When managing trouble accounts asymmetrically, the validation of one testimony often disqualifies the other (Emerson, 2015). Accordingly, the disputes were presented as an incident with a clear perpetrator and victim, sometimes leading to dismissal.

Most concerning was perhaps the dismissal of relatives’ trouble accounts presented under the first theme. Previous research suggests that a barrier to relatives making complaints is a fear that their considerations will be ignored or not taken seriously (Payne & Fletcher, 2005, Saga et al., 2021), which unfortunately seemed to be the case in a few of the analyzed reports. In dispute domains, resources and procedures determine who is successful in having their concerns heard (Miller & Holstein 1995). In particular, documentation – staff members’ written accounts of their everyday work – was a heavily used dispute-domain resource. Documentation is not neutral, but it is nevertheless often used as evidence when determining accountability in social care (Åkerström & Jacobsson, 2019). In this study, when the organization was given “ownership” of the narrative through a reliance on documentation, relatives’ accounts could easily be dismissed and their personal knowledge and observations treated as less credible. Some investigators also demonstrated distrust of the real motives behind relatives’ concerns, suggesting they were controlling or overly protective, so-called “troublesome relatives” (Saga et al., 2021). In addition, when an investigator sided with the organization, the investigations seemed to largely function to establish whether staff had acted in accordance with routines, rather than to understand the cause of the trouble account. How routines were executed, or whether they were appropriate, was not explored. In some cases, operating outside of routines may have been an appropriate course of action. Taken together, this way of managing reports could be interpreted as “defensive” (Scott et al., 2021), with the main aim being to clear staff of blame and avoid scrutiny of the organization.

In contrast, investigators almost always showed a willingness to validate reports initiated by service users. This contrasts with previous research suggesting that service users’ complaints are trivialized (Persson & Wästerfors, 2007). The service users as victims of mistreatment and staff culpability were made “factual” (Smith, 1978) through documentation and witness testimony. Service users were depicted as trustworthy, and in some reports the importance of trusting their perspective was treated as a higher order principle. In other words, here investigators gave service users’ “ownership” over the narrative. Importantly though, the reports analyzed in this article were those that had already been successful to some extent. The service users were able to skillfully communicate their experiences to a member of staff or the manager, who often served as a key witness. In turn, their complaints had been acknowledged and investigated as potential mistreatment. However, previous research demonstrates several barriers for older people to raise concerns in care for older adults, such as cognitive impairment, lack of ability to communicate, embarrassment, and dependency on the same staff they want to complain about (Persson & Berg, 2008, Payne & Fletcher, 2005). Thus, those who cannot communicate their personal perspective may instead have to rely on their relatives to bring attention to mistreatment.

Moreover, the defense accounts presented from the perspective of accused staff included references to organizational challenges, but these were dismissed and individual staff often blamed. This way of managing reports may be counterproductive, considering that staff loyalty and fear of conflict, and sanctions can prevent reporting (Hirt et al., 2022, Lund et al., 2023). Mandatory reporting relies on the willingness of staff to self-report. Preventing the concealment of mistreatment, neglect, or abuse must be weighed against workload (Kangasniemi et al., 2022) and other considerable barriers for staff to carry out their work.

When managing complaints more symmetrically (Emerson & Messinger, 1977), relatives’ trouble accounts were included in investigators’ judgments as credible information. At the same time, investigators chose to minimize the most serious allegations and validate mitigating circumstances, absolving staff of moral responsibility. According to Emerson (2015), managing a dispute symmetrically is a way to move beyond discussions characterized by blame, guilt, and mistrust toward a solution. Therefore, one reason for investigators to absolve staff of guilt may be to steer discussions toward quality development and learning.

More generally, the different ways of managing reports illustrated in this article – defensive reporting versus taking the side of service users or treating a report as a conflict – may speak to, as Trainor (2016) puts it, a clarification of “the roles and responsibilities” (p. 60) of designated officers. How they can best manage the conflicting perspectives of involved parties is a topic for further discussion.

Finally, the results of this study indicate that the individual resources and knowledge base of investigators may affect the management of complaints, especially those made by relatives. While relatives’ accounts were treated as credible in some reports, the importance of their knowledge and perspective was only stressed in one instance. Family members can provide valuable knowledge about the needs of service users (Havreng-Théry et al., 2021), and relatives sometimes see themselves as the voices of their (in some cases) voiceless family members (Saga et al., 2021). While relatives’ descriptions of service users’ suffering may not reflect the exact experience of the service users themselves (Harnett and Jönson, 2010), in these reports, their complaints often related to mistreatment that resulted in serious injury or death, incidents that service users may have been unable to communicate.

Implications for policy and practice

The result may provide insights for policymakers and practitioners into the investigative procedures of mandatory reporting. The different strategies used by designated officials highlight the difficult, and sometimes ethically complicated, task to validate and compare different perspectives of problematic incidents. While acknowledging the complexity of the investigative procedures, the result suggests that some of these strategies could be revised. To begin with, relatives’ personal knowledge can be further utilized to detect and prevent mistreatment of older people in social care. Second, staff documentation may best be approached as partial information rather than treated as factual (Åkerström & Jacobsson, 2020). In this study, we discovered that relatives’ complaints were sometimes dismissed with a reference to the lack of organizational evidence to support their claims. It might not always be possible for relatives to provide such evidence. While reports of single complaints may not be possible to verify, they can still form part of a broader pattern of problems that, together, could result in serious mistreatment (see also Björne et al., 2021). Thus, rather than trying to prove the factuality of a complaint, it may be crucial to further explore and understand the experience behind it. Equally, to utilize mandatory reporting for development and learning, the staff’s version of a problematic incident, their experiences, and explanations must also be considered, even when there is a lack of written evidence to support them. To help investigators, better and more unified strategies should be developed on the best way to manage reports initiated by relatives and service users, and on how to manage conflicting versions of mistreatments. Overall, the result calls for more training in investigative techniques for the designated officials and, perhaps, a more open approach toward relatives’ knowledge and insight into the service user’s situation.

Limitations

The analysis is solely based on the text provided in reports. Investigators decisions were also likely to be affected by the organizational culture and social context, but the influence of these factors was unknown to us. For example, previous incidents that were not reported in writing may have played a part in investigators handling reports in a particular way. In addition, power relations between staff, managers, and investigators may also have influenced cases and investigations. That said, in this study we did not seek to analyze the various contextual factors at play in the investigations, only to analyze investigators’ arguments and discuss their implications.

Another contextual factor that we believe would have added another dimension to this analysis is gender. However, because information about gender was anonymized in most of the reports, it was not possible to analyze how this might have affected judgments. We did ask municipalities to include this information in the data provided to us, but our request was denied.

Conclusions

Mandatory reporting of mistreatment aims to detect and prevent elder abuse. Safeguarding legislation differs across countries. In Sweden, staff are obliged to report what is known to them, and the complaints of service users and their relatives is one source of information. Relatives’ complaints are particularly important for staff to acknowledge, as older people may have difficulties raising their own concerns (Havreng-Théry et al., 2021). Using the designated officials’ investigations of mandatory reports, we have shown limitations of safeguarding older people in Sweden. The investigations offer valuable information that can help in understanding how the mandatory reporting system may be better aligned with the often complex care situation involving older people. The study revealed that the care facilities have more to learn from listening to and including service users’ and their relatives’ views. The dismissal of some relatives’ trouble accounts may have prevented service users from having their voices heard. On the other hand, ignoring the perspectives of staff on mitigating circumstances and organizational challenges may present barriers to staff reporting, which could further conceal neglect and abuse. We have argued for further training in investigative techniques for development and learning and for giving service users and relatives a greater say in the reporting process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, [KB], upon reasonable request.

Additional information

Funding

This work was supported by FORTE under Grant number [2020-00195].