In this blog I’m talking about Sarah Hillcoat-Nallétamby’s paper ‘Pathways to choice’ of care setting. The paper is about older people’s involvement in decisions to move to an extra-care housing scheme. Extra-care housing combines accommodation where people can live independently with on-site personal care and domestic support. There can also be communal spaces and activities. Extra-care facilities are so diverse that it’s hard to put a figure on how many there are; the best I could find is the Housing LIN (Learning and Improvement Network), which cites the Elderly Accommodation Counsel figure of 49,000 units of extra-care housing in the UK in 2014. There’s evidence that the comfort and privacy of extra-care settings is preferable to that of care homes (Moriarty, 2015).
Hillcoat-Nallétamby’s paper encourages readers to reflect on the limitations of the core assumptions of rational choice theory in explaining older people’s decision-making about health or social care. All theories are simplifications of reality and rational choice theory is no exception. It is about understanding the economy through understanding the actions of a single, rational person, and then assuming everyone acts in that way. Rational choice theory assumes that individuals are self-interested, know what they want (and are consistent in these preferences), and have the information at hand to make optimal choices.
For the purposes of her paper, Hillcoat-Nallétamby is interested in the actions of individuals, not the economy. She questions whether older people do act as rational consumers, with consistent preferences, who are able to exercise choice over the care and support they need.
Hillcoat-Nallétamby does this by analysing interviews with 29 older people who were participants in a larger study (see Burholt et al., 2011). They all lived in Wales, had been assessed as eligible for social care and chose to relocate to an extra-care facility in preference to receiving home care or moving to a care home. Their mean age was 82. Seventy nine per cent were female and 83 per cent lived alone.
Topics covered in the interviews included experiences and perceptions about health care; social activities, support networks, frailty and disability and motives, triggers and choices for moving.
Interview transcripts were analysed with a particular focus on engagement and temporality. Engagement explored the role of others in shaping a person’s decision-making and, drawing on work by Reed et al. (2003), how much people’s moves to extra-care facilities were their own preference, and how much they were strategic, reluctant or passive moves led by someone else. Temporality considered the timing and sequence of events, and, using pro-active coping theory (Aspinwall and Taylor, 1997), considered if, and how, people took actions to avoid or lessen elements of the decision they anticipated might be stressful.
As a result of this analysis, each participant’s decision-making story was mapped to one of six ‘pathways to choice’. These pathways built on the analytical and interpretive frameworks developed from theory and illustrate the complex interplay between engagement and temporality:
- The degree of engagement with decision-making. Some people made choices on their own or in combination with their spouses, with no external help (‘deliberate own’); others (either as individuals or couples) led the process but had help from other people, which was welcomed and empowering (‘deliberate assisted’). A third group were helped by others but in a disempowering way, which resulted in the older person taking a passive role in the process (‘passive delegated’).
- The influence of time, which manifested in two ways:
- First, a minority of people made choices quickly in response to one-off events such as a sudden change in health (‘non-cumulative’). Most made choices over a longer time period in response to a sequence of events (‘cumulative’).
- Second, people coped with potentially stressful changes in life circumstances by responding in different ways. Most were ‘reactive’, following an event or sequence of events. A second group were ‘pro-active’ and a handful coped by being ‘passive’.
The paper concludes that the process older people follow in making choices about care options is complex and diverse, more so than recognised by a rational choice perspective. I entirely agree with this and I am not surprised.
For me, other key conclusions are that: (1) it’s important to recognise that sometimes people choose to take on board others’ views and feel empowered by them, but these views can be overpowering, resulting in people backing off and letting others take control; and (2) trigger events can prompt positive or negative responses.
Strengths and limitations
One of the strengths of this paper is that it gives a full and detailed description of a number of theories relevant to decision-making and choices. It also brings together the concepts of engagement, temporality and coping strategies to shed light on real life experiences of making decisions about moving to extra-care settings. The findings are presented as stories, which give detailed illustrations of older people’s decision-making journeys.
The analysis used theory to develop a framework focusing on engagement and temporality. This framework was then tested in the context of older people making decisions about moving to extra-care facilities. Six different choice pathways were identified from the interview data. This is not an exhaustive list of all possible pathways using this framework. The important issue is not that there are six pathways but that engagement, timing and coping strategies interact and are different for different people in different circumstances.
I had some trouble with understanding the differences between participants’ reactive and pro-active coping responses but that’s probably a weakness on my part, not of the paper. Both were described as occurring in response to events. After a bit of reading around, I came to the conclusion that pro-active responses to events were ‘pull factors’, driven by an individual’s positive desire to act, whereas reactive responses were ‘push factors’ following events that left people feeling they had no choice but to act (Kaplan et al., 2015). These are important differences to understand.
Implications for practice
The paper suggests three very sensible practice implications.
This first concerns life events that trigger decisions about the appropriateness of current living circumstances, such as bereavement, falls and hospitalisation. If these events were systematically flagged, the author suggests they could act as pointers for targeted information or advice. It’s worth noting that these examples can all be ‘push factors’ that risk making people feel they are not in control.
The second suggestion from the author is that networks of people who help shape an older person’s choices should be mapped. She suggests this could take place when drafting a care and support plan. I think it probably already happens. We should remember though that not all older people considering their housing needs have care and support plans, or discuss these needs with a professional. Self-funders, for example, are a group who generally are left to navigate the system and make decisions without professional support, so who could help map their networks? Equally important, as Hillcoat-Nallétamby’s paper shows, older people may not want everyone in their networks to help with shaping their choices.
Finally, where people are very attached to their homes, and that attachment dominates all decisions, the author suggests extra-care providers open their doors and enable people to see the reality of extra-care and learn from current residents. This is a good example of a ‘pull factor’. This sharing of peer experiences may be the extra piece of information people need to make, dare I say it, a more rational choice.
Conflicts of Interest
Hillcoat-Nallétamby, Sarah. (2019). ‘Pathways to choice’ of care setting. Ageing and Society, 39; 2: 277-306. doi:10.1017/S0144686X17000940
Aspinwall, L. G. and Taylor, S. E. 1997. A stitch in time: self-regulation and proactive coping. Psychological Bulletin, 121, 3, 417–36.
Burholt, V., Nash, P., Doheny, S., Dobbs, C., Phillips, C., Phillips, J., Marston, H., Hillcoat-Nallétamby, S., Evans, S. and O’Mahoney, S. 2011. Extracare: Meeting the Needs of Fit or Frail Older People? Centre for Innovative Ageing, Swansea University, Swansea, UK.
Housing LIN [online]. Accessed 11/06/2019. https://www.housinglin.org.uk.
Kaplan DB, Andersen TC, Lehning AJ, & Perry TE (2015). Aging in Place vs. Relocation for Older Adults with Neurocognitive Disorder: Applications of Wiseman’s Behavioral Model. Journal of gerontological social work, 58(5), 521–538.
Moriarty J. Social Care Elf [online]. Published 13 January 2015. Extra care housing vs nursing homes for disabled older people.
Reed J, Cook G, Sullivan A and Burridge C (2003). Making a move: care-home residents’ experiences of relocation. Ageing & Society, 23, 2, 225–41. [Abstract]
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