Overall, most participants were engaged and contributed to the discussion. Van assistants and van drivers described a variety of passenger behavioral expressions they believed interfered with safe transportation. Only one van driver joked while hearing stories shared in the focus group and said, “I guess I'm a drill sergeant. I don't have no problems. They love to see me. My clients love to see me. They love me.” Similarly, one van assistant expressed that she did not have behavioral expressions on the van, stating:
On our van we just listen to gospel [music] because they older and always, they grew up off of church music and they always listen to church music inside the center, so they keep them calm and they also sing along with the songs, so gospel is the key on our van and there is no problem...
One primary theme emerged for a common behavior on the van: Removing Seat Belts. The second theme addressed another common behavior, Verbal Behaviors (e.g., cursing at the van assistant or van driver), which could be distracting and lead to safety issues. Two additional themes emerged: Physical Aggression and Conflict Between Passengers. These behaviors were unusual and episodic, yet they left lasting impressions with van assistants and van drivers.
Removing Seat Belts. Passengers removing their seat belts while on the van occurred regularly. This behavior was most concerning when passengers got out of their seats while the van was in motion. One van assistant (#1) described the removal of seat belts as “the biggest problem” on the vans and a “safety hazard.” No matter how many times a passenger removed his/her seat belt, van assistants fastened it again or van drivers requested it be re-buckled while reiterating the importance of seat belts for the passenger's safety. A van driver (#4) stated “you always have one” who unbuckles the seat belt right away:
Within, let's say 30 seconds, they unbuckle the seat belt, ‘cause you can hear it click. “Can you please buckle the seat belt?” Within the next 15 to 20 seconds they do it again and this might go on from the house to the center. Then when they get to the center, now they want to buckle.
Although a van assistant (#1) and van driver (#5) acknowledged that some passengers did not like being “strapped in,” other participants reiterated that it is not safe for passengers to have their seat belts unbuckled. A van driver (#5) shared that it is “kind of scary” when passengers gets out of their seats when the van is in motion stating, “You can only do so much as a driver while you're maintaining your eyes on the road,” while the van assistant is paying attention and can redirect the person back to his/her seat. This van driver shared a situation where he was driving and an older adult removed her seat belt and then walked up to the front of the van surprising him. She was standing next to him looking out the front window telling him it was her stop, which it was not her stop.
Participants also described instances where some passengers with dementia would take their seat belts off when arriving at another passenger's home thinking it was their stop and would attempt to get off the van. This action, in turn, required redirection by van assistants or van drivers to keep the passenger on the van until it was his/her actual stop. Examples of redirection given included sitting next to restless passengers; providing redirection through conversations and questions, such as “What are you going to do when you go home?”; and reconnecting seat belts while explaining safety. One van assistant (#5) provided an exemplar, stating:
I have one that comes out of her belt all day long and she plays like, “That ain't me, that's him, that's him,” but she's holding the seat belt together but it's not locked and stuff, so I redirect that conversation with her, so I'm trying to redirect her to stay in her seat, so some days it's hectic.
Verbal Behaviors. Another common behavior described was verbal behaviors from passengers directed at van assistants and van drivers. These behaviors included passengers insulting, snapping at, and most commonly, cursing at the worker. Verbal behaviors from passengers were conveyed as a routine behavior, particularly if passengers believed they were not having a good van experience or were not in a good mood. Multiple examples were given of passengers cursing at van drivers and name-calling for reasons such as what radio station was playing on the van, not getting the passenger to the center on time for breakfast, the van was making too many stops, or the van driver took a wrong turn. One van driver (#8) said, “I have a client that cuss me out every morning…I know he's gonna cuss you out” and further explained that the passenger will also curse at the van assistant if he is not able to get on the first van trip home and must wait for the second trip.
One van assistant (#13) recognized that if a passenger is in pain and not happy about something “they cuss you out…and say nasty things to you.” She expressed that no matter how nice she was, members still might snap at her. Another van assistant (#5) conveyed:
And then we have some who um…is a little more demented than others, when you talk, they think everything you're saying you're talking directly to them or it's directed at them, no matter what you say, and they just take offense to it and then it's just…they blow up and you can't stop them. Like you just have to walk away.
The same van assistant (#5) described using redirection as an intervention when passengers were being disrespectful:
There's a lot of things we have to put up with on being disrespected by the passengers. We still have to put up with that, have to redirect our conversation, um…you know, watch what we say, try not to agitate them more.
One van assistant (#16) described a passenger who was crying all the time when she first started coming to the PACE center. The van assistant was able to provide one-on-one attention to this passenger and described her interaction with her:
…me picking her up in the morning, talking to her, having a lot of communication, showing her the attitude, like I care about you, I want you to be okay, I don't want you to be crying…. Her attitude every day was changing, she was eating at her house, laughing, dancing, like personal attitude was changing....
Physical Aggression. Although not mentioned as frequently, the third theme focused on the behavioral expression of rare episodic physical aggression toward van employees. Some passengers attempted or actually scratched, bit, punched, or hit van assistants and/or van drivers with their hands or assistive devices, such as canes or walkers, which were referred to as weapons in this context. Physical aggression primarily occurred while older adults were getting off and on the van. Van assistants and van drivers described being worried about their physical safety when passengers became physically aggressive.
Van assistants and van drivers spoke about times they were hit or punched, and they were able to identify the trigger either before or after the incident. One example was picking up a passenger at her home and learning from her daughter that she had a “bad weekend.” The van assistant (#7) stated, “When she got on the van, she started punching on the driver, hitting on the driver.” Another van driver (#7) related that when he reached out to stop a passenger from falling, she started hitting his arm and yelling “don't touch me” and identified the trigger of her behavior being her fingernail falling off. Van drivers also described other passengers who would hit and grab them when they “didn't expect it.”
Van assistants provided two examples in which they were concerned about their personal safety because of passengers' actions. In the first example, a van assistant (#5) recalled a time a male passenger was “shouting all in my face” and “threatening” her because she asked him to sit in a seat near the front of the van (because he was going to be dropped off first) and he wanted to sit in the back of the van. The passenger “blasted” the van assistant and got into a stance to lift the van assistant off her feet and throw her. The van driver heard the van assistant screaming and ran on to the van to get the older adult off the van and into the PACE center. In the second example, a van assistant (#8) described witnessing a passenger physically threatening a van driver:
He was upset because he felt as though another older adult was sitting in his seat. And the driver explained to him that there's no assigned seats. He was at him [physically threatening].... Having to talk him down from that was an experience, you know try to explain to him you…really don't want to hurt anybody and you're scaring the ladies that's on the van. It was something else. I mean he finally calmed down, but that reminded me how serious they are about those seats on the van.
Approaches that van assistants and van drivers have taken when working with passengers who were physically aggressive included trying to calm the passenger and making “light” of the situation with redirection and joking. Van assistants and van drivers also reported these incidents to the PACE center nurse practitioners (NPs), which resulted in NP consultations, medication changes, staff in-services, and, depending on the situation, suspension from van services. Van assistants and van drivers believed follow up from the NPs was sometimes helpful in reducing the behavior. One van assistant (#13) felt supported by the PACE center's behavioral health team:
We have a good behavioral health system here because we have people having a situation or they agitated and everything and we take them there…. And also, we have in-services that they help us with, with the people that are problematic and so that helps us a lot. I am noticing now that we have a lot of members now that are coming in here with a lot of psych issues and they [NPs in the behavioral health department] are addressing it more and more, so that helps us how to handle that.
There have also been cases where van assistants and van drivers had talked to the PACE administrator to request and subsequently been granted that the passenger be removed from their van, at least temporarily, due to concerns about safety.
Conflict Between Passengers. The final theme was conflict between passengers. Van assistants and van drivers discussed conflicts they observed among passengers on the vans, which were primarily verbal behaviors, although in some cases escalated to physical behaviors. Examples given were passengers insulting, cursing at, and threatening each other. In some instances, the conflict involved arguments over what radio station to listen to during the van ride. Many times seating arrangements provoked the conflict. Van assistants and van drivers described that there were no assigned seats on the vans because of variability with pick-up and drop-off schedules. Despite explaining this to passengers, some wanted to sit in the same seat all the time or did not want certain (or any) older adults sitting next to them. One example given by a van driver (#6) was: “She thinks she owns the seat wherever she sits. So, if someone sits beside her, now she wants to try to throw hands and thinks she can bully this person off of the van.”
Physical aggression among passengers was not “common place” (van driver #10) but did occur. One van driver (#10) shared a story of two older adults physically fighting, which was the first time he witnessed an incident like this in 3 years of working on the vans:
There's two passengers that we had to separate ‘cause they were fighting. Uh…I just think that they don't like each other and so when they would get on the van, if one person's jacket hit the other person on the head when they were sitting there, they'd argue. It would escalate…but I mean it's just no different than any other mode of transportation where we got a bunch of people. Sometimes…you know, sometimes people are irritable.
In addition, one van assistant (#9) described how passengers were anxious to get off the van when they arrived at the center, stating “they be trying to fight on the van to get off. One woman will bum rush other older adults to get off, pushing them with her walker so she can be the first person off the van.” When conflicts did escalate, administration was made aware.
Participants mentioned that they work to calm passengers, particularly if they were anxious and it was influencing other older adults. One van assistant (#5) described it as:
A lot of people with the dementia [when disturbing others on the van], they don't hear you when you're talking, so I normally go to them, touch them and let know, or let them see my face, or whisper in their ear and most of the time they… you know, they calm down…can be redirected or even I just strike up another conversation.