Healthcare Clinicians’ Perspectives on Managing Suspected Elder Abuse: “We Don’t Want to Just Swoop in and Do What We Think Is Best”

Abstract

Background and Objectives

Elder abuse (EA) is common and has significant health impacts. New initiatives seek to capitalize on opportunities to respond to EA from within the healthcare system, but little is known about what clinicians may need to be successful in these efforts. Our objective was to understand perceived barriers and facilitators to managing all phases of EA within an integrated healthcare system from the perspectives of frontline clinicians from a range of different disciplines.

Research Design and Methods

Thirty-seven clinicians (10 social workers, 9 physicians, 7 psychologists, 6 nurses, and 5 advanced practice providers) from different clinical sites within 2 large Veterans Health Administration (VHA) medical centers participated in semistructured interviews. The interview guide was designed to elicit facilitators and barriers to discrete stages in the process of addressing EA, including detection, reporting, intervention, and monitoring. Transcripts were coded using deductive (based on a prespecified conceptual model) and inductive approaches and analyzed using thematic analysis.

Results

Most (78%) participants were women, ranging in age from 33 to 64 years, and practicing in a variety of settings (e.g., primary care and emergency department) with between 4 and 25 years of VHA experience. We identified 5 interrelated themes that cut across the different stages of EA care: situational context (theme 1), degree of trust in familial and healthcare relationships (theme 2), extent of education and skills (theme 3), and existing system infrastructure (theme 4) all contributed to clinician empowerment and motivation toward action (theme 5).

Discussion and Implications

Efforts to enhance skills training, build trusting relationships, and improve system infrastructure could help to equip clinicians to engage in healthcare system interventions to reduce harm from EA.

Translational Significance: Elder abuse is a common yet underidentified problem with devastating health consequences for older adults. Although healthcare system encounters present meaningful opportunities for detection and intervention, there is limited knowledge about the facilitators and barriers experienced by the different clinicians involved in responding to elder abuse in integrated health systems. In this qualitative study of 37 clinicians from 5 different disciplines, we found important overarching themes and developed a new model for identifying potentially modifiable targets for interventions to improve healthcare system capacity to respond to elder abuse.

Background and Objectives

Every year, approximately 10% of older adults in the United States experience abuse, neglect, or exploitation with devastating consequences to their health and well-being and that of their families (Lachs & Pillemer, 2015). When any of these acts occur in the context of a trusting relationship, they are referred to as elder abuse (EA). Although experiencing EA is linked to numerous adverse health outcomes, including nursing home placement (Lachs et al., 2002), hospitalization (Dong & Simon, 2013), and mortality (Schofield et al., 2013), there is a lack of standardized screening, identification, reporting, and documentation of EA in most healthcare settings (Baker et al., 2016; Beach et al., 2016). Prior qualitative research exploring reasons for these healthcare system gaps has largely focused on the pre-hospital or emergency department setting and has not examined the full spectrum of EA response from different disciplines. These earlier studies have revealed that poor training and education, insufficient resources, communication gaps, lack of time, concern about potential adverse consequences for patients, and inadequate systematized procedures all may serve as barriers to EA detection and reporting specifically (Jones et al., 1997; Myhre et al., 2020; Reingle Gonzalez et al., 2016; Rodríguez et al., 2006; Rosen et al., 2017; Schmeidel et al., 2012; Taylor et al., 2006). Additional research is needed to understand the perspectives of clinicians from different disciplines, who typically work together in teams to address EA, on facilitators and barriers to EA response in an integrated health system.

We aimed to elicit the perspectives and experiences of a diverse group of healthcare professionals on addressing EA across the spectrum from detection to intervention from multiple clinical settings in an integrated healthcare system. We conducted this study in the Veterans Health Administration (VHA), the country’s largest integrated health system, serving over 4 million Veterans ages 65 years and older, many of whom are at particularly high risk for EA (Makaroun et al., 2018). The VHA is a useful setting to conduct this evaluation given its mission to address health-related social risk factors and its resources to address EA, such as robust mental health programs, home- and community-based services, widespread geriatrics-trained clinicians, and nearly 20,000 social workers nationally, many of whom are embedded in primary care teams (Cornell et al., 2020). However, the VHA, similar to other systems, does not currently have standardized approaches to EA detection, documentation, or intervention (Makaroun et al., 2023). Given the large population of high-risk older Veterans and the integrated services available, the perspective and experiences of multidisciplinary clinicians practicing in the VHA could help to inform the development of a framework for addressing EA within healthcare settings. Furthermore, VHA has often been a leader in the development of innovative geriatric programs (Farrell et al., 2023), so lessons learned in VHA could help advance the field more broadly. We designed a qualitative study to examine barriers and facilitators across all stages of EA care from the perspectives of multidisciplinary clinicians to inform strategies to enhance capacity for healthcare system-based EA response.

Research Design and Methods

We followed recommended Consolidated Criteria for Reporting Qualitative Research guidelines for reporting on qualitative studies (Tong et al., 2007).

Study Design and Participants

Clinicians practicing at two large VHA medical centers located in different regions of the United States were recruited and interviewed between November 2019 and November 2020 (with a brief hiatus from March to June 2020 due to the COVID-19 pandemic). We recruited clinicians from different disciplines involved in EA detection and response, specifically: (1) psychologists, (2) nurses, (3) physicians, (4) social workers, and (5) advanced practice providers (nurse practitioners and physician assistants; APPs). Our recruitment goal was to reach “meaning saturation” (Hennink et al., 2017), and we continued to recruit until we felt our thematic analysis was sufficiently well developed to generate a rich understanding of the issues (Braun & Clarke, 2021b).

Recruitment and Data Collection

We first invited clinicians who worked in clinical settings with high proportions of older patients (e.g., Home-Based Primary Care, Geriatrics, Nursing Home) to participate in our study by general email list distributions and at in-person or virtual informational presentations during service-line group meetings. We then pursued snowball sampling by asking those who agreed to participate to suggest others with potentially useful insights who we could contact. Participants received no compensation. One-on-one interviews followed a guide designed to elicit facilitators and barriers to EA detection, reporting, intervention, and monitoring, reflecting our initial understanding of how clinicians would think about addressing EA, namely in discreet steps (see Supplementary Material for interview guide). The interview guide was informed by barriers and facilitators identified in prior studies examining individual steps (e.g., reporting) and by expert opinion of the investigative team. Interviews were conducted over the phone by a study team member (L. K. Makaroun, G. Klima) and audiorecorded with oral consent. Telephone modality was used to enhance feasibility of scheduling busy clinicians across various geographic locations because videoconferencing modalities were not yet approved for research use in VA at the time interviews were conducted. Audiorecordings were then transcribed verbatim for analysis and verified by one study team member (M. Nichols). Study activities were approved by both sites’ Institutional Review Boards.

Qualitative Analysis

We reviewed and coded transcripts using both deductive and inductive approaches (Fereday & Muir-Cochrane, 2006). A priori codes were informed by prior literature, expert opinion from the authors, and two existing frameworks: the Elder Abuse Theoretical Risk Framework proposed by the National Research Council (2003) and the Abuse Intervention Model proposed by Mosqueda et al. (2016). Both models indicate that factors related to the older adult, the alleged harmer and the contextual situation are important considerations for EA intervention and engagement. Over time, we added codes inductively as these emerged from the data and removed a priori codes found to be less relevant. Two authors (L. K. Makaroun, N. Shin) independently reviewed and co-coded the first seven transcripts to compare and align interpretation and application of codes. After establishing a consistent approach to coding, these two authors subsequently divided and coded the rest of the transcripts, meeting regularly to review codes, discuss challenges, and resolve disagreements via negotiated consensus.

We used a meaning-generating approach to thematic analysis (Braun & Clarke, 2021a) in which we used a codebook to generate meaning-unified stories from the data rather than topic summary themes (Braun & Clarke, 2022, 2023). This approach was felt to be the most illuminating for our data as, in the process of preliminary analysis, we found that focusing solely on facilitators and barriers did not adequately capture the full story of clinicians’ experiences. Three members of the study team (L. K. Makaroun, N. Shin, K. L. Hruska) developed the initial themes after reviewing the codes and transcripts. These were then presented to the broader study team for input and iterative adaptations to the thematic story. We used NVivo 12 software to aid in analysis.

Results

Thirty-seven clinicians (19 from VA Pittsburgh and 18 from VA Puget Sound) participated in this study, including 10 social workers, 9 physicians, 7 psychologists, 6 nurses, and 5 APPs. Most (78%) participants were women, with between 4 and 25 years of VHA practice experience and working in a wide range of clinical settings (see Table 1).

Table 1.

Characteristics of Study Participants (N = 37)

Characteristic	Median (IQR)	No. (%)
Age in years	44 (38, 50)
Gender
Woman		29 (78.4)
Man		8 (21.6)
Race/ethnicity
Non-Hispanic White		33 (89.2)
Non-Hispanic Black		2 (5.4)
Asian		1 (2.7)
Hispanic		1 (2.7)
Profession
Advanced practice provider		5 (13.5)
Nurse		6 (16.2)
Physician		9 (24.3)
Psychologist		7 (18.9)
Social worker		10 (27.0)
Years in VHA practice
1–5		8 (21.6)
6–10		7 (18.9)
11–20		14 (37.8)
21–30		8 (21.6)
Primary practice location
Emergency department		2 (5.4)
Geriatrics clinic		5 (13.5)
Home-based primary care		14 (37.8)
Inpatient		2 (5.4)
Mental health		4 (10.8)
Nursing home		5 (13.5)
Outpatient primary care		5 (13.5)

Note: IQR = interquartile range; VHA = Veterans Health Administration.

Although we originally structured our interview guide to ask about specific facilitators and barriers across discrete stages in the EA care process (i.e., detection, reporting, intervention, and monitoring), we found that participants did not conceptualize their experiences this way. Instead, they described barriers and facilitators that were not specific to particular stages. We generated five main themes in our thematic analysis that applied to all disciplines and had salience to interactions between clinicians and stakeholders at multiple levels (patients/families, clinicians, the health system, and external agencies). Specifically, we found that (1) situational context, (2) degree of trust in relationships, (3) extent of education and skills, and (4) existing system infrastructure interrelate and contribute to (5) patients’ and clinicians’ sense of empowerment and motivation toward action (Figure 1).

Figure 1.

Themes elicited from multidisciplinary healthcare clinicians on addressing elder abuse in the healthcare system. APS = adult protective services.

Theme 1: Situational Context

Circumstances surrounding an EA situation could make addressing concerns easier (e.g., presence of financial resources) or harder (e.g., cognitive impairment). These contextual factors were often nonmodifiable.

Cognitive impairment

Cognitive impairment in either the patient or the caregiver posed numerous challenges to accurately assessing whether EA was occurring (Table 2). One social worker reported, “Folks with cognitive impairment have difficulty explaining, perhaps, what has happened to them… They might have a distorted perception of what is going on.” Another social worker indicated how this uncertainty can create moral distress for clinicians:

Table 2.

Themes on Situational Context and Trusting Relationships With Exemplar Quotes

Theme	Subthemes	Example quotes
Situational context	Cognitive impairment	I think one of the challenges is… the reliability of the report of the Veteran. For example, if the Veteran does have some degree of cognitive impairment, either in executive impairment or memory impairment, trying to get just accurate information about what’s going on in the household is a challenge. [psychologist #4]
	Availability of complete and reliable information	And then if it’s a primary caregiver that is responsible for the abuse that’s really tricky also because you might run into that caregiver sort of trying to run interference, giving you bad information. So, it’s just actually finding accurate information can be tricky. [psychologist #5] So, sometimes we have to kind of use our clinical decision-making and rely on the interdisciplinary team to put a bunch of pieces together to try to parse out whether it’s actually something reportable. [psychologist #3]
	Differences in perception of patient experience as abusive	I wouldn’t say most people really understand and even realize that they are abused. Sometimes they, I guess, they just don’t know any better. They’ve been in a relationship for 50 years. To us it’s abuse but to them it’s just the norm. [social worker #1] You find that the family member doesn’t really understand what’s going on with their loved one, and they say all this is just the way they always lived. No, this isn’t normal. [nurse #4] In part, it’s older people themselves not necessarily recognizing that something’s a problem. When it happens to them just figure, “Okay, I guess this is just how it is.” And so they sometimes don’t even recognize that that’s something that they can be helped with, that shouldn’t be happening. [psychologist #6]
	Patient and family resources	A number of cases that have really, really needed guardianship and the person had no funds and, or minimal funds, and no family that could step up or nobody that wanted to step up and actually be the guardian. [social worker #6]
Trusting relationships	Patient and family relationship with clinician	I think I’m pretty lucky in that, within my program, within my job title, that I’m able to create a little bit more in depth relationship with these Veterans to make it to where we build trust, we build rapport, so they’re able to come to us if they have concerns. Or, we get to know them well enough to be able to read the signs when things are not going the way that they should be. [nurse #5] So that is definitely something to think about because it’s not only just the patient but also, in the setting that I work in, often times you’re dealing with families, as well. So, sometimes you’ll worry about fracturing a relationship, if you have a good rapport with a Veteran and their family, fracturing that relationship. [APP #2]
	Patient relationship with family or caregiver	Also, intervention with family members, getting them involved in the case if they haven’t been involved in the case, so that they’re aware of what’s going on, having a family meeting to make sure everybody’s on the same page… if they recognize that this is not a good situation that they’re in; if family members are willing to become guardians and take over the financial management, that makes it a lot easier, it’s a dream, in fact. [social worker #6]
	Clinician relationship with external agencies	So, we do report to the Adult Protective Services when we’re concerned. However, we also know the caveats of reporting to Adult Protective Services. And, one of the caveats is that we never find out what happened. And so, sometimes we will follow-up with the patient and we don’t know, did they actually contact them? Who did they speak to? Is there something more we should have told them, that might have made this more compelling? [physician #3] We’re working closely with the Department of Aging, where having some sort of rapport with them would be more helpful, and maybe looking at how they’re doing their testing versus how we do ours, to compare, so we’re all on the same page, because it doesn’t seem like we are in a lot of instances. The findings are just so different. [nurse #1] I think active outreach to the local reporting agency can be helpful, on behalf of the facility or the department or something but just so that there is an open door and that people know each other, I think can be really helpful because APS is a part of our care team, even though they don’t work for the VA. [psychologist #6]

When they don’t have decision making capacity it’s really a clinician’s judgement call as to whether or not it’s abuse. So, if you’re wrong, you’re making pretty strong allegations against someone.

Although most identified impaired decisional capacity as a challenge to identifying EA, one physician expressed that this could sometimes make intervening feel less complicated: “If someone doesn’t have capacity I think it’s easier to swoop in and get someone else to manage the finances.”

Availability of complete and reliable information

Understanding complex EA situations often required triangulating information from multiple different sources. In clinical encounters, access to high-quality, reliable information can be limited, particularly during brief, hospital- or clinic-based encounters. One physician remarked, “You might have suspicions, but then you never really get any better information.” This can make it challenging to determine whether “something has really met that threshold” for EA, forcing greater reliance on clinical judgment. In situations where self-neglect is suspected, the absence of a “reliable collateral source” of information was a commonly cited problem.

Differences in perception of patient experience as abusive

Participants described the subjectivity of what patients and family members might consider abusive behavior and how the perception of an EA situation may be heavily influenced by past experiences and “long-established norms within the family.” One physician remarked:

The patient may not recognize it as being abusive because they’ve been experiencing this for a long time or the fact that their family’s being what I consider verbally abusive, maybe the patient thinks is normal.

Patients and clinicians often disagreed on the need for intervention, stemming largely from differing perceptions on what constitutes abuse, neglect, or exploitation. Such differences can lead to situations where clinicians feel conflicted over whether and how to intervene when the patient does not agree that there is a problem, particularly given an increased emphasis on patient-centered care in recent years. One nurse stated, “… they’ve been married for 40 years… it sounds like they’ve never had a fairy tale marriage. So who are we to say this isn’t what the Veteran wants or what should happen?”

Patient and family resources

Services that could help prevent or address EA, such as private pay home health aides or legal services, were seen as “super expensive,” making patient financial resources an important factor conditioning intervention. One social worker noted, “if they’re willing to pay or if they have money, we can get all kinds of things, if they can afford it.” Sometimes, financial strain was also seen as the root cause of the problem, with one psychologist stating, “Sometimes neglect is happening just out of financial necessity.”

Theme 2: Trusting and Functional Relationships

Participants highlighted the importance of trust and good communication between multiple different stakeholders when addressing EA in the healthcare system (Table 2).

Patient and family relationships with clinicians

Trust in the patient–clinician relationship was seen as critical for enabling patients to share sensitive information and accept help. One nurse noted that a “good rapport” with a patient was more valuable than screening questions for identifying EA because it allowed patients, “to feel comfortable enough with me to tell me what’s going on.” Conversely, clinicians’ close relationships with patients and families could act as a double-edged sword, making them reluctant to act on EA concerns due to fears of disrupting those ties. Another nurse noted, “If you’re accusing their caregiver… you’ve now jeopardized that relationship and that trust.” This left numerous participants feeling like the “bad guy” when reporting EA. Delegating the work of EA reporting to a team member without a close relationship with the patient was seen as one way to protect close therapeutic bonds with primary providers:

I don’t mind that I have to be the bad guy who makes the report… I think it’s great that there’s a psychologist that can swoop in, assess the situation, make the report and still preserve the patient’s rapport with the medical team. [psychologist]

Patient relationship with family or caregiver

Although getting a supportive family member, friend, or caregiver involved was cited as a key strategy for intervening in EA, close relationships could also be the source of harm. Fear of disrupting close relationships, especially those from which the Veteran was deriving some benefit, could make clinicians nervous about intervening.

We had a Vet that we suspected the daughter… was pretty much cleaning him out as far as his finances. But she was also taking care of him as far as managing his medications for him… so when the investigation came about she left and completely distanced herself from the Vet. He didn’t recover the money, and he lost contact with the rest of his family. [psychologist]

Intervening could be seen as especially risky in situations where patients were already socially isolated with few options for alternate caregivers.

Clinician relationship with external agencies

Working closely with external agencies, such as adult protective services (APS), to respond to EA was seen as important by clinicians because, “we all have a common goal in mind.” Although some participants felt they had good working relationships with APS, most noted challenges with coordination and communication. Some challenges were seen as structural, with different agency rules and practices leading to “fractionated” communication, and to what one participant described as a “black hole” where after reporting to APS “things fall apart.” Participants also perceived differences in evaluation findings between APS workers and VA staff as well as misconceptions about VA’s role in intervention. This issue frequently came up in the context of decision-making capacity assessments and guardianship:

APS can initiate the guardianship procedure through the [state] attorney general but they don’t believe that the VA should go through that system, that the VA is a federal system, and that the federal system should take care of guardianship, and our attorneys do not do that. [social worker]

Participants noted that poor communication with and between external agencies could lead to poor coordination of services and mistrust between agencies:

They may be making progress in their way but we don’t know that… our brains are really good at making up the hypothesis for why. And that hypothesis is usually, they’re not doing their jobs. [physician]

Fragmented communication was seen as a systems-level problem to which participants responded by cultivating one-on-one relationships with colleagues at other agencies.

Theme 3: System Infrastructure

Program structure, policies, resources, and technology were seen to influence EA response both within and outside the health system (Table 3).

Table 3.

Themes on System Infrastructure and Education/Skill Development With Exemplar Quotes

Theme	Subthemes	Example quotes
System infrastructure	VHA health team and care delivery structure	I think, in my case, the fact that we have multiple team members that interview the patient makes it simpler, because it’s not just my 30 or 60 minute visit, it’s many other people, who may get different clues and hear different things. So, sometimes patients may be more willing to speak with the social worker about details, or even the speech therapist or the physical therapist may pick up different bits of it. And so, I think we get a little bit more of a 360 view of the patient. [physician #3] I’m on a team that goes into peoples’ homes, so it’s a little bit more personal than someone coming into an office for half an hour, so you’re able to spend some time sort of looking around their environment, maybe asking questions based on things you see in their environment. Where, if somebody comes into the office you don’t know that they have no food or you don’t know that they’re, they don’t have running water. [APP #2] I feel like out of any healthcare organization, just the number of social workers we have and their skill set and their accessibility is tremendous. [physician #9]
	Healthcare technology, policy and systems support	You know, it might be helpful, and I’m not sure if they already do this, especially among social work, that once there’s a concern, that it’s flagged somewhere so their primary care PACT team is aware and that they’re monitoring it, too. I mean, I don’t know if there’s a central spot where that is put into the chart. It would be good to have, though. [physician #3] So, there’s just not a good system in place, this is definitely a systems problem, where ideally, it would be step-wise, you’d identify the problem. There’d be some check marks in a form, and then there would just be steps and people… [physician #7]
	Supportive resources and services (both VA and non-VA funded)	And then I think the other thing is just, even though the VA offers resources, the Department of Aging offers resources, I just, it doesn’t feel like it’s enough. And I feel like I’ve been a provider, and I know frequently other members of our team feel this way, too, we sort of feel like the burden of it all is put on us. Sometimes the families will sort of say, “Well, why can’t the VA do more?” [physician #1] [I’m] very mindful about like not overusing Adult Protective Services when I’m aware of what their budget is, and trying not to make big asks of them and being mindful of how like we can use, like what can I do here at the VA that would help with the Veteran’s care and aid an APS investigation, without tapping into like the precious resources for all the vulnerable Veterans and non-Veterans APS takes care of. [psychologist #3]
	APS system for reporting and response	But they’re just, it’s just not a good system, again, a systems problem where APS doesn’t have authority to really pursue very much. So, especially when the family’s the problem. If the family says, “No, everything’s good.” Then the APS worker lets it drop. [physician #7] They often lack the authority to take any action at all unless the victim wants the action to be taken and can cooperate with the problem, process. If the victim becomes incapacitated APS kind of hits a stone wall and then they’re unable to do anything. [social worker #9]
Education and skill development	Clinician training and education	So, just kind of a refresher for the team may make us aware, “Hey, 20% of Veterans,” I don’t even know what the, I’m just throwing a number out there. “Hey, this is how prevalent it is. This is what we do for screening, but these are all the resources.” Just make sure everyone’s on the same page, ‘cause we just don’t talk about it, that stuff formally. [physician #2] Additional training on how to identify elder abuse. A lot of people in the VA who care for elders are not in geriatric clinics, and so, having primary care providers be more aware of the existence of elder abuse and signs of elder abuse I think would be beneficial. [APP #3]
	Clinician experience	[The most helpful thing] is clinical experience on my end. It’s kind of one of those things where the more you start to pick up on the red flags of a clinical situation, you’re more inclined to cue, maybe say something about it and have more confidence about saying something about it. [physician #5]
	Professional responsibility and role delineation	It’s more important that they’re safe and I’ve done everything possible within my clinical position to ensure that, help that, follow policy, than it is whether I’m uncomfortable seeing them because they’re going to be upset with me. It doesn’t, that doesn’t matter. What matters more is their safety and their wellbeing. [social worker #3] I had a Veteran who reported to a nurse that his family was stealing his social security checks. So, they don’t ask any questions. Like they don’t, the nursing staff doesn’t do a detailed interview. They will just say, “We’ll call in social work.” [social worker #4]
	Patient and family education	I’ve had a couple of family members who have locked their person in their bedroom with a padlock. And, I’ve done education around the fact that that’s called imprisonment and it is a crime and they had no idea. They were just trying to do what they could do, and so educating them about that and maybe doing behavior interventions to talk about what their choices are to manage that kind of behavior at home, what they can do safely, getting the family member educated about, these are dementia behaviors and these behaviors are not volitional and this patient can’t help it. [social worker #6] The most positive outcomes are the caregivers who—, if the patient has dementia and the caregiver really doesn’t understand what’s it’s all about and you educate them and you work with them to help them to understand. And then they can look at their loved one in a whole new light… [nurse #4]

Health team and care delivery structure

Clinicians from all disciplines acknowledged numerous features of clinical programs and structure that enhanced EA response efforts. Many participants reported that working in a well-integrated interprofessional team was “the most helpful thing” for addressing EA. One psychologist elaborated:

The most effective catches I’ve made have been in the context of working with an interdisciplinary team, where we’ve got multiple people with multiple professional perspectives and credentials, laying eyes on the patient, working collaboratively on a coordinated care plan.

Participants acknowledged that each member of the team not only has different training and expertise but also a different relationship with the patient that might encourage disclosure. One physician stated, “A patient may tell me something that they’d never have told their nurse.” The ability to go into people’s homes was also seen as a valuable feature of care delivery that significantly aided EA assessment. Another physician explained, “Without being in the home, I’m just not sure it’s possible.” Having access to a patient’s home environment was frequently cited as the reason an EA situation was identified, with one physician stating, “If I had been seeing this patient in the clinic, you would never have known that any of this was going on.” Adequate time to do these kinds of thorough assessments was also seen as a “huge obstacle.” Finally, many participants acknowledged the crucial role of having highly skilled social workers integrated into the care team and available for involvement in EA response. One physician remarked that responding to EA, “is complicated, and really completely relies on the energy and expertise of the social worker.”

Healthcare technology, policy, and systems support

Clinicians identified a lack of an integrated clinical workflow to screen, report, and intervene in cases of EA within VHA. Multiple participants indicated that having access to high-quality, evidence-based screening tools would be valuable. Once concerns are identified, participants described that there was no standardized way to document the concern in the electronic health record (EHR), nor to indicate if a report to APS had been made. Following identification and documentation of EA concerns, clinicians desired more embedded protocols and procedures for how to respond. One suggested an “internal report” alerting someone within VHA to do further assessment and follow-up could be an important adjunct to APS, and the idea of a site-based “elder abuse coordinator” or champion was raised by many. Participants felt there were precedents for similar response protocols in VHA with a psychologist stating, “We’re more aware of the algorithms if someone is psychiatrically unstable or suicidal in the clinic but then the elder abuse thing sort of flies under the radar.” Participants acknowledged the challenges of generating detailed policies and practices that would apply to a national system given the variability in state laws governing EA, but appreciated that VHA has high-level national policy regarding abuse and neglect reporting (VHA Directive 1199: Reporting Cases of Abuse and Neglect, 2024). One social worker even acknowledged it was helpful to be able to “hide behind the VA policy” when justifying to a Veteran the need to report, explaining to them, “it’s part of my job and the VA requires it.”

Supportive resources and services

Access to supportive services, such as home health aides and caregiver support, was seen as crucial for intervening in EA cases, but limited capacity of formal programs led to restrictive eligibility criteria. Participants noted that some VHA programs were reserved for, “the worst, most difficult cases, that people who are basically bed bound,” potentially missing opportunities to prevent harm before crisis hits. Despite resource limitations, the breadth of services offered by the VA, such as respite care and the Caregiver Support Program (a national VA program providing resources, supports, and services to caregivers of Veterans), was seen as a major strength compared to other health systems and, when available, gave clinicians a sense of agency to do something for their patients rather than just, “kicking it out to APS and hoping for the best.”

APS system for reporting and response

The challenges in forming trusting relationships with APS described in theme 2 were partially rooted in structures dictating the APS system. Although respondents found the APS technical system for making reports easy to use, several stated that inadequate APS staffing created a barrier to making warm handoffs. One APP stated, “On each occasion that I have called Adult Protective Services, I have never been able to physically talk to a person.” Clinicians also felt that APS privacy rules stymied its ability to provide feedback to reporters on case findings and outcomes, even if APS workers wanted to. Finally, participants acknowledged that APS’ prioritization of autonomy often led to a system where they could do little to intervene unless the patient was willing to engage.

Theme 4: Education and Skill Development

Participants cited a critical need for educating clinicians, patients, and families about EA (Table 3).

Clinician training and education

Several needs for clinician education were identified, particularly for clinicians who do not typically learn about EA during their professional training. One social worker remarked, “I don’t think it should just stop at social work. I think it should be to all disciplines to recognize abuse.” Universal education was seen as particularly important given the aging of the patient population and limited access to clinicians with geriatrics expertise. Nonphysician participants noted that physicians in particular were often unaware of their responsibility to report EA to APS and would benefit from more training in this area. Better training was also seen as important for frontline team members who may be most likely to pick up on EA concerns:

… doing a little bit of extra training with the people who are more front line with these Veterans… but have the closest relationship with the Veterans, I would focus much more heavily on CNA’s [Certified Nurses Assistants] than I would on anybody else. [APP]

Clinician experience

On-the-job experience with EA cases helped to build confidence and comfort in addressing this complex problem. For some, experience came as a result of their discipline. For example, one social worker stated, “As social workers, I think that we’re used to addressing uncomfortable things, it’s easier for us… that’s something just in our practice.” Having experience with EA led to greater familiarity with the reporting process and confidence with how to follow-up. Without experience, participants felt that clinicians were more likely to ignore warning signs due to not knowing what to do if they identified a problem. Training was seen as both complementary to and synergistic with experience, with training guiding and empowering clinicians to identify and act in cases of suspected EA, thereby contributing to their real-world experience addressing EA.

Professional responsibility and role delineation

The likelihood of responding to EA concerns was seen to reflect participants’ sense of their professional responsibility or “duty” to do so. Although, according to VHA policy, all VHA staff engaged in patient care are required to report EA, participants did not think that all disciplines equally shared this sense of professional responsibility. Social workers in particular felt that other professions saw EA response as the role of social work, often inappropriately delegating the work of reporting to them. One social worker expressed frustration with physicians in particular:

They seem to think social workers are the only ones that can report. And I’m a big believer in like, ‘Nope, nope, nope. This is now secondhand information. You’re a mandated reporter so you need to call APS.

Some physician interviewees confirmed this sentiment, with one explaining, “My focus and my time is directed towards their medical issues.”

Patient and family education

Participants identified patient and family education from the healthcare system as a potentially powerful tool for addressing and preventing EA, especially in cases where the Veteran had dementia. One psychologist stated, “Education can absolutely be helpful, especially if it’s education around dementia and dementia behaviors because we do see abuse in that context,” with a social worker elaborating that, “it’s really lack of education. Families don’t understand dementia. They don’t understand the patient’s needs.” Some participants observed that poor caregiver education around dementia was sometimes the primary driver of abusive or neglectful behavior. Participants noted how providing adequate caregiver education could help to alleviate caregiver stress and reduce potentially harmful behavior:

Because it very well may be that you could teach a caregiver something that would kind of change the whole way they’re doing something and free up some time and energy that they can give back to themselves. [nurse]

Participants also identified opportunities during healthcare encounters to educate older adults about common types of EA (e.g., scam calls) to empower them to protect themselves.

Theme 5: Empowerment and Activation

Multidisciplinary clinicians described varying levels of empowerment and activation for themselves and patients to address EA (Table 4). We found that the four previously described themes contributed to clinicians’ level of confidence in addressing EA, shaping their sense of empowerment and agency (Figure 1).

Table 4.

Theme on Empowerment and Activation With Exemplar Quotes

Subthemes	Example quotes
Patient reluctance to change	Also, I think patients are concerned because, if I point out that there’s abuse and we move forward with further steps, then maybe they’re living with this family or person, and where are they going to live next? They don’t necessarily want to move to a nursing home or another place. So, a lot of times they don’t want to make accusations, because they kind of see like, “what am I going to do anyway?” [physician #3] The majority of our group is in their own homes and that is where they want to stay and that’s where they want to die. And so if they are reporting any sort of abuse and neglect or anything like that then they know that if that person gets removed that’s it, and they have to move. [social worker #10] They don’t know what’s going to happen. They don’t know if they’re going to lose their place to live or that their loved one might be punished in some way and they love them, they don’t want them to be. [social worker #6]
Clinician lack of faith in the system	I do understand that there are some barriers, but sometimes I want to be like, “Well, why did we even call you [APS]?” It didn’t really do anything; it didn’t help the situation. [social worker #8] And I understand that, I mean it’s de-institutionalization, and we can’t force people to live where they don’t want to live but it’s frustrating definitely, when you know it’s a dangerous situation and there’s nothing you can do about it. [social worker #10]
Weighing the potential risks and harms of intervening	I worry that if, if it’s taken the wrong way by the caregiver that we might get pushed out of the home. And then, if APS says nothing is wrong, we may get pushed out of the way, out of the home, and then I worry if there’s any kind of safety net for the Veteran after that. [nurse #2] I do have concerns about that, especially when my focus includes practices to build trust and rapport. I don’t like the idea of going behind someone’s back and disrupting their life. But ultimately, it always comes down to what’s the best thing for the patient in the long term and keeping them safe. And unfortunately, I would prioritize their, a patient’s well-being over our personal relationship, if we need to change providers in order to accommodate their well-being in the future, I’m willing to do that. [APP #3]

Patient reluctance to change

One of the biggest challenges that clinicians expressed when attempting to address EA related to patients’ concerns about intervention. Participants attributed this reluctance primarily to older adults’ desire to preserve relationships and to stay in their own homes. One physician described, “They’re worried about getting another person in trouble, particularly if it is a family member or someone that truly is a trusted person to them,” with a social worker explaining, “… even though they’re being abused, they love the abuser. They don’t want that relationship to end.” The desire to preserve relationships may be particularly strong when it allows patients to stay in their own homes, with one social worker stating, “we had quite a few that would put up with a lot of crap at home because they don’t want to go to a nursing home.” Clinicians expressed moral distress in negotiating the tension between their duty to report and the patient’s wishes to preserve the status quo. A physician also noted that their intervention may be limited by the patient’s willingness: “A lot of it just depends on the cooperation and willingness of the patients to receive the care that is offered,” and, “If the Veteran declines, we’re done.”

Clinician lack of faith in the system

Clinicians varied in the extent to which they felt that healthcare teams and systems were responsible for initiating EA interventions, with some feeling strong professional responsibility and others preferring to delegate responsibility to APS alone. For those who felt like healthcare teams had an important role to play, there was disappointment at a lack of options for intervening before things got “really bad” for patients, with one physician stating, “I’d say the negative experience is just knowing that things are going on and there’s nothing more you can do, on the VA side.” Disappointment with the APS system was nearly universal, with few feeling like reporting to APS resulted in meaningful improvements for patients. One social worker stated, “I guess that sometimes if we have a concern, in the back of my mind it’s like, what’s the point of calling APS? They’re not going to do anything anyway.” The sense that a report to APS was more an act of checking a required box rather than engaging a system that would actually lead to important changes for their patient made clinicians disinclined to report. This perceived ineffectiveness of APS led some to argue for more within healthcare system resources to address EA.

Weighing the potential risks and harms of intervening

Faced with limited system infrastructure (theme 3), inadequate training and education (theme 4), and situational factors (theme 1) that often felt outside their control, clinicians were left to weigh the potential benefits against real perceived harms when deciding on whether and when to intervene. Sometimes these concerns were so significant that they determined not to act. One psychologist described:

I guess, being a psychologist especially, that patient-provider rapport and bond is very important. And so, it can be kind of an ethical dilemma sometimes. Is it worth breaking that relationship to help?

Because participants had little faith in the formal reporting process, they expressed ambivalence about whether it was worth risking their relationships with patients (theme 2) to report, given the perceived benefits of maintaining the therapeutic bond. Participants also described concerns about straining their relationship with patients’ families and caregivers:

I guess there’s a lot of angst going in ahead of time, like, “Is this the right thing to do versus not?" If you have somewhat of a fragile situation and then you feel like you’re forced to call APS, I’m sure it erodes whatever trust that you have established with a caregiver. [nurse]

Discussion and Implications

In this study of multidisciplinary clinician perspectives on addressing EA in a large, integrated health system, we identified multiple potentially modifiable factors that can shape whether and how clinicians choose to intervene. This study is the first, to our knowledge, to explore the experiences of a wide range of different clinicians across the entirety of the process of addressing EA, from detection to intervention, within an integrated national healthcare system. Using insights gained from this analysis, we developed a novel conceptual model (Figure 1) that may be used to identify targets for interventions that could improve clinician engagement with addressing EA. The themes and subthemes encompassed in the model apply across healthcare disciplines involved in interdisciplinary EA intervention and highlight opportunities both within healthcare systems as well as between healthcare and other service systems for improving overall EA response.

The themes identified in this study present both challenges and opportunities and reflect the complexity of addressing EA. Although we initially conceptualized this study to ask about separate steps in an EA care “process,” we discovered in detailed interviews with study participants that this was not how they viewed their experiences. What might constitute a facilitator at one step in the process of addressing EA and in a given clinical context, could at other times function as a barrier to this process. For example, cognitive impairment made getting reliable information more difficult but for some it was seen to make intervention easier if the individual lacked the capacity to decline services. Close relationships with patients could enable trust and disclosure while at the same time making the clinician less likely to intervene out of fear of damaging that therapeutic relationship. Additionally, participants did not see their work in dealing with EA cases as being part of a sequential linear process. Rather, they described identifying EA risk and harm while concurrently balancing the need to report, ways to intervene, and how to keep track of patients during follow-up. These findings can inform how programs aiming to support healthcare clinicians in addressing EA may be structured to account for the overlapping nature of the phases of addressing EA.

Some of our findings align with the results of prior qualitative studies conducted in different settings. We found that cognitive impairment was an important nonmodifiable factor that frequently made dealing with EA more challenging for clinicians, which has been previously reported as a barrier to helping older adults who have experienced violence (Bows, 2018; Fraga Dominguez et al., 2020). In our study, cognitive impairment in caregivers and alleged harmers was additionally identified as a frequent challenge. Concerns held by older adults and caregivers about the consequences of EA disclosure, particularly fears of fracturing long-term relationships and losing their home, have been previously described (Choo et al., 2021). In our study, VHA clinicians shared this perception and also voiced their own concerns about the consequences of addressing EA, which mirrored those of patients and included impacting patients’ living situations and important relationships, including those with their healthcare team. In our study, education, training, and clinical experience were seen as factors that could empower clinicians to address EA harms while taking these concerns into consideration, but, as found in prior studies (Krueger & Patterson, 1997; Mercier et al., 2020; Schmeidel et al., 2012), many of the clinicians with whom we spoke felt like they lacked adequate training and experience, particularly those belonging to professions other than social work.

The experiences of social workers stood out as distinct from those of other healthcare disciplines. Social workers often had the most in-depth and nuanced experiences dealing with EA cases, likely because of their professional training and expertise in managing interpersonal and family conflict as well as VHA policy (VHA Directive 1199) that all mandatory reports for EA should also be referred to VHA social work. This was seen by social workers to lead to a kind of learned helplessness on the part of other disciplines, a lack of ownership over their role in response, and a frustration that other clinicians frequently delegated duties to social workers (e.g., reporting) inappropriately. This feeling mirrors participants’ sentiments that while the VA has more services to offer than many community organizations/agencies, such as APS, this can paradoxically lead outside agencies to be less active in managing EA for VA-enrolled Veterans, believing that the “VA will take care of that.” These findings highlight the way effectively leveraging available skills and resources, both within and between systems, can often be a challenge and the tendency for those who feel poorly equipped to deal with EA to avoid this responsibility. This supports our findings that improving education and skill development as well as improving system infrastructure present two promising opportunities for bolstering capacity to respond to EA within and across systems.

The findings from this study align with multiple conceptual models of EA risk and intervention. As proposed in the Abuse Intervention Model (Mosqueda et al., 2016), participants described themes that cut across the older adult, the alleged harmer, families, and situational context. Our findings add that EA intervention is also influenced by healthcare staff, including their prior experiences and training, their own fears of the consequences of intervening, and the relationships they hold with their patients. Our findings also align with the RISE model developed by Burnes et al. (2022) which describes intervening at the individual, relational, social, and environmental levels in EA cases. Although these models focus on individual case intervention, our study provides additional insights into promising healthcare system approaches to build capacity for intervention.

Many resources and services that already exist in the VA and other healthcare systems could be directed to address themes identified in this study. For example, to improve education of families and caregivers on EA, caregiver trainings, such as through the VA Caregiver Support Program or the Centers for Medicare & Medicaid Services (CMS) Guiding an Improved Dementia Experience (GUIDE) Model (CMS, 2023), could add relevant EA content. Improved professional training on EA focused on discipline-specific roles and responsibilities and multidisciplinary collaboration could be developed and deployed for the many different teams of clinicians, particularly nonsocial workers, across healthcare settings encountering EA on a regular basis. To support family relationships in the presence of mistreatment, VHA could draw from its experience implementing a national program for intimate partner violence. To enhance features of system infrastructure that were seen as particularly valuable, VHA could increase flexibility for more programs to conduct home visits, or utilize highly functioning teams, such as Home-Based Primary Care, to conduct time-limited evaluations and consultation for complex EA cases. Non-VHA healthcare systems can learn from what VHA clinicians indicate are particularly valuable elements of VHA care delivery for addressing EA and other complex social needs: highly interdisciplinary teams, integrated and well-supported social workers, and the ability to conduct home visits. Systems with an integrated EHR could implement an evidence-based EA screening tool and a standardized note template for documentation of EA reports to APS to increase systems and clinical workflow support, efforts of which some are underway in VHA (Makaroun et al., 2023).

Our findings should be interpreted in the context of study limitations. Participants were from only two sites, but we did not find major differences in perspectives between sites. Second, the experiences of those practicing in VHA are influenced by unique aspects of the VHA patient population and practice environment and thus might not be transferable to other systems. Third, this study did not elicit perspectives of patients, families, or APS workers; future qualitative research to understand facilitators and barriers to EA from the perspectives of older adults experiencing EA and their families and caregivers will also be important in identifying potentially fruitful interventions.

In conclusion, there are many unrealized opportunities to improve how EA is addressed within the healthcare system to reduce harm and improve well-being for older patients experiencing or at risk for EA. This study identified specific elements that could help empower clinicians to engage in action and supported the development of a model elaborating these themes that could guide practice, quality improvement, and future research in this area. By both leveraging existing resources and services to specifically address core modifiable elements in this model, and by creating new programs that address others, the capacity for healthcare system response to EA could be greatly strengthened.

Funding

This work was supported by a U.S. Department of Veterans Affairs (VA) Health Systems Research Career Development award [IK2HX003330 to L. K. Makaroun] and a VA Pittsburgh Geriatric Research, Education and Clinical Center Pilot award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Veterans Affairs. The sponsors had no role in the design, methods, data collection, analysis, or preparation of this paper.

Conflict of Interest

None.

Data Availability

This study was not preregistered. The data from this qualitative study are not available to outside researchers given IRB restrictions.