Goal negotiation with older people in three day care settings

Health and Social Care in the Community

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(6), 380–389

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© 2000 Blackwell Science Ltd

Abstract

Drawing on a wider study of effectiveness in three models of day care, this paper explores the process and outcome of goal negotiation with older people in a day hospital, an outreach service and a day centre. Using qualitative data from interviews with day care attenders and focus groups with service providers, differing perspectives on goal setting and achievement are presented. It concludes with a brief discussion of this approach in the wider context of promoting older people’s participation in decision-making in day care settings, where the espoused emphasis is on maintaining and maximising personal autonomy and independent living.

Keywords:

day care, goal setting, negotiation, older people

Accepted for publication

30 June 2000

Blackwell Science, Ltd

Goal negotiation with older people in three day care settings

Jackie Powell

1

MA Dip Soc Admin Dip App Soc Studies, Jane Bray

2

RGN, Helen Roberts

3

BSc MBChB FRCP Andrew Goddard

4

BSc PhD CIPFA FCA, Eric Smith CQSW

5

1

Senior Lecturer, Department of Social Work Studies, University of Southampton, UK,

2

Research Nurse, Elderly Care Research Unit (ECRU) Southampton University Hospitals NHS Trust, UK,

3

Consultant Physician, Director ECRU, Southampton University Hospitals NHS Trust, UK,

4

Professor, Department of Management, University of Southampton,

UK and

5

Team Leader (Older Persons Sector), Social Services Department, Southampton City Council, UK

Correspondence

Jackie PowellDepartment of Social Work Studies University of Southampton Highfield Southampton SO17 1BJ UK E-mail: [email protected]

Introduction

Promoting autonomy and independence for olderpeople within health and social care settings can beseen as part of the wider development to improve theoverall quality of services and promote increasedparticipation of service users in decisions effecting theirlives and well being (e.g. Patient’s Charter, Departmentof Health 1991). Goal-orientated approaches have beenused by many professional groups working in a rangeof health and social care settings for many years, and arewidely seen as valuable in promoting greater involvementof service users in decision-making. For example, the useof contracts and task-centred work as more structuredapproaches to social work provide the opportunity forbuilding partnerships established via negotiation on acommon aim (Doel & Marsh 1992). This model of moreactive intervention directed towards achievement ofagreed goals has also been used in a number of healthsettings. Over a decade ago its value was recognisedas a means of achieving higher standards of individualcare and service provision in the field of terminal care(Hillier & Lunt 1980). Central to this process was theemphasis on goals rather than problems, and the

participation of the patient in the process of goalsetting. Furthermore, it was seen as widely applicable,both to the rehabilitation aspect of terminal care, and insituations where a person’s condition was deteriorating(Lunt & Jenkins 1983).

More recently, the use of goal setting with olderpeople in a rehabilitative setting has been arguedpersuasively by Rockwood & Stolee (1994). Given themultiple problems frequently encountered in workingwith frail older people, a focus on their aspirations andgoals can be a means of attending to the active role elderstake in shaping their own futures (Rapkin & Fischer1992a). Attention has also been drawn to the benefitsof goal setting in providing the means of allowing judge-ments to be made about the effectiveness of serviceprovision (Rockwood & Stolee 1994).

Day care plays a prominent role within the spectrumof health and social care provision for older peopleliving at home. Traditionally day hospitals, funded bythe NHS, have focussed on rehabilitation and main-tenance of skills; and day centres on social care, respiteand maintenance. Outreach services are typically moreconcerned about clinical rehabilitation issues. Thereis often some overlap between these services with

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Goal negotiation with older people

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distinctions between them becoming increasingly blurred.An Audit Commission Report in 1994 (Audit Commis-sion 1994) underlined the particular contribution madeby day hospitals and required purchasers of day careto define the role of the service. Providers were alsoexpected to demonstrate the effectiveness of theirservices. In a field where the difficulties of assessingeffectiveness are well documented, it has been suggestedthat the use of goal negotiation and goal achievementmay provide an alternative approach (Royal College ofPhysicians/British Geriatrics Society 1994).

The study

The focus of this paper is on the process and outcomeof goal negotiation with older people in day care set-tings. It draws on a wider project, funded by the NHSExecutive South and West Research and DevelopmentDirectorate, to investigate methods of effectiveness inthree models of day care (Roberts

et al

. 1998). Buildingon earlier work on goal negotiation (Elderly CareResearch Unit 1996) and alternative forms of day careservices (Turner

et al

. 1997), this two year study hadthe following aims:

1

To identify the characteristics of the elderly populations receiving different types of day care and develop criteria for attendance.

2

To determine whether achievement of a negotiated goal(s) is the most appropriate outcome measure for elderly people attending day centres or day hospitals.

3

To determine which of the three models of day care studied is the most effective and the most cost-effective.

The study took place in three different settings. Onewas a social-services-department funded day centre,which catered for a diverse elderly population withmixed physical and mental disabilities. It sought toprovide social activity and carer relief and was staffedby a manager, deputy manager, a number of part-timecare workers and two drivers, with occasional inputfrom voluntary workers. Of the two health care settings,one was an NHS outreach service for older people withcomplex rehabilitation needs. This service focusedon providing treatment to older people in their ownhomes and/or on a group basis once a week in nearbypurpose-built day hospital premises. The outreach teamcomprised a nurse, a physiotherapist, an occupationaltherapist, one full and one part-time team assistant, withinput from other professionals, e.g. speech and languagetherapist or dietician, as required. The third setting wasa traditional, purpose-built NHS day hospital, offeringrehabilitation on four days a week to older people whose

main problem was a physical disability. It focused onproviding therapy with medical and nursing input.During the period of the study, the day hospital wasthe only setting to accept patients living in residentialor nursing home care. The multidisciplinary team com-prised a sister in charge, three staff nurses, an auxiliarynurse, two physiotherapists and an assistant, an occu-pational therapist and an assistant, a consultant geri-atrician, two clinical assistants, an administrator and asecretary. There was also input from a speech andlanguage therapist and dietician as needed.

A sample of newly referred older people was identi-fied in each of the three settings. Fifty patients wererecruited from the outreach service and day hospital. Theslower admission rate at the day centre limited recruit-ment to 39 people over the study period. A multimethodapproach was adopted to collect both quantitativeand qualitative data from a variety of sources. A rangeof data was extracted from day care records and ispresented in Table 1. This shows baseline demographicdata on the 139 patients initially recruited to the overallstudy. People in the different care settings were com-parable in terms of age and ethnic group with a higherproportion of females and widowed people attendingthe day centre.

Data on patients’ medical and social problems werealso extracted from day care records. All the settingsrecorded medical problems (Table 2), but in the case ofthe outreach service and day hospital, social problemsor needs were not routinely recorded. Social isolationwas the main reason for referral to the day-centresetting.

Of the total population (139), 135 older people andtheir associated carers (48 from the day hospital, 49from the outreach service and 38 from the day centre)were interviewed at the time of entry to day care andfollowing discharge or review three months later. Anumber of standard assessment instruments were usedto collect data on functional status. Additional qualit-ative data on the process and outcome of goal negotiationwere gathered via in-depth interviews with 45 day careattenders (15 from each setting) and, where applicable,their informal carers, plus two focus groups with mem-bers of each of the three teams. Costs data were alsocollected for each setting.

Findings

The findings discussed here draw on qualitative data(see above) collected in relation to the second aim ofthe study. These findings offer a detailed picture ofthe process and outcome of goal negotiation from theperspective of day care attenders and those providingthese services. Given the different purposes and practices


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associated with the three settings, team members’ viewson the process of goal negotiation are presented along-side those of attenders and carers for each setting.

The characteristics of this subsample of 45 olderpeople were broadly comparable with respect to age,gender, marital status and ethnic group to the overallstudy population. The identified medical problems werealso similar, with strokes and arthritis accounting forover half the sample and dementia as a more commonreason for attendance at the day centre. The problemor goal as perceived by both patients and carers in thissample fell into two main categories: mobility and socialinteraction. The latter was almost exclusively associatedwith the day centre setting, and mobility with the out-reach and day hospital settings.

Day centre: team members’ views

Goal identification and negotiation

The primary aim of this setting was to provide socialand respite care and facilitate interaction amongstthose attending the centre. Members were encouragedto participate on their own terms. Staff attempted toidentify any particular interests of members andactively sought ways of engaging individuals in vari-ous social and practical activities:

I think mostly people come to get away from their isolation.They need to socialise and sometimes they discover, whenthey come here, that they have got other talents and can doother things and get much more from their day care thananybody originally realised.

Table 1 Patient characteristics by day care setting

Overall populationn = 139

Day centre settingn = 39

Outreach servicen = 50

Day hospitaln = 50

Median age 79.6 79.9 77.2 80.5(Inter-quartile range) (74.9–84.6) (76.6–85.8) (72.1–84.2) (77.0–84.5)

Gender (%)Male 49 (35) 8 (21) 16 (32) 25 (50)Female 90 (65) 31 (79) 34 (68) 25 (50)

Marital status (%)Married 45 (32) 7 (18) 21 (42) 17 (34)Widowed 85 (61) 29 (74) 28 (56) 28 (56)Divorced 3 (2) 3 (6)Single 5 (4) 3 (8) 1 (2) 1 (2)Unknown 1 (1) 1 (2)

Ethnic group (%)White 137 (99) 38 (97) 50 (100) 49 (98)Black Caribbean 1 1Mixed race 1 1

Domestic situation (%)Lived alone 58 (42) 21 (54) 19 (38) 18 (36)With spouse/partner 41 (29) 5 (13) 20 (40) 16 (32)With family 29 (21) 13 (33) 11 (22) 5 (10)Rest home/ 10 (7) – – 10 (20)Nursing home 1 (1) – – 1 (2)

Table 2 Main identified medical problems

Overall population n = 139

Day centre n = 39

Outreach service n = 50

Day hospitaln = 50

Stroke disease (%) 52 (37) 9 (23) 24 (48) 19 (38)Arthritis (%) 30 (22) 14 (36) 8 (16) 8 (16)Mobility/falls (%) 17 (12) 1 (2) 8 (16) 8 (16)Other physical problems (%) 23 (17) 5 (13) 10 (20) 8 (16)Mental health problems (%) 11(8) 10 (26) 0 (0) 1 (2)Parkinson’s disease (%) 6 (4) 0 (0) 0 (0) 6 (12)




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All staff emphasised their commitment to involv-ing members and carers in decisions about attendanceat the day centre. Although not necessarily articulat-ing their practice as ‘goal negotiation’, they gave everyindication of including members in any discussion ofways in which their attendance at the centre mightmeet their need for greater social contact.

A feature of this setting was the continuous monitor-ing of members’ needs through observation and listen-ing, frequently expressed as ‘keeping an eye open’ or‘you just chat … and they do tell you’. All membersof staff worked closely together as a team, sharinginformation informally between themselves and withthe day care manager, who acted in a coordinatingliaison role, and sometimes as advocate, with thesocial services department (SSD), local area centre andother agencies. Similar processes operated in relationto carers, where the role of the driver and escort werevery important in identifying any changing needs ofthe carer or in the wider home situation. As the daycentre manager observed:

I think the driver and the escort have very, very importantjobs. They are the ones that go into people’s homes. Theymay be the first people that these older people have seen fordays. Quite often things are blurted out … I think it’s quite astressful job because you have to be patient and kind andstill remember things [to share with colleagues].

Goal achievement and review

A regular review of members at 3 months was intro-duced during the study period and usually undertakenby the day care manager. Regular meetings with adesignated social worker based at the social-services-department local area centre were also instated duringthe study period. These meetings provided an opportun-ity to formally identify any member’s changing needsand consider additional or alternative forms of support.

Team members identified a range of possible out-comes relevant to this setting, although given its primaryaim of promoting social interaction, improved socialfunctioning was seen as the most appropriate outcome.There was no formal attempt to measure achievements,although their own (i.e. team members’) observations ofmembers’ interaction and participation in a range ofactivities and feedback from members and their carersprovided the basis for their assessment of achievements.

Carer relief was also seen as a possible outcome,generally demonstrated by carers’ expressions ofobvious relief and an observable improvement in theirappearance. In specifically negotiated situations, per-sonal care, bathing or foot care might be an identifiedoutcome. Whilst prevention or delay of admission toresidential/hospital care was also identified as a possibleoutcome, in some situations preparation for admission

into residential care or respite care might be equallyappropriate.

Day centre: members and carers views

In all 15 situations, both those attending the centre andtheir carers shared the view that the primary reason forattendance was social interaction. This was generallyexpressed in terms of ‘getting out of the home’, ‘meetingpeople’ and ‘to have some company’. In two instances,there was the additional goal of personal care. In 11 ofthe 15 situations, full goal achievement was reportedby the attender, 10 of whom reported being very satis-fied with the service. Asked whether she felt she hadachieved her goal identified as ‘company mostly’, MrsA replied:

Yes, I do. I think I’ve something to look forward to everyweek for a start and I like the friends I’ve made … which Iwouldn’t have made without that you see.

Mrs B, aged 95, who lived alone and had no identifiedcarer, was initially reluctant to attend but was facilitatedto join in, despite her sensory impairment.

Well, I was so struck with the place that I decided to start … ithas shown me I was mistaken … I imagined all sorts of things.

Despite her tentativeness, she had accepted the offerof a bath. Mindful of her ever-increasing dependencyshe also admitted that she was now more prepared toconsider residential care.

If I want … decided to go into a home, which I haven’t, notyet … I wouldn’t mind going there [residential home locatedin same building].

Mrs C, who lived alone and was identified asdepressed and in need of company commented:

I think I’ve achieved what I set out to do – the company –and mucking in with all the games.

This view was shared by her daughter:

I think it’s made a difference to her. She’s more outgoing andless withdrawn. I think she’s learning how to cope better.

In two of the four situations where partial goalachievement was reported in association with ‘verysatisfied’, one was qualified by the member’s desire todo more to help other members, although limited byher physical frailty. In the second case, whilst the goal‘to get me out of these four walls’ had been achieved,it was qualified by this member’s reported lack ofopportunity for exercise, a view shared by her husband.She had previously been in receipt of the outreachservice.

Of the remaining two situations where partial achieve-ment was reported, levels of satisfaction were reported


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as ‘uncertain’ by the attender. In one case, Mrs Ewas attending primarily at the request of her daughter,who considered the goal of ‘social interaction’ fullyachieved. In response to her mother’s view of thecentre, ‘hated it … you get used to it’, the daughtercommented:

When you come home you’re full of beans, you’re sort ofdifferent … you know, as soon as I come in from work Iknow she’s been and she’s all bright and breezy and she’stalking her head off. She doesn’t realise she’s like that. Likewhen I come in from work sometimes she’s asleep in thechair, but when you’ve been to the day centre I come in andyou follow me around the house telling me all about it.

In the other case, the woman attending the centrehad very limited short-term memory, although herhusband, clearly distressed by the situation, felt somebenefit himself.

Outreach service: professionals’ views


The primary aim of this setting was rehabilitation basedon improving or maximising patients’ mobility in waysthat took account of their particular needs and homesituation. Although team members felt they made aconsiderable effort to involve their clients in planningtheir care, there was general agreement that their attemptsto negotiate goals tended to be implicit rather thanexplicit:

We’re talking about what we do informally. We don’t have acertain structure or framework to it. I think the only time wetend to do it very rigidly is dependent on the patient. If theyneed that type of approach then we can offer that and agreethat is what is needed.

The value of adopting this approach was wellrecognised:

The interesting thing is that the goal they are so focused on,its the one they make the most functional gain. [For example]… We all thought that it was unrealistic, a particular lady wehad seen, she was wheelchair-dependent and she expressedthe will to go upstairs. We got rid of the hospital bed in thefirst few weeks and once she got over that hurdle then hergoal was to go up stairs and then start to walk. She just wentin leaps and bounds because that was what she wanted toachieve.

The process of negotiating an agreed goal wasacknowledged as time consuming and sometimesdifficult where there were differences of view:

If the goal was to get her walking, we would clearly explainthat our first step to walking is to be able to stand. We breakthe goal down into short-term goals and this is what we’relooking at. Like Lucy [for example], her goal eventually is to

get back playing golf, and we all feel that that’s totally inap-propriate, but there’s no way that we would say so to her.You’re not going to do that because golf had been her lifebefore she had the stroke. Instead, we say ‘this is what youneed to achieve first’. And you can’t remove somebody’s hope.It might be what they’re pinning their whole rehabilitationprocess on, that particular goal. You remove that and don’treplace it with anything; it could be shattering for them. We’rereally careful I think with people’s coping strategies becausesome people’s coping strategies make them very unrealisticabout their goals.

Practices varied however, with some members ofthe team more active in the promotion of what wasdescribed as ‘a more realistic goal’ based on a pro-fessional assessment of what was achievable. Theseprofessionals felt that it was not always possible toachieve a shared view of the most appropriate goal, asthis sometimes involved professionals in taking anunnecessary risk.

A common assessment form was used as the basisfor drawing up an agreed action plan. Initial plans werediscussed in the context of regular team meetings:

We tend to try and work on what the patient sees as thepriority first, but when we’re doing that we discuss as a teamwhat we think is important, the logical sequence that weshould take a patient through. Say, for instance, is washingand dressing the first thing you should look at or is it furtherdown the line? As a team we negotiate the process, but wewould also take into account what was most important forthe patient and carer.

Plans were more frequently made use of in thecontext of domiciliary care or where several membersof the team were involved in the overall treatmentprogramme. This led to a degree of overlap andinterchange of roles, although each team memberretained a primary focus based on their professionalexpertise.

There was relatively little involvement of carers inthe development of the plan, although this mighthappen on an

ad hoc

basis depending on whether thecarer was present at the initial home visit. In somesituations use was made of a formal contract when itwas recognised that someone needed to have a morefocused and purposeful approach to their treatmentover time.

Goal achievement and review

A formal review of each attender, in preparation fortheir discharge, was undertaken by the team between6 and 11 weeks after admission, although weekly teammeetings provided the opportunity for discussion ofall attenders’ progress. Planning discharge was seen as




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less problematic where short-term goals that focusedon rehabilitation had been achieved. However, for thosewho had been attending the rehabilitation day centre,referral to alternative day care, if available, was pursued.

The discharge letter to the GP provided a formalwritten record of achievements. This might be inform-ally discussed with patients, although there was noformal practice of reviewing goals at this stage. Mem-bers of the outreach team recognised the difficultiesassociated with developing outcome measures in rela-tion to either maintenance or absence of deteriorationof function. Problems in identifying either earlierhospital discharge or prevention or delay of admissionas achievements were also acknowledged. Teammembers, however, were aware of working withpatients in their own homes who, on the basis of theirown previous experience, would not have been seenas ready for discharge.

Outreach service: patients’ and carers’ views

In all but one situation, mobility was perceived byboth day care members and their carers as the mainreason for the person’s involvement with the outreachservice. The one exception was a situation where someimprovement in speech was identified as the primarygoal.

Of the 15 cases, three reported ‘full achievement’ ofgoals, all associated with the patient and carer being‘very satisfied’ with the service. In each situation, someparticular feature of the setting was evident. For example,Mr F had experienced two strokes but appreciatedhaving realistic achievable goals identified:

I can get your hand working a bit as well. (physiotherapist)

I have to exercise every day. I had treatment and they gotthis arm working. And you could talk to them and ask any-thing and they gave you a straight answer. (Mr F)

This emphasis on a modest but realisable goal wasshared by another attender: ‘… achieved my hopes …I wanted to get on my feet and I got on my feet’. Havinghome visits where treatment could be made directlyrelevant to a person’s needs was much appreciated bythis elderly couple, as Mrs G commented:

Well they got you walking again, didn’t they.

Mr G continued:

I don’t think I could have done what they done for me on myown.

His wife replied:

[The physiotherapist] said to him, because I was watchingout the back, and she said ‘Come on, we’ll go across the road.’

And he says ‘What over there?’ ‘Yes, come on up the kerb’.And of course, he’d never been up the kerb … managed itdidn’t you.

Of the 12 patients who expressed partial achievementof their goals, equal numbers reported being verysatisfied and satisfied with the service. In all 12 situ-ations ‘partial achievement’ of their goal of improvedmobility was qualified by a statement indicating thatthey had hoped for more progress. However, this wasoften associated with a recognition that their expecta-tions were unlikely to be achieved. For example,

They got me on my feet. I can stand but I can’t walk. I cannotwalk like I used to on my own. I cannot do anything on myown.

Her daughter, who lived with her mother, also framedher mother’s improvement in mobility in a positiveway.

You can move about a bit better than when you came out [ofhospital].

In all 12 situations satisfaction, as in Mrs H’s case(see above), was associated with attendance at the daycare centre once a week, which was variously describedas ‘enjoyable’, ‘providing company’ and ‘something tolook forward to’.

Day hospital: professionals’ views


Access to a full multidisciplinary assessment was a keyfeature of this setting. The early identification of medicalconditions associated with ageing, problems relatingto nutrition or drug maintenance were seen as key areasof possible intervention, although mobility was the mainpresenting reason for referral. The range of problemsand associated goals identified mirrored the variousaims of the setting identified by the team. The primaryaim was on sustaining daily living skills where mobilitywas seen as a key objective. Social interaction or carerrelief were acknowledged as valid goals, although notcentral to the purpose of this setting.

The team had developed a common core assessmentform, although some team members kept additionalrecords in relation to their specific inputs. Potentialpatients were invited into the day hospital for assess-ment, which involved all members of the multidis-ciplinary team. The team subsequently met to decide thetypes of treatment required, the number of days attend-ance and the ‘key worker’. The latter had, until recently,been a nurse, although this was extending to includethe occupational therapist and physiotherapist. Formalrecording of a patient plan took place at this stagewith a full identification of problems based on the


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several individual professionals’ assessments. Separategoals relating to the various planned interventions fromdifferent team members were recorded at this stage.Multiple goals were frequently recorded and differentteam members might become involved at differentstages during the patient’s time of attendance. Teammembers saw themselves as involved in continuousgoal setting and review, although this was basedprimarily on discussions between professionals overprioritising professionally identified goals. Involvementof patients in this process was seen as a checking outof their problems and aspirations in the context of afull multidisciplinary assessment.

I think what we have got to get into the habit of doing isgoing back and discussing the goals we’ve set with them tomake sure that those are the goals they want. Because wetend to set goals for obesity and diabetes and one patientturned round to me and said, ‘oh it’s that goal! I’m not goingto do anything about that’ [change in diet].

Goal assessment and review

Review took place in the context of discharge plan-ning. Previous discharge arrangements included theopportunity for patients to participate in a dischargesupport group, where goal achievement was discussed.Resource constraints have led to its disbandment.A discharge checklist was in the process of beingdeveloped and a review of original goals was encour-aged. Professionals views on goal achievement/outcomewere frequently expressed as ‘got as far as we can go’,or ‘we can do no more: discharge’.

Improvements in physical and/or mental function-ing, with an emphasis on mobility and personal carewere seen as the most appropriate outcome measuresfor this setting. Maintenance of function or delay indeterioration were not seen as primary goals for patientsattending this day hospital, although a patient originallyreferred for rehabilitation might move into a situationwhere maintenance was a more appropriate goal. Socialinteraction was not regarded as a primary reason for apatient’s attendance, although it could be associatedwith other reasons for attendance, e.g. mobility. Specificnursing care was only seen as appropriate if undertakenas part of an overall package, although drug educationwas identified as an area of growing activity for teammembers. Preventing or delaying admission was seenas a possible role for the day hospital. Satisfaction withthe service was regarded as the main indicator ofsuccess from the attender’s perspective,

(S)he might need reminding of the initial plan, but if somechange over the period of attendance at the day hospital couldbe identified, then this could form the basis of a satisfactoryoutcome. (from the professional’s perspective)

Day hospital: patients’ and carers’ views

In nine of the 15 situations, the primary goal identifiedby the attender was some improvement in mobility. Inthe other six situations, patients were either uncertainabout why they had attended the day hospital orperceived a difference of view between themselves andthe professionals involved over what might be theiridentified goal.

Of the nine situations where an improvement inmobility had been achieved, attenders reported eitherthe full (3) or partial achievement (6) of this shared goal.In the three situations where ‘full goal achievement’ wasreported, all were associated with being ‘very satisfied’with the service. Comments associated with goal achieve-ment were positively framed and frequently expressedin conjunction with an appreciation of the opportunityfor social interaction. For example, Mrs M appreciatedthe company and felt there were others worse off thanherself.

Well the gentleman told me, ‘I can’t do anything more foryou’. I’m glad about that. The company was wonderful.

She continued:

A lot of people worse off than me. That’s good for me, see.You get self-centred, don’t you, all day by yourself.

Her daughter commented:

I think it eased her mind a little. She wonders how much isdue to her age. How much is due to her stroke. I don’t thinkthere’s an awful lot more can be done – things are not goingto improve with her knees or her speech patterns.

Of the six reporting ‘partial achievement’, fourreported being ‘very satisfied’ and two ‘satisfied’ withthe service. In all six cases there were references toenjoying the company, appreciation of going out andso on, again associated with some degree of improve-ment in mobility framed in a positive way. For example,Mrs P, who suffered with a very painful arthritic knee,remained positive:

I achieved a lot. I achieved friendship and kindness and well,they did try to solve what was wrong with me but … I gotthe treatment for that, but it didn’t work.

Similarly, an 85-year-old resident in a rest home hadconsiderable difficulty walking following a fall.

Well it helped me a lot, but it didn’t make me as well as Iwould have liked. There’s no miracle that you can get upand walk when you can’t. I’m glad I went. I enjoyed it but Ican’t say it did as much as I hoped. But that’s not their fault.

Four attenders recorded no achievement of goal andexpressed uncertainty about the identification of anygoal or specific reason for attending the day hospital.




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In each situation, goals had been identified by theprofessionals involved. For example, whilst an 86-year-old man was uncertain why he had been referred, thecase notes indicated that a range of problems, includ-ing poor mobility, painful knees, and low mood, hadbeen identified by the team. All four patients, however,considered themselves either ‘satisfied’ (three of thefour) or ‘very satisfied’ with the service. For example,Mrs R, aged 90 years, whilst uncertain about her reasonfor attendance other than the ‘doctor sent me’, reportedbeing very satisfied.

It meant a lot to me … the exercises I was given were of helpand I still remember them … well, if happiness was it, I hadit there.

The goals recorded by the team in this case were:mobility and treatment of a previously unidentifiedcase of diabetes.

In the remaining two situations where no goalachievement was recorded, one person was uncertainabout his satisfaction with the service. He had hopedfor some treatment to relieve his painful ankle andback but had experienced no improvement in his con-dition. He had been told that there was no cure. Thecase notes stated, ‘I don’t think there’s much more wecan do’. In the other situation, where dissatisfactionwith the service was reported, there had been dif-ferences of view regarding the goal. This 90-year-oldman, who was living in a rest home, had suffered astroke, was confined to a wheel chair and had diffi-culty with both his vision and hearing. He referred tohis visual impairment as his main problem with whichhe wanted some help, whereas the team had seen hisdifficulty in swallowing and poor speech as the mainconcerns. Mr S felt dissatisfied with the service as hehad liked attending the day hospital.

I could listen, but no-one seemed to worry about me. Icouldn’t join in.

At the time of discharge, his situation was reportedin the case notes as ‘we don’t feel further speechand language therapy or swallowing rehabilitation isrequired’.

Discussion

Having presented these findings in the context of theirspecific settings, differences in overall aims of each ser-vice and in working practices have been emphasised.In setting the views of service users alongside thoseproviding the day care, one key feature to emerge is thedifference in views held by professionals and attendersat the day hospital. Although the other two settingshad different aims, widely shared views were held by

professionals and day care attenders as to the purposeof each of these settings. Moreover, attenders weregenerally clear about their achievement of identifiedgoals. Whilst goal setting was undertaken at the dayhospital and discussed within this multidisciplinarysetting, the process of goal identification and negoti-ation offered little opportunity for the involvement ofthose attending the day hospital.

The difficulty of setting goals in a multidisciplinaryhas been reported elsewhere (Rockwood & Stolee 1994).Several factors have been identified, not least the needfor commitment to the process and an openness on thepart of all team members. The need for each teammember to be explicit about their contribution can betime consuming and challenging. Some day hospitalstaff, for example, were reluctant to give up theirindividual case records in which they identified theirspecific inputs. Members of the outreach team, however,were keen to emphasise how their practice had evolvedand the ways in which they recognised some overlap-ping of roles alongside their distinctive contributions.This sense of shared purpose appeared to enable themto explore some of the difficulties of negotiating jointlyagreed goals. Trust between colleagues engaged incollaborative working has been identified in a numberof studies on assessment and goal setting in multi-disciplinary settings (Nolan & Caldock 1996).

Findings from each of the settings indicated waysin which older people could be actively involved inidentifying and negotiating goals. This was not a straight-forward task in any context, although arguably the roleof a day centre in providing social support is morewidely recognised and easier to explain. However, thevalue of making this goal explicit and finding waysof making this meaningful to potential attenders is evid-ent from the ways in which (day centre) respondentsdescribed their experiences in terms of participation andachievement. Involvement in decision-making formsan integral part of rehabilitation where there is anemphasis on individuals regaining some degree ofindependence and control over their lives (Davies

et al

.1997). Members of the outreach team recognised thisin their attempts to make goals relevant to the olderperson’s particular situation and future aspirations.Moreover, the way in which some older people in thissetting expressed their achievements in very personalterms emphasised this sense of ownership of goals.Although they were generally satisfied with their experi-ence of the service, attenders at the day hospital referredless frequently to their achievements. Day hospitalstaff also framed their involvement more in terms ofthe limitations imposed by a person’s condition ratherthan any improvement or maintenance of health orwell being.


J. Powell et al.

388 © 2000 Blackwell Science Ltd, Health and Social Care in the Community 8(6), 380–389

These differences in findings across the threesettings suggest different underlying models of serviceprovision in meeting the health and social needs of olderpeople. The prevalence of ageism in the constructionof assessment with older people is well documented(Hugman 1994) and much work has been done todevelop a theoretical basis for assessment rooted inantiageist practice (Hughes 1995). As a new and inno-vative form of provision, the outreach service was keento develop a more person-centred approach explicitlybased on a goal-orientated framework. This was incontrast to the more problem-based model, traditionallyfound in geriatric care, particularly hospital settings,where the prevailing medical metaphor of ageing asdisease, decline and deterioration can lead to both over-and under-treatment of older people in the health caresystem (Clark 1996). This alternative model, rather thanbeing professionally orientated around expert know-ledge, attends to the individual’s own definition of healthand health needs, and facilitates their active participa-tion in defining their health goal priorities. Effectivecommunication between professional and older personlies at the heart of this process and, if achieved, can pro-mote empowerment and enhance well being (Clark 1989).

Negotiation and making goals explicit is crucial ifgoal achievement is to make any sense as an indicationof outcome. Goals should offer some direction and beobservable and capable of description. Individuallythey may be very modest, but, as part of a more extensiveplan, they can lead to significant achievements. Membersof the outreach team elaborated this part of the goalsetting process very clearly when outlining the need toexplain the several steps involved, for example, inregaining mobility. This ability to convey an adequateand meaningful explanation is an integral part of thenegotiation required to arrive at an agreed goal. Manyfrail older people have multiple problems that some-times can be associated with either unrealistically highexpectations of improvement or perhaps with no expecta-tions at all. Such complexity of need and expectationrequires careful and sensitive investigation on the partof the professional. This is a demanding task as it callsfor an approach that recognises and accepts the validityof the older person’s perception of the problems andtheir aspirations, alongside the knowledge and expertiseof the professional (Le May 1998). Staff in the day hos-pital recognised the importance of this but found it hardto put into practice in a multidisciplinary context whereprofessional expertise was highly valued and contestedby team members. The outreach team, smaller in numberand working in a community setting, found ways oflistening to and learning from their clients. Severalof their comments revealed how they had to rethinktheir own expectations in some situations and be more

prepared to identify goals which were sufficientlychallenging, yet realistic and individually focused. Thesefeatures mirror many of the ‘benchmarks for good prac-tice in assessment’ identified by Nolan & Caldock (1996).

In presenting these findings, which provide someevidence of the various aspects of goal setting – identi-fication, negotiation and achievement – in all threesettings, an attempt has been made to draw out somekey features of this approach. The findings suggestthat goal negotiation, if done well, can actively involveolder people in decision-making about their future. Ingiving attention to older people’s goals, alongside theirproblems, this approach provides the opportunity toexplore their assumptions about what is possible anddesirable for them to achieve. As Rapkin & Fisher (1992b),in their discussion of older people’s life satisfaction,conclude: ‘it gives them a voice by asking them directlywhat they want out of life’ (p. 148). Moreover, it buildson the skills and experiences that older people haveacquired over their lifetime to respond to problemsand preserve their independence (Seale 1996).

These findings also suggest that achievement ofnegotiated goals has potential to be used as a suitableoutcome measure. This approach combines the use ofa common framework with the setting of individuallyfocused goals. It ensures some degree of standardisa-tion and therefore equity, whilst attending to theindividual aspirations of the older person (Woolham1996). The latter ensures that the overall approach isnot reduced to a mechanistic exercise of resourcemanagement, but remains person centred rather thanpredominately agency focused (Richards 2000). It alsoaddresses issues of process and outcome, as well asproviding a base-line against which any changes canbe assessed (Nocon 1996). Its use as an outcome meas-ure across a range of day care settings is important asit offers a means of promoting standards common toboth health and social care settings, whilst acknow-ledging their different but overlapping roles. Withits emphasis on user involvement and the promotionof autonomy, it provides a common standard forthe commissioning and evaluation of these services.With the call for close working between health andsocial services in the Audit Commission’s report (1997)entitled The Coming of Age and the need to producelocal joint investment plans, the approach to workingwith older people and to evaluating individual andservice outcomes outlined here has much to recom-mend it as a more humane and humanistic model ofpractice. Based on partnership between service usersand providers, it identifies some key features associ-ated with issues of quality in later life, as well as servicequality in a relatively neglected area of communityprovision for older people.



© 2000 Blackwell Science Ltd, Health and Social Care in the Community 8(6), 380–389 389

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Documents

Goal negotiation with older people in three day care settings