Away from home: an ethnographic study of a transitional rehabilitation scheme for older people in...

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Social Science & Medicine 60 (2005) 1241–1250

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Away from home: an ethnographic study of a transitionalrehabilitation scheme for older people in the UK$

Elizabeth Harta,�, Mark Lymberyb, J.R.F Gladmanc

aSenior Lecturer in Social Anthropology, School of Nursing (Room B50), The University of Nottingham, Nottingham NG7 2UH, UKbSenior Lecturer in Social Work, School of Sociology and Social Policy, University of Nottingham, Nottingham NG7 2RD, UK

cReader in the Medicine of Older People, Division of Rehabilitation and Ageing, B Floor Medical School, University Hospital, Nottingham

NG7 2UH, UK

Available online 16 September 2004

Abstract

While intermediate care is an international phenomenon, it is particularly developed in the UK where it is a central

element of the Government’s response to the care needs for older people (The National Service Framework of Older

People. London: HMSO). In the UK, intermediate care services are proliferating despite lack of evidence of

effectiveness. We present the findings of an ethnographic study of an intermediate care scheme in six residential care

homes that examined the perspectives of three key groups—older people, care home managers and rehabilitation staff.

We discovered a consensus among managers and rehabilitation staff that the scheme was successful, yet no such

agreement existed amongst older people. We also found that the scheme created the conditions for the emergence of a

more optimistic vision of the potential of older people, with rehabilitation assistants seeing core elements of their work

in a new light. However, much of what was characterised as ‘rehabilitation’ was more a process of adaptation to the

norms, expectations and values of the institution. Our findings point in positive and negative directions: positive in that

this scheme may have generated a new culture of more personalised care amongst experienced care staff, and negative in

showing the limitations of a rehabilitation scheme that is not based within a person’s own living environment. Our

findings have implications for policy makers, researchers and managers of services.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Intermediate care; Older people; Ethnography; Rehabilitation; Health and social policy; UK

Introduction

Historically, large amounts of health expenditure in

the UK has been in hospitals and the bulk of social care

budgets for older people has been used to pay for places

in long-term care homes. The institutional dominance of

the health and social care system has left the UK with a

e front matter r 2004 Elsevier Ltd. All rights reserve

cscimed.2004.07.007

nding: Trent NHS Executive, UK

ing author. Tel.: +44-(0)115-9709323; fax:

9955.

ess: [email protected] (E. Hart).

relatively small rehabilitation sector. The length of stay

in hospitals has been steadily falling in recent years,

increasing the need for rehabilitation for those who are

disabled by illness, many of whom are old and

vulnerable to institutionalisation or re-admission to

hospital. In a cost-contained system, this creates a

vicious cycle because there are limited rehabilitation

services available. The objective of intermediate care

policy is to develop rehabilitation services so that the

vicious cycle can be broken, with the ultimate aim of

improving health and reducing overall health and social

care costs.

d.

www.elsevier.com/locate/socscimed

ARTICLE IN PRESSE. Hart et al. / Social Science & Medicine 60 (2005) 1241–12501242

‘Intermediate Care’ includes a variety of short term,

rehabilitation services either in peoples’ own homes or in

settings such as residential or nursing homes. In the UK

the development of intermediate care is key to Govern-

ment policies for the care of older people (Department

of Health, 2000, 2001), the purposes of which are to

contain the rising costs of health and social care services

and to ameliorate the personal and social costs for

individuals and families of disease and disability. These

problems are not confined to the UK. A number of

countries with ageing populations (eg. Japan) (Ishizaki,

Kobayashi, & Tamiya, 1998) have responded by

developing a similar range of intermediate care services.

There has been research into some aspects of

intermediate care. For example, early discharge services

have been extensively evaluated (Early Supported

Discharge Trialists, 2003; Parker, Bhakta, Katbamna

et al., 2000; Shepperd & Iliffe, 2003), and home based

admission avoidance schemes rather less so (Caplan,

Ward, Brennan, Coconis, & Brown, 1999; Wilson,

Parker, Wynn, Spiers, & Parker, 1999). There have been

relatively few large scale research projects of intermedi-

ate care in residential settings, although numerous small-

scale uncontrolled research studies have claimed con-

siderable success (Trappes-Lomax, Ellis, & Fox, 2001;

Younger-Ross & Lomax, 1998). Nevertheless, even

those engaged in such work have concluded that there

is a dearth of hard evidence regarding their overall

effectiveness (Younger-Ross & Lomax, 1998). Building

on the evaluative studies above, our study contributes to

the re-emergence of interest in ethnographies of ageing

in different contexts (Gubrium & Holstein, 1999; Hazan,

2002; Stafford, 2003), drawing on the classic studies of

institutionalisation (Goffman, 1961) alongside literature

that focuses on the experiences of older people in

institutional care (Gubrium, 1993; Hazan, 1992).

The national service framework for older people

The national service framework (NSF) for older

people presents intermediate care as a central element

of the UK Government’s strategy to meet the care needs

of older people in England (Department of Health,

2001). As defined in the NSF, intermediate care involves

a short period of intensive rehabilitation and treatment,

normally no longer than 6 weeks, to meet the needs of

older people who want to return home following

hospitalisation, and/or who are at risk of long term

residential care. It may also consist of intensive care for

older people in their own homes to prevent unnecessary

admissions to hospital or to long term institutional care.

One of the aims of the NSF is to root out age

discrimination at all levels in health and social care.

However, the NSF has itself been accused of institutio-

nalised ageism (Grimley Evans & Tallis, 2001). This

charge is mainly directed at the NSFs concern to prevent

admission to hospital by targeting resources at inter-

mediate care. Grimley Evans and Tallis (2001) argue

that this serves an ageist political agenda based on the

belief that it is too expensive to provide old people with

hospital care. Ironically the NSF emphasises the

importance of ‘enabling’ older people to have a voice

in service development and yet places such views at the

very bottom of the hierarchy of evidence. Irrespective of

how they would be valued, there is very little informa-

tion available about the views of older people who use

intermediate care services.

This paper reports on a 2-year ethnographic study of

the transitional rehabilitation (TR) scheme in Notting-

ham. The research explored the perceptions of those

people who were central to the process of care—older

people, care home managers and a variety of rehabilita-

tion staff. This ethnographic study ran in conjunction

with an independent randomised controlled trial (RCT)

of the same scheme (Fleming, et al., 2004).

The transitional rehabilitation scheme

The TR service began in 1997 (Nottinghamshire

Social Services Department, 1998). By September 2000

(when our evaluation began) the project was based in 5

residential care homes for older people, with a sixth unit

opened the following year: 4 units had 5 beds, and 2

units had 10 beds. The TR scheme was located in units

that were separate from the ‘normal’ care provided in

each residential home. The units were intended to be as

much like ‘home’ as possible and were positioned to

reduce the possibility of older people on the TR unit

mixing with ordinary residents in the care home. Each

unit had a sitting room with comfortable armchairs,

footstools and a television. Residents slept in single

bedrooms with an armchair, wardrobe and chest of

drawers, and were able to spend some time in their

rooms during the day. Most units had en-suite bath-

room and shower facilities, although when our evalua-

tion began some bathroom facilities were shared. The

kitchen was the focus of activity and, as in similar

institutional settings for older people (Hazan, 1992),

attendance at meals made it possible for staff to observe

and supervise residents. The kitchen was where people

‘re-learned’ skills of cooking and washing-up, and also

‘re-learned’ to interact socially with other residents and

staff—such as when sitting down together for meals.

Pictures, ornaments and pot plants were all intended to

add to the ‘homely’ atmosphere, as was the emphasis on

making and drinking tea together. Units were staffed by

non-qualified, hourly paid rehabilitation assistants, the

majority of them local women, many of whom

commenced as care assistants in residential care homes.

The TR units were more favourably staffed than the

ARTICLE IN PRESSE. Hart et al. / Social Science & Medicine 60 (2005) 1241–1250 1243

residential side. Rehabilitation was led by occupational

therapists (OT) who were assisted by community care

officers (CCO)—non-registered salaried staff. There was

also a dedicated social worker, community nurse and a

physiotherapist.

The majority of referrals to TR came from the two

hospitals within the health authority. A minority were

referred from the community. Admission to the scheme

required that people should be at least 65 years of age

with medical needs that did not require continuing

hospital care, ‘eligible’ for long-term residential/nursing

home care and unable to return home immediately, and

in need of therapeutic intervention and support to

enable them to do so. The key factor was that the

individual must be at imminent ‘risk’ of admission to

institutional care at the point of referral. The project

aimed to ensure that people were enabled to return

home within 6 weeks of admission. It was anticipated

that the planned intervention would provide them with

the opportunity to relearn skills of daily living and the

confidence to apply them.

Aims, methodology and analytic approach

This study aimed to explore issues surrounding this

sort of intermediate care through an understanding of

TR as a social process, including interpersonal, cultural

and organisational dimensions. We were concerned to

gather the views of people—especially those older people

who used the service and rehabilitation assistants who

staffed the units—who have been little heard in the

research to date.

The ‘core characteristics’ of ethnography were ex-

emplified in this study (Hammersley, 1990; Savage,

2000): it was small in scale, focussing on TR as a social

process in the settings in which the scheme was

organised and delivered. Our analytic focus evolved in

response to emergent findings and unanticipated events.

It was concerned with an understanding of ‘TR’ from

the varied perspectives of participants—older people,

managers and rehabilitation staff. Participant observa-

tion and field visits, combined with interviews and

documentary analysis provided insights into the inter-

personal, cultural and organisational context. Thus, the

analytic approach was inductive, interweaving data

from interviews, field-notes and observations, compar-

ing and contrasting them so as to enable a range of

perspectives to emerge.

Research design

Our study was designed to make it possible to trace

the development of the scheme over 2 years, with

fieldwork concentrated in two phases, 12 months apart.

Altogether 55 people were interviewed, including 17

older people, the service co-ordinator, 7 care home

managers and 30 rehabilitation staff (6 OT, 1 phy-

siotherapist, 6 CCO, 16 rehabilitation assistants, 1 social

worker). In total we (EH and ML) conducted 58

interviews, including 4 interviews with older people on

their return home—one of whom was also interviewed

while in TR—and a group interview with 3 occupational

therapists and 4 community care officers. All taped

interviews were transcribed and entered onto NVivo 2.0

for analysis. We also worked directly with hard copies of

the transcripts and field-notes, reading and re-reading

them to retain an oversight of the overall context of the

study. We used purposive sampling (Silverman, 2001) to

select participants on the basis of their experience and

in-depth knowledge of the scheme rather than, as in a

survey, because they were representative of a larger

‘population’ (Davies, 1999). The theoretical purpose

behind our sampling strategy was to understand how

each of three key groups experienced the scheme—

managers, care staff and older people—and explore

similarities and differences within and between groups.

We were aware of ethical issues in the research process

(Association of Social Anthropologists, 2003), particu-

larly in respect of interviewing vulnerable older people:

we stressed that we were separate from the TR scheme,

and that each person had the freedom to decide whether

or not to talk to us—and two people did not want to.

We produced an information sheet about our research

which we made available at each unit; staff and clients

had the research process and purpose explained to them

and were asked to sign a form giving their permission to

be interviewed with our details should they want to

contact us for any further information. The study was

approved by the local research ethics committee.

Findings

Our findings are structured around three emergent

themes. The first is ‘consensus versus mixed perspectives’

which reflects the wide range of perceptions of staff and

older people. The second is ‘a new culture in the making’

which refers to the emergence of a new culture (Batteau,

2000) of rehabilitation for older people in social services.

The third theme of ‘rehabilitation or adaptation’ refers

to the way in which ‘rehabilitation’ was being inter-

preted as a process of becoming adapted to the daily

life and routines of the TR units. (All names are

pseudonyms.)

Theme 1: consensus versus mixed perspectives

Here we highlight that while there was consensus

amongst managers and rehabilitation staff that the

scheme was successful, older people’s own accounts


highlighted markedly different ways in which they

experienced the scheme. All managers and rehabilitation

staff believed that the TR scheme was successful in its

core goal of enabling older people to return home. For

example, from a group interview with OTs and CCOs

the following statement was made: ‘‘We’d say that 90%

go home. Even someone who’d been in hospital 3 times

with falls has gone home.’’ This view was echoed by a

manager of one residential care home in which the

scheme was located:

I think we should carry on because it’s been a

wonderful project y I mean the ladies we’ve had in,

and the gentlemen, have been older, they’ve been in

their 80s and 90s, but they still returned home, so I

think there’s a great need there.

(Interview transcript—M3U1[2nd intv]:1)

Respondents also believed that many older people

would have been unable to go home without the

intervention. The following quotation from a rehabilita-

tion assistant emphasises this:

y I think if they’re going to make it it’s because

they’ve been here. I don’t think they should come out

of hospital and go straight home because they aren’t

going to make it y They need a bit of help y

they’ve got to get themselves back in order.

(Interview transcript—RA2U3:12)

While echoing this point, another rehabilitation

assistant also drew attention to the disabling effects of

a stay in hospital on older people:

Interviewer: So they come in here and you think that

they couldn’t have gone home straight away?

Participant: No. Oh no! None of them y it’s took

the skills away from them [being in hospital]. Because

y Ethel was 5 or 6 month in hospital y the first

time she made a cup of tea she was forgetting to put

water in the kettle and things like that because simple

things like that they’ve forgot. I think they want

boosting up because y on a 30 bedded ward with 2

nurses and a staff on, they aren’t going to have a

conversation with them.


Although this is not an accurate view of the staffing of

a hospital ward, it reflects the fact that all the older

people we interviewed reported less than satisfactory

experiences of their time in hospital.

Turning now to the mixed views of older people, the

first interviewee encapsulated a sense of the TR scheme

as a much-needed period of convalescence:

Interviewer: Do you think you could have gone

straight home from hospital?

Participant: No I don’t think, I don’t think I would

have got on so well. They’ve fed me well y I mean

they give you really too much as I say but y I mean

look at me now [about 9 stone] and I don’t think I

weighed 8 stone when I came in.

(Interview transcript—C13U5:3)

The second interviewee spoke of the TR scheme as

helping her to regain the will to live after being ‘‘very,

very ill’’ in hospital:

Participant: It was marvellous. y One day [the care

home manager] said, ‘‘We never expected you going

out on your two legs’’ he said, ‘‘Your eyes were sunk

in your head’’ and he said, ‘‘you looked in deep

depression’’. He says, ‘‘We never thought we’d get

you better like this’’ and he was so pleased. You

know you could see he was brimming over with it,

‘‘so happy that you look like this’’. But that’s how

they were.

(Interview transcript—C9U2/H:6)

The third interviewee viewed the TR scheme in a

much more critical light, seeing it as an unwelcome

deprivation of her rights and liberties:

Participant: I felt well I don’t want to be sort of

imprisoned or anything like that because I’ve done

nothing wrong y and while I don’t think there’s any

question of them thinking they’re keeping us from

doing what we want to do I think er, you, you could

feel a little bit like that occasionally because your life

belongs to you doesn’t it? And what you do is very

important to you and your way of going on is very

important to you. Then I think, ‘they’re very kindly

people who have got your interests at heart’, but

you’ve got to be a bit careful sometimes er you’ve got

to be careful.

Interviewer: What do you mean?

Participant: Well, I mean impeding people from

carrying out their own lifestyle and their own wishes.

Well you do want the kindness and that sort of thing

and I know there are occasions when you’ve got to be

looked after but er, you see when you said about you

would rather take the risk [of falling at home], yes I

would, I would, I would rather take the risk y I’ve

been here quite some time [about 5 weeks] and I feel

now I want to go, I do want to go home more than

anything in the world y

(Interview transcript—C10U1/H [1st intv]:13)

The fourth example attests to the potential of

rehabilitation to enable an older person—who in this

case initially did not want to return home—to regain the

will to do so.

Interviewer: Do you think you’d have got home

without going in there [transitional rehabilitation]?

Participant: No, no and it also gave me time to

assess, get used to the terrible things that have


happened [sudden death of her husband Martin]. Well

I had no intention of staying here [in her house]. None

at all y No I just didn’t want to be home here

without Martin.

(Interview transcript—C1H/U1:22)

The following comment from a rehabilitation assis-

tant highlights why someone might not want to return

home, irrespective of whether or not they are well

enough to do so:

And he [90 year old man] turned around to me and he

said, ‘‘I don’t want to go home you know that’s why

I’m not trying y do you know where I live it’s

vandals and I’ve had my window smashed and y I

just don’t want to go home y I want to go into care

y and when they says do you want to go to a

rehabilitation unit you know for rehab and that y I

thought if it gets me out of hospital I’ll go

anywhere—and that’s what happened.’’


Thus, the variation in older people’s views of the

scheme may be strongly influenced by structural factors

external to the scheme such as urban deprivation and an

associated sense of loneliness and isolation. It also

suggests that there are occasions when older people will

agree to anything that holds out the prospect of an early

‘release’ from hospital.

The difference in perspective between staff and older

people highlighted their different understandings of key

concepts such as ‘risk’, ‘choice’ and ‘enablement’ which

were central to the vision of TR. If she had been given

the ‘choice’ the interviewee above who felt almost

‘imprisoned’ would have chosen to go home and run

the ‘risk’ of falling rather than enter the TR scheme.

Indeed, at the point of entering the scheme she neither

appreciated that she had such a ‘choice’ nor that the

purpose was to ‘enable’ her to return home.

Nevertheless, older people’s experiences of the

scheme—even those who did not want to be there—

confirmed managers’ and rehabilitation staff’s beliefs

that the scheme was ‘personal’ in contrast to the

‘impersonal’ nature of hospital care. This personal

approach—founded simply on listening and talking to

older people—formed the basis for the development of

the kind of friendship and trust which seemed to be

essential for change and development. The implications

of this create the basis of the second theme.

Theme 2: a new culture in the making

Amongst experienced care home staff who now

worked as rehabilitation assistants, the data revealed

that the scheme had begun to generate a new way of

thinking about the capabilities of frail older people,

given the opportunity and appropriate support. Reflect-

ing on previous ways of working, rehabilitation assis-

tants began to recognise that in the past they may,

unwittingly, have contributed to older people becoming

dependent and institutionalised. When older people

went home from TR staff felt rewarded for their efforts.

This was in marked contrast to their experiences of what

happened to ordinary residents who, as one rehabilita-

tion assistant put it, when they do leave ‘‘it’s either dead

or gone into hospital or gone to a nursing home’’.

The skills of a rehabilitation assistant were seen as

different from the skills normally required for residential

work. This distinction is expressed by one care home

manager:

Interviewer: You mean the older person’s got to want

it to work?

Care home manager: The older person and also the

staff. They’ve got to have this commitment y you’ve

got to think that little bit more y it’s a lot of

patience, sitting talking, not just doing the personal

care. It’s a lot of time with the client, talking, getting

to know them, getting to know the family back-

ground, getting to know the family y You’ve got

to be able to sit and listen. A lot of people can’t do

that y

(Interview transcript—M3U1:19)

While the manager saw the work as requiring different

skills, rehabilitation assistants often spoke of the

enhanced levels of job satisfaction they experienced, as

exemplified in the following extract:

But the most rewarding part about it [TR] was—with

working in a [residential] home you see them

[residents] everyday, you never seen anybody going

home y and my biggest pleasure was the very first

time, I was on here [TR] for quite a while, I took that

lady to the front door and I was so proud that she’d

come out of hospital with a broken hip, but within 8

weeks I’d helped her to get back to how she was say 6

month ago and to put her in the car, the feeling’s

tremendous, ‘I can’t believe I’ve done this for

somebody’. Do you know what I mean?


Rehabilitation assistants also reflected on some of the

older people they had worked with in residential care

and realised that transitional rehabilitation may have

been able to counteract the social isolation that often led

to admission into long-term care.

I worked in residential care and I think from what my

experiences from past clients that have gone now,

I think they would have fitted into this perfectly y I

can remember one person that went into residential

care because she was lonely. It’s not that she couldn’t

help herself, the person that she looked after died so

there was a gap there and I think y we would have


been able to fill that. Make sure she was at home

properly, make sure she had the support that she

needed in the community like going to day centres

and things like that.


Various rehabilitation assistants explained the differ-

ence between working on the residential side and TR.

Although expressed in different ways, their preference

for the work of a rehabilitation assistant was consistent,

as these two examples indicate:

Well the residential side you y get into a routine and

everything’s more or less the same y On the rehab

you’ve got that many people coming in it’s different

every week y plus there’s more input. You’re more

involved with what goes off with them at home and

their personal life and everything y

(Interview transcript RA18U4:1)

Here you’ve got the chance to talk to them more

because you’re doing exercises with them or you’re

learning them to make tea or make a sandwich y

Whereas downstairs (in the residential home) you’re

with them to wash them and dress them and bath

them, take them to the dinner table, bring them back.

But you’re not sitting with them to talk to them are

you? So you’ve got more personal up here.


When asked about what it was that in their experience

made TR work, rehabilitation assistants in particular

emphasised the importance of getting older people to

‘trust you’ and of gaining their confidence. During

fieldwork the researcher [EH] explored this idea with one

of the most experienced CCOs who confirmed what the

rehabilitation assistants were saying:

I asked [the CCO] about Helen and Maria [the two

rehabilitation assistants on the unit] and the con-

fidence thing and she said they picked it up,

encourage people to do things—have an approach

and people trust them and they get that person’s

confidence—they [residents] know that Maria and

Helen don’t ask them to do things that they can’t do.

She said that ‘whatever they were able to do we get

them back to that and better’.

(Field—notes EHU112701:14)

Feelings of love and attachment were an important

part of the work for one rehabilitation assistant. This

was despite the fact that this participant reported that an

occupational therapist had told her that such feelings

were ‘‘not professional’’:

When [Vera] she went home it upset me y she locked

herself in the toilet when she was going home and I

says, ‘‘Are you alright Vera?’’ and she says y ‘‘I

don’t know whether I want to go home or not you

know’’ she says, ‘‘I want to go home’’ she says, ‘‘but I

love you and all’’. y She was 90 odd and I looked at

Chris [community care officer] and Chris looked at me

y and she says, ‘‘She made me cry as well’’ and she’s

the community care officer! y So you could never

ever, I don’t care, if people don’t shed tears they’re

not in the job, they’re not right for the job. Must

have hearts of brick.


The importance of close bonds of affection—even

love—was also emphasised by older people, as this

extract illustrates:

y to be with somewhere where they loved you is

something in this day and age isn’t it really? It really

is. Everybody was so kind and I was looked after.

Because I was just a wreck when I went there [after

leaving hospital]. [One of the rehabilitation assistants]

used to work mornings and nights and I was going

home on the Wednesday. Tuesday night about ten

o’clock she tapped on the door she says, ‘‘Rose are

you still awake?’’ I said, ‘‘Yes’’—I’d only just gone to

bed. So she came and sat on my bed, she put her arms

around me and she hugged me and she said, ‘‘I’ve

loved looking after you’’, she said, ‘‘Now you will eat

won’t you?’’—because that was my trouble I wasn’t

eating y That’s how they work there so you can

imagine.

(Interview transcript—C9U2/H:5-6)

A number of themes emerge from these accounts, all

of which bear on the general point, that the process of

‘TR’ enabled the development of a different culture in

work with older people. The contrast between the nature

of the work in TR and the experiences of staff as care

assistants in residential homes was stark. They con-

sidered that effective rehabilitation required a much

more personalised approach, with a particular emphasis

on relationship building. By contrast, the work of a care

assistant emphasised the mechanics of group care. The

routine of ‘bed, dressed, breakfast, dinner, tea, back to

bed’ depersonalised the nature of the care work. The

extent to which the rehabilitation assistants had devel-

oped an awareness of this shift, and the extent to which

it improved their level of job satisfaction, was striking.

In addition, strong personal relationships were devel-

oped between rehabilitation assistants and older people

themselves; it was often the nature and quality of these

relationships that were best remembered by older

people.

Theme 3: rehabilitation or adaptation?

The TR scheme was developed on the assumption that

the OT would direct both what was done and how it was

carried out. However, while the OT assessed people and


prepared the individual goal plans it was generally the

rehabilitation assistants who were responsible for put-

ting them into practice and keeping them up to date.

Thus, there was potential for the therapeutic goal plan

to be translated into something subtly different—given

that it was put into operation by people who were not

professionally trained therapists. The following field

notes illustrate this point and concern one resident

whose goal plan was to make him more ‘hygienic’ by

enabling him to change his socks—which he did not

normally do because, following a hip operation, he

found it painful to do so:

yI asked if I could go with Maria and George to

watch her watching him put on his socks y I’d asked

Maria before y how she knew what to do, and she

said that she ‘‘just worked it out for herself’’, and not

from the OTs,yI stood slightly behind him to his left

and Maria sat on his bed. He sat on a chair facing the

door with his back to the window. He crossed his

right foot over his left thigh [as Maria instructed him

to do] and then tried to lean forward to put on his

sock, which he just couldn’t reach. She kept saying:

‘‘Try. You can do it’’ and he kept saying: ‘‘I can’t, I

can’t, I can’t’’. In the end I had to say: ‘‘He can’t do

it’’, and then she said: ‘‘He can’t do it can he?’’

[Looking to me]. I’ll tell the OTs that he can’t do it.

He’s tried and he can’t do it’’.

(Field-notes—EHU112701:22)

It was disturbing to observe this interaction because

George, who in the end was almost pleading, was

perched awkwardly on the chair and at one point he

seemed likely to fall off. This was both non-ergonomic

and unnecessary because extension devices are available

which would have made this task easy.

In contrast the next extract highlights how a skilled

OT was able to transform the life of one older person,

making it possible for her to walk without the need for a

walking frame:

y the physio [Melanie—in fact, an OT] y said, ‘‘I

am going to get you up!’’. I said ‘‘No!’’ You might as

well have said take my feet away! Because I was so

dependent on this frame and couldn’t bear the

thought of it y So, came the day y and I said,

‘‘No, no, I can’t’’. So she [Melanie] said, ‘‘Yes, you

can, come on try it anyway.’’ y So I had to get on to

the stick and of course somebody would link me

[through her arm]. Melanie was very good at assessing

because she said quite early on you know, ‘‘Your

balance is improving daily’’ and she knew when I was

ready. She was excellent y

(Interview transcript—CAU1/H:22)

Our data challenged the view that the scheme

provided a ‘‘simulated home environment’’ (as one

occupational therapist described it). Our findings

suggest that managers and rehabilitation staff perceived

the units as being like home but also as training units.

For example, rehabilitation assistants used a socially

constructed notion of ‘home’ which was abstract and

general. By contrast older people used a personally

constructed notion of home which was specific and

personal to them. For older people the meaning of the

place called home was ‘‘inexorably tied up in the lives of

individuals as they are born, age and die’’ (Rubinstein,

1990: 40). As Mrs Frazer explained it:

y more than anything in the world I want to go

home, back to my home. Because the house does

belong to me and it’s the house that mother and I

bought together y and I think we both bought it for

each other you know for whatever happened. And er,

so that’s how I came about that house and it’s a nice

house and I am very fond of it y

(Interview transcript—C10U1/H [1st intv]:3)

In the newer units in particular, the idea of

‘rehabilitation’ as a period of ‘training’ which might

enable the older person to use equipment which they did

not previously have at home—especially microwave

cookers—had become part of the shared vision of

rehabilitation assistants. Within this vision, ‘making a

hot drink’ (i.e. tea) was a common and powerful idiom

carrying symbolic and practical significance. It was

symbolic in that the making and drinking of tea was a

social activity and marked the older person’s integration

into the norms of the unit. It was practical, because it

required basic skills (like remembering to put water in

the kettle) which were essential to everyday life at home.

Amongst rehabilitation assistants in particular, but also

CCOs and OTs, an older person’s progress was assessed

by her ability to make a cup of tea.

Alongside the ‘personal’ and ‘home like’ approach,

therefore, and somewhat in opposition to it, emerged the

idea of ‘training’ older people in ‘batches’. Amongst

rehabilitation assistants in particular, the concept of

‘training’ sat uneasily alongside that of ‘rehabilitation’ in

the sense of promoting independence. We observed that

in two of the units the corridors were very long; during

one visit we observed two residents going for a walk

around them and getting lost—indeed they passed us

three times. In this one purpose built unit the ‘training

kitchen’ was so far from the residents’ day-room that it

was an effort for them to get there, especially with a

frame. Rehabilitation assistants had ideas for ‘improve-

ment’ which highlighted this instrumental emphasis on

training, as the following extract indicates:

We want to knock a wall down. We want a couple

more wall units and a couple more sinks and make it

more as a training centre for them. With another

fridge and another microwave so we can get them in.


If there’s two of us we can get four in at once you

know and get them doing y


From our observations over the two-year period we

noted that a process of re-institutionalisation seemed to

be taking place in response to the drive for bigger (ten

bedded), more cost effective units:

It’s going to, we’re going to have everything. We’re

going to have us proper kitchen where we can

actually cook with them, us own laundry room y I

mean this is like a makeshift room. This is what we

did ourselves, you know just made it into a makeshift

thing. But to actually go into a proper rehabilitation

centre, plus we’re going to have ten instead of five so

it’s going to be a really big challenge.


Nevertheless, not all rehabilitation assistants we

interviewed were as excited by the prospect of becom-

ing what one described as ‘‘institutionalised’’. One

expressed concern that an increase in bed numbers

would have a negative impact on the team-based

and personalised ways of working from which she

derived great satisfaction. Indeed, the increase in size

and scale of rehabilitation may have the paradoxical

effect of vitiating the very factors that drew the most

positive comments both from older people and rehabi-

litation assistants, the focus on being cared for and

loved.

Therefore, we believe that as the TR scheme

progressed it changed its essential nature. In terms of

the rehabilitation process, we identified that adaptation

to the norms of the institutional setting was almost as

important a concept as the promotion of independence.

In addition, we noted that, as the TR scheme progressed

there seemed to be a gradual re-emphasis on some more

institutionalised features—‘training’ kitchens, and the

like.

Discussion

Our findings resonate with earlier work in a number

of areas. For example, the ethnographic approach

confirmed the advantages of this research method in

generating data of considerable richness, depth and

breadth (Hammersley, 1990; Savage, 2000), particularly

when applied to various forms of institutional care for

older people (Stafford, 2003). It enabled a focus on the

perspectives of older people, and also on the views of

staff (in this case, rehabilitation assistants), who have

been absent from much intermediate care research. In

addition, drawing on previous studies (Smith & Cantley,

1985; Hart, 1999), the breadth of these perspectives has

enabled us to conclude that the scheme cannot simply be

labelled as a ‘success’ simply because many of those

providing it presented it in such a way, having a

tendency to ‘eulogise’ over its performance. Our findings

indicate that ‘in some ways it was a success and in some

ways not’ (to paraphrase Smith and Cantley). However,

older people voiced a wider range of views including one

older person who felt almost ‘imprisoned’. In addition,

confirming the findings of Hazan (1992), the attitudes of

staff members to their work were highly complex. While

some members expressed highly emotional views of their

work, others focused on an instrumental view of the

purposes of the scheme, emphasising the ‘training’

elements of the units leading to our conclusion that

the concept of ‘adaptation’ became as important as the

original notion of ‘rehabilitation’. Furthermore, the

findings of the independent RCT showed that there had

been no better outcomes (in terms of survival, long term

institutionalisation, disability or psychological well-

being) for those going through the scheme than those

in the control group (Fleming, et al., 2004). While we

recognise that this may be because an RCT cannot

readily encompass the views and experiences of different

people—as our ethnographic study was designed to

do—it introduces a note of caution especially when

interpreting providers’ claims of success.

Our findings also reflect on the classic concepts of

‘institutionalisation’, drawing particularly on Goffman

(1961). One of the key elements of the TR scheme is that

it used institutional settings for a short period in an

attempt to avoid greater use of long-term institutional

care. From the testimonies of many staff it is evident

that the changed patterns and priorities of work were

starting to effect a change in their attitudes towards the

general potential of older people to live independently.

However, to balance this, there were also indications

that new forms of institutionalisation were emerging—

notably in the growing emphasis on adaptation to the

norms and routines of the establishment as a proxy for

being able to live independently in the community. As

Goffman (1961) emphasised, one of the key aims of an

institution is its desire to remake the individual into a

being that conforms to the priorities of the institutional

environment—which appeared to be happening in the

study. Both themes 2 and 3 therefore contain material

that is pertinent to the continuing study of institutiona-

lisation.

For example, in addition to showing how an

institution is always that—however ‘home-like’ it tries

to be—our study raises a question about the assump-

tions that home is always best and that it is desirable and

possible to simulate a home environment in an institu-

tional setting. The concept of ‘home like’ served for

rehabilitation staff and older people alike to express the

difference between hospital and TR, including the

latter’s more ‘personal’ approach. At the same time,

for older people being in a unit was not like being in


their own homes (the communality, the routines, being

watched to see what they could do). Tensions arose

when trying to create a transitional ‘home’ away from

home in a long-term care setting. This was partly

because rehabilitation assistants tended to promote

‘adaptation’ to the extent of re-conceptualising rehabi-

litation as a form of ‘training’, including new skills

which the older person might not need when at home.

This was especially so in the larger purpose built units.

Despite this, the more personal approach had begun to

change the relationship between rehabilitation staff and

older people in such a way that they were able to

establish a partnership based on trust. Trust is one of the

key attributes of home-based rehabilitation which helps

to make the therapy more relevant to the needs of older

people (von Koch, Holmqvist, Wottrich, Tham, &

Pedro-Cuesta, 2000).

Our findings are also relevant to a key policy debate

about whether such initiatives are driven more by the

need to cut costs by ‘unblocking’ hospital beds than

by a concern to provide older people with access to

high quality care in specialist units (Grimley-Evans &

Tallis, 2001). The TR scheme was a potentially cheaper

alternative to specialist hospital care because it relied

on low-paid, mainly part-time and relatively untrained

women to staff the units. Nevertheless, the findings

also show that it created the conditions for the

emergence of a new culture which challenged ageist

assumptions about the limited ability of frail older

people to benefit from rehabilitation. While this latter

development was not a substitute for access to specialist

care, it provided a ‘personal’ service, different from,

and preferable to, what older people reported had

happened to them in hospital. Furthermore, older

people did have direct access to specialist input

from OT and physiotherapists of a kind which thera-

pists claimed they would neither have had the time

nor resources to provide for hospital patients. These

points bear directly on the NSF for Older People

(Department of Health, 2001), in relation to the priority

given both to intermediate care and to ending age-

related discrimination in the provision and delivery of

services.

Conclusion

Our study has highlighted the need to understand

intermediate care from the different perspectives of older

people, providers and managers, and to recognise the

possible consequences, positive and negative, of provid-

ing rehabilitation away from home. Providers gained

considerable personal satisfaction from what they

perceived as the ‘success’ of the TR scheme in that it

seemed to reverse the normal trajectory of dependency,

institutionalisation and the grave. Some of the older

people in the scheme echoed those of providers in

recognising that without TR they would not have been

able to return home.

Despite a view that high quality institutional

care is too expensive for policy makers, our findings

suggest that is just what some ‘ordinary’ people

want. Our findings also suggest that it is possible, even

within an institutional setting, to provide specialist

rehabilitation services for those older people who want

them which transform their lives for the better.

However, we conclude that policy makers need to be

cautious in the development of residential forms of

intermediate care, for two linked reasons. First, it

should not always be assumed that home is best for

all older people. Secondly, it is by no means straight-

forward to simulate the conditions of home in an

institutional environment—especially one that is

purpose-built.

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