Service Users’ Decision-Making During Transition to Long-Term Care: Social Workers’ and Older People’s Perspectives

As the world’s population rapidly ages, older people are increasingly placed in long-term care institutions. Although this global trend is supposed to protect older people, it is unclear whether they have any voice in decisions about such placements. The aim of this paper is to report a qualitative study into whether and to what degree social workers involve older people in these decisions. The study employed in-depth semi-structured interviews, focused group discussion, sociograms, and the daily and weekly schedules of 17 respondents (7 social workers and 10 older people in long-term care) in Warsaw, Poland. The findings show that social workers did involve older people, but only in minor decisions after their placement to help them adapt to the new situation. This practice seems to be attributable to neoliberal and managerial tendencies in the policy guidelines that social workers must follow in performing inherently relational tasks. The paper concludes by outlining the implications of these findings for social work.

fears, wishes, and expectations (Koch & Webb, 1996), and this contributes to higher mortality in LTC (Andersson et al., 2007). These results suggests that involvement is a fundamental component of a healthy transition. 1 Despite this knowledge and the power and influence they have (Uggerhøj, 2014), social workers often dismiss clients' participation. Social workers all over the world have been shown to impose decisions based on neoliberal and managerial service delivery guidelines (Jönsson, 2019).
LTC institutions are often stigmatized as places for the poor, abandoned, homeless, and isolated (Golinowska, 2010). With that impression may come the conclusion that most older people move into LTC involuntarily, driven by poor conditions of life or chronic illness (Styczyńska, 2012). Heliker and Scholler-Jaquish (2006) argued that this conception may allow social workers to characterize people transitioning to LTC as dependent and to deny them opportunities to choose and negotiate about where, when, and which residence to move to, or even what to move with. This attitude contravenes social work principles of self-determination, human rights, and human dignity. Given this background, this study aimed to investigate whether and to what degree social workers involve older people in decisions about their transition into LTC.

The Role of Social Work in the Transition Into LTC Institutions
Healthy transitions into LTC institutions require systematic planning and coordination before the actual relocation (Reuss et al., 2005). Evidence suggests that social workers, because of their skills in making social diagnoses, should be at the center of developing transitional care plans (Wilson, 1997). Further research suggests that social workers organize facility tours to allow individuals in transition to interact with staff and residents and to learn about the facility's services, policies, and procedures (Perrin & Polowy, 2008, p. 3). This could clarify their expectations, allay their fears, and allow older people to make wise decisions about where to relocate and what facilities they want well before they finally move. Social workers have a critical role in enabling healthier, more successful transitions to LTC institutions and thus enhancing older people's quality of life and well-being.
This professional role obligates social workers to enhance their clients' selfesteem and self-determination through allowing them choices, independence, and opportunities to function at their highest possible level during import transitions. Milne et al. (2014) concluded that gerontological social workers must take a holistic view of older people, including their bodies, their minds, and their experiences, before any admission to a care home. While the transition to LTC is inherently complex (Reuss et al., 2005), social workers can help clarify complex situations, connect older people to appropriate services, and support them to make the best choices (Wamara & Carvalho, 2019). Due to their knowledge, values, and ethical basis, social workers possess a unique ability among professionals to work with service users in difficult times (Wamara, 2017;Butler & Webster, 2004).
The mission of gerontological social work includes enhancing older people's decision-making abilities (Phillipson, 2008) and providing spaces and alternatives to enable them to make difficult decisions. Social workers should use a client-centered approach, pertinent skills, and specialized knowledge to help people manage complex life situations. They can also encourage older people to participate in the transition process by establishing trust, conveying respect, and allowing them choices (Iwasiw et al., 1996). This support helps to reduce the harmful effects of such a major change to a new life.

The Study
The study aimed to discover whether, and to what degree, social workers involve older people in decisions during their transition to LTC, with the understanding that such involvement is one of the elements of a health and successful transition (Andersson et al., 2007;Brandburg, 2007;Tanner et al., 2015). Many social work studies focus on the experiences of new residents in LTC institutions, their adjustments to the new life, and the consequences of poorly executed transitions, but few if any ask whether social workers allow older people to participate in decisions during the transition. To address this gap, we conducted a qualitative analysis of social workers' descriptions of their interactions with older people during transitions into LTC.

Setting
We conducted the study, at the state-funded (welfare) home for older people, Dom Pomocy Spolecznej (DPS) in Warsaw in April and May, 2018. At the time of the study, the DPS had 156 residents (47 in nursing and palliative care and 109 under the care of social services). The DPS operates under the Warsaw Center for Helping Families, a municipal welfare institution charged with helping vulnerable families achieve dignified lives. It employs a multidisciplinary team including nurses, social workers, physiotherapists, psychologists, doctors, and music instructors to offer comprehensive services to the residents. The study focused on the transitions of older people into the social care services component.

Participants
We used purposive (Patton, 2002) and convenience sampling techniques to select social workers employed at DPS and residents who could answer all the research questions. Selection criteria for both groups were availability, ability, and willingness to participate in the study. Additional criteria for residents were being under the care of social services and having lived at DPS for less than a year. The selected sample comprised 7 social workers (4 women and 3 men) with work experience ranging from 3 or > 10 years (3-5 years = 2; 5-8 years = 3; > 10 years = 2) and 10 residents (7 women and 4 men) aged 73 to 82.

Research Design and Data Collection
We used a qualitative research design (Denzin & Lincoln, 2011) to seek information directly from social workers and residents about older people's participation in their transition to LTC. To collect rich and detailed data, we used multiple methods including in-depth semi-structured interviews with the social workers, a focus group discussion (FGD) with the older residents, sociograms, and the daily and weekly schedules of both social workers and residents.
The interviews and the focus group asked social workers and residents, respectively, whether and how older people participated in decision-making before and after their admission to LTC. The FGD with the older residents was critical in confirming the interview data.
Sociograms established social relationships between residents, social workers, fellow residents, other staff members, and family members. We also consulted daily and weekly activity schedules to compare the patterns provided by social workers with those provided by the residents and to better understand the kinds of activities residents engaged in.

Data Analysis
We analyzed the data using qualitative content analysis (Berg, 2001). We first recorded the interviews and the FGD on a mobile phone and manually transcribed the recordings into texts. We then read each text to get a sense of its whole. Next, we sorted passages in the interview text into four themes reflecting topics almost every social worker discussed (older people's involvement in the pre-admission, admission, and adaptation phases and barriers to that participation), after which we further questioned and compared text passages in every theme to gain credibility and trustworthiness (Guba, 1981). At the same time, we analyzed the data from residents in the same way, using the same themes, to gain a balanced view of older people's participation and to derive appropriate implications for social work practice. Both groups are represented in the findings.

Ethical Considerations
The study received approval from the Research Ethics Committee of the Faculty of Education at the University of Warsaw. We informed participants of the aim, methods, expected benefits, and planned dissemination of the findings verbally and in writing (in Polish). At the beginning of each interview, we emphasized participants' rights to abstain from or terminate their participation at any time. We provided participants with information sheets and consent forms to read and sign as a confirmation that they had understood the research and agreed to participate. We also obtained written informed consent from Warsaw Center for Helping Families and DPS.

Findings
Most participants reported that older people had no involvement in decision-making in the pre-admission phase and only nominal participation during admission and adaptation stages. The analysis resulted in four themes reflecting older people's participation in the transition process: (1) pre-admission, (2) admission, (3) adaptation, and (4) barriers to older people's involvement in the transition. Because transition is a continuous process, it is difficult to clearly define where one phase ends and the next begins, and barriers to older people's involvement occur in all three phases.

Theme 1: Pre-Admission
Reflecting on their work with older people, social workers made it clear that they were required to adhere to state policy guidelines: "Here in Poland we have guidelines that we follow, and we expect our clients to cooperate" (Social worker 2, interview, April 11, 2018). Community-based social workers reviewed older people's health documents, sanitation, housing conditions, and income and worked with their families to ascertain whether, with or without help, they could safely continue to live independently. When poor living conditions threatened an older person's welfare, social workers reported to the municipality immediately. In any case, the municipality decided, with no input from older people, whether or not to move them into LTC: Every community has a social worker whose job is to assess the welfare of families. For the older people, they assess how often they are in contact with their families, their income status as well as sanitation and housing conditions. If the conditions are far below the expected standards of living, they advise the municipality to relocate the person to the welfare home. (Social worker 2, interview, April 11, 2018) Although the municipality decided whether to move older people to LTC, those decisions were based entirely on the social workers' assessments; the opinions of the older people were not sought. Social workers attributed this to the government's greater concern for older people's safety and health than for their preferences.
Following the decision to move a person to LTC, the municipality would then identify which facilities had space. If there was only one, the municipality would inform both the person, who had no choice but to accept, and the selected facility. Only if there was space available in more than one welfare home would the older person be allowed a choice.
Yes, I had a choice. There were a few homes, but they were [far] away and I preferred to be here in Warsaw. Apart from this place they offered me two other homes, but they were far from Warsaw. One of them was near Białystok, and I don't remember the location of the second one. (Older person, FGD, May 9, 2018) Participants emphasized that such opportunities were few and available only to those willing to relocate.
Social workers reported that the policy guidelines did not promote the voices of older people during pre-admission, nor did staff at the receiving home have any knowledge of new residents until they received a letter from the municipality indicating the facts of the admission. "There is no participation for older people in their transition, especially before they move to this place" (Social worker 4, interview, April 15, 2018). Staff therefore often worked with people who refused to talk on their arrival, making it difficult to determine their proper care, and they could also misunderstand new residents' questions as insistence and resistance. This was a professional challenge, not just in practical terms, but because it against their professional social work values.
After receiving the letter from the municipality, we organize a multidisciplinary meeting to prepare for the incoming person. We decide on who to pair with this person, which floor the person will be on, and the kind of rehabilitation activities to offer them. However, because these people have not been prepared to relocate, they are upset, and sometimes they refuse to eat or talk, which makes it hard to provide for them. (Social worker 1, interview, April 11, 2018) Social workers said that older people's involvement in the pre-admission phase was essential, and regretted that the state guidelines did not provide for it. Some older people also reported that because they had not been involved in decisions before their transition, they remained confused about why and for how long they would be in the facility.
I was told to apply and come here for a while until my personal challenges with the bank are solved. What I don't know is whether I will go back to my home or not. The community social worker did not explain to me well. (Older person, FGD, May 9, 2018) This was confirmed by another social worker: Some residents think they are on the vacation or in the hotel. They don't realize they are in the LTC. They have not been told. Some think they are here for only a month or couple of months. One of the residents thinks that he is here to repair his bones and will go back home. (Social worker 4, interview, April 15, 2018) Residents expressed their dismay that no one had talked to them prior to their move and felt they should have had the right to decide on what to take or leave and where to go.
For me, it was as if they were just throwing away old stuff from my house. I did not like how I was brought here. Now, I like this place because the manager is good and talks to us well. (Older person, FGD, May 9, 2018).
Participants further revealed that old people were first instructed to admit themselves to the selected LTC facility. If a person refused to go to the new home as instructed, the home would inform the municipal authorities, who would then process a court order for community social workers to bring that person to the home. Social workers reported this to be common among those receiving nursing and palliative care.
The results in this theme show that in addition to the lack of interaction between social workers and incoming residents, there was no collaboration between the agencies responsible for implementing the transition. Community social workers, whose major task was to conduct pre-admission assessments, worked independently of the institutional social workers. Not only were new residents excluded from decisions about their move, but there were also no coordinated transition plans for them.

Theme 2: Admission
Just prior to admission (as reported in Theme 1: Pre-admission [Social worker 7, interview, May 4, 2018]), institutional social workers met to decide who the incoming resident would share a room with, on which floor, and when the move should happen. These critical decisions, made at the discretion of the facility staff, were in place before the new residents arrived. New residents had no knowledge or, or participation, in these decisions.
Social workers explained that because of their training in working with people undergoing stressful life changes, they were the first people to receive new residents and acted as "shock absorbers" for the hostility displayed by some new residents.
When the person relocates, we social workers are the first people to talk to the person. We give a warm welcome, show the person the room, and allocate a carer to this person if they need one. We also tell the person about the available services in the home like telephones, TVs, entertainment, the internet, and indoor games. If the person has cooperated with the staff, then we read them the rules and regulations of the home. (Social Worker 7, interview, May 4, 2018) Social workers emphasized that this was the most challenging part of the transition as new entrants would usually be upset about the relocation. They reported providing therapeutic talks with new residents to foster their adaptation to the new environment.
At this stage, residents had their first opportunities since the beginning of the transition to make choices, including making their own personal timetables for activities including painting, volunteering in the canteen and in the gardens, playing table tennis or pool, reading in the library, watching TV, listening to music, reading newspapers, playing cards, attending various therapy sessions, surfing the internet, attending church services, writing articles in the institution's magazines, and singing. Social workers reported, however, that these types of choices did not actually influence any institutional decisions.
In this home, residents have food to eat, a place to sleep, and [ways to] entertain themselves. There are things residents can participate in fully, especially during their free time, but when it comes to what to eat or where to sleep, what to bring into the home, they do not have much power to decide. However, residents have their own kitchen where they can decide what to cook, what they want, but it closes at eight p.m. (Social Worker 3, interview, April 13, 2018) Residents, however, disagreed that they could choose their own food: "The kitchen coordinator decides for us what to eat even if you don't want that type of food." (Older person, FGD, May 9, 2018).
Although social workers were the first to interact with the new residents, large caseloads meant they had insufficient time to involve the older people as they should under the professional social work code.
We have many residents that social workers take care in this DPS. Each social worker attends to fifty-two residents, which weakens the capacity of social workers to attend to every resident. (Social Worker 3, interview, April 15, 2018).
Social workers also had to deal with documents from the municipality and court decisions that required much of their time. They felt the paperwork deprived them of their time with residents.

Theme 3: Adaptation
Recognizing residents' lack of choices, especially before but also during admission, DPS had developed strategies to enhance older people's participation after admission. As described in Theme 2: Admission (Social worker 7, interview, May 4, 2018), social workers tried to promote residents' agency by providing them all the information necessary to make informed decisions about participating in the available activities. The institution's policy was to provide this information as soon as the person was admitted, and social workers continued to provide it during the adaptation phase: "We try to give them information about the available services as much as possible so that they keep busy. We have services that can keep them busy such as the library, entertainment, and games that they can play" (Social worker 3, interview, April 13, 2018). Participants overwhelmingly agreed that clear and adequate information was critical in supporting older people's participation.
Another strategy was involving two residents (a man and a woman) on an eightmember management board charged with making decisions in the home. "We have a management board comprised of eight people that meets once a month. Two of the members are residents, and they can talk about everything that they don't like" (Social worker 4, interview, April 15, 2018). Residents confirmed this in the FGD: "We have a management board of residents, and I am the chairperson of this board. In the board there are eight people, and we have meetings with the director every month, and then we can talk about everything that we don't like" (Older person, FGD, May 9, 2018). The residents' board, however, was more concerned with evaluating the services at the home than with promoting residents' voices during their transition and adaptation to LTC.
Weekly meetings between social workers and residents were another strategy for enriching residents' participation in decision-making. At these meetings, all residents, rather than just the two on the board, had an opportunity to suggest ways to improve services. However, the home did not implement all of their suggestions, and residents perceived the meetings as mere consultation, not full participation.
Finally, to help residents adapt more quickly to the transition and to enhance their engagement at the facility, social workers made themselves available during office hours. "We maintain an open-door approach to allow our seniors to come to our offices and make suggestions" (Social worker 1, interview, April 11, 2018). This strategy was intended to bring residents closer to social workers and provide them with space to engage social workers in their needs. Social workers also visited residents in their rooms to listen to their concerns and inform them of the steps to take if they wanted something from the institution. Social workers felt the visits also gave them an opportunity to listen the residents' life stories in order to understand the circumstances that had led to their present state.

Theme 4: Barriers to Older People's Involvement
Participants said that state policies, paperwork, low self-esteem, and increased demand for LTC institutional services are barriers to older people's participation in the transition. Social workers said they followed both state policies and their professional ethics and values, but they agreed that when state polices came first and social work came second, they were no longer able to perform person-centered and relational tasks. Paperwork was a barrier to older people's participation as social workers spent so much time preparing documents and working on the computer that they had little time left for consultative transitions. They repeatedly mentioned the accelerating demand for LTC institutions as a barrier to older people's effective participation transitions. They felt overwhelmed by the number of people relocating to the home and found it difficult to listen to all of them.
It is not easy for older people to participate in the transition process because there are so many residents in most of the public long-term care institutions facilities here in Poland. For example, here we have a hundred and fifty-six residents served by only three social workers with a ratio of one to fifty-two, which makes it hard to attend to everybody's needs (Social worker 1, interview, April 11, 2018).
Interviewees repeatedly linked low self-esteem among residents and those in transition to the negative public perceptions of LTC institutions in Poland, which they said damaged older people's confidence and discouraged them from actively engaging with service providers.
People in Poland think these homes are for poor people, so some people come here with their personal confidence already low. Without the morale to participate in the decision-making processes. Even when we provide the opportunity to participate, they do not feel they have what it takes to contribute anything to their new home (Social worker 7, interview, May 4, 2018).
Relocating to an LTC institution, therefore, seemed to be a sign of defeat for some residents.
Social workers highlighted that although social work principles required them to promote service users' involvement, their job descriptions emphasized assisting new residents to settle in, preparing documents, and conducting room visits to explain the facilities over promoting residents' involvement.
My role here as a social worker is to talk to the new entrants on arrival, prepare documents for the center for the municipality and courts regarding the new resident, visit residents in their rooms, and explain the facilities available to them. I also read the rules of the house to the new residents since some come here with some behaviors that we do not encourage, like drinking alcohol. (Social Worker 1, interview, April 11, 2018).

Discussion
The aim of this study was to examine whether or not social workers involve people in decisions during their transition to LTC institutions. Through qualitative content analysis, we considered the themes of pre-admission, admission, adaptation, and barriers to older people's involvement in the transition. Participants considered older people's participation to begin after admission to the home and to include only minor decisions such as what activities to engage in, rather than major decisions such as what to eat, who to share a room with, and where to sleep. This is pseudo-participation since despite the social workers' descriptions of older people's participation in the transition, it lacks the element of active involvement or agency. Making decisions solely on how to pass the time in a welfare home denotes passive participation. Explanations of older people's participation in the literature also portray older people not merely as recipients of support, but also as active people making choices after admission despite the greatly limited available to them (Lord et al., 2016;Lymbery, 2005;Walker, 1999), but our results show that their participation is passive and limited to trivial decisions.
The findings in this study were somehow discordant with those in earlier studies. Rather than describing older people's involvement in planning and coordination (Perrin & Polowy, 2008) and inclusion in discussions with family members (Rehfeldt et al., 2000;Reuss et al., 2005), the major finding in this study was that participation occurs only after admission, and then to a very limited degree. This likely stems from the discriminative structures in the social care services that view older people not as resourceful participants in their own lives, but rather as receivers of charity (Jönsson, 2019). Another possible reason is that participating social worker may have described transitions from the policy perspective, which does not consider older people's active involvement before admission.
Both social workers and older people accepted that some residents had been compelled to move in without prior consultation. Therefore, they felt angry and confused. In addition to the psychological consequences, this shows disregard for residents' human dignity and violation of the right to participation in the United Nations' principles for older people: Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter, care or treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives. (UN, 1991: Principle 14).
By this principle, social workers have a duty to promote older people's rights and self-determination. The right of older people to participate in decisions about their lives is prominent in social work literature (University of Brighton and Age UK Brighton & Hove, 2013) and significant in shaping critical decisions to provide older people services that meet their needs.
We found that social workers in Warsaw executed transitions followed state policy somewhat more closely than the ethical requirements of social work. Transitions were determined by municipalities based on assessments by community-based social workers. The municipality made the major decisions about whether and where to relocate someone and issued instructions on where and when to move the person. This is common in contemporary society, which restrains democratic choices to buying and selling. Unfortunately, this shrinks the space for social work to operate professionally while upholding its values and ethics. Uggerhøj (2014) argues that social work today focuses more on compelling citizens to obey authoritarian guidelines than on following its central value of promoting self-determination. This arises from contemporary neoliberal welfare policies that are oriented more toward resource maximization than to human rights.
Social worker participants mentioned that state welfare policies undermined their efforts to promote older people's participation in the transition to LTC institutions and agreed that they do not negotiate with older people because the policies allow no room for negotiation. Arguably, such policies are based on the neoliberal stance that "people can only exercise choice through spending" (Monbiot, 2016: online). Mik-Meyer and Villadsen (2013) allow a more nuanced analysis of current welfare policies, heralding a new era involving the use of "sovereign and paternalistic power" over some people in society. Hence, it is safe to conclude that neoliberal policies do not provide alternatives, but rather compel people to comply and act in ways that contribute to further disenfranchising the vulnerable older population.
Our findings reveal that older people's transition to LTC institutions in Poland is government controlled, as demonstrated by the state guidelines that allow social workers little or no influence on the management of transitions. This finding resonates with earlier studies indicating that the economic recession gave rise to reviews of social welfare systems, which led in turn to neoliberalism and the privatization of social care systems. That outcome left citizens with two choices: to be self-sufficient or to obey authoritarian guidelines governing the consumption of social services (Disney & Johnson, 2001;Haugen et al., 2016). Similarly, Rogowski (2013) argued that management of transitions according to state guidelines is a consequence of controlling social welfare structures underpinned by privatization that leave vulnerable groups such as older people no choices in accepting services.
Social workers in our study believed that excessive administrative work from the municipality and the courts took up too much of their time and thus hampered their capacity to listen to and involve older people. Rogowski (2013) argued that increasing administrative work meant social workers could no longer play their relational role. In a similar study on paperwork in contemporary child welfare practice, Gibson et al. (2018) found that to achieve quality services, managerial policies required social workers to document all service delivery processes, and that focus on paperwork cost social workers their relationships with the service users.
The social workers in our study described their core responsibilities as talking to new entrants on arrival, preparing documents for the municipality and courts, visiting with residents, and explaining the facilities available to them. This is a very limited role in light of the literature, which shows that gerontological social workers provide a range of services throughout the transition including supporting older people in choosing an institution, creating warm relationships with them, promoting their full participation before and after admission (Kaplan & Berkman, 2015), and helping to clarify complex situations through involving them in every step of their transition into LTC (Reuss et al., 2005).

Limitations
The study relied on an interpreter since the principal investigator does not speak Polish. Some important ideas may have been missed due to non-equivalent words, idiomatic expressions, and possible culture-specific interpretations of the questions. The sample included social workers and residents from only one LTC facility; therefore, the findings cannot be generalized to all other LTC facilities in the country. Finally, the study was conducted in April and May of 2018 and, therefore, reports participants' experiences at that time, not their current situation. Despite these limitations, the narratives provided in this study, however, are detailed and can be relied on in efforts to improve transitions.

Implications for Social Work Practice
The findings call on social workers to try to understand older people's physical and emotional challenges during transition to LTC and to facilitate a process which empowers them to make significant decisions about their well-being. Moreover, given that social workers have an ethical duty to support their clients' participation in life-changing decisions, they should facilitate transitional care planning to support people's self-esteem during important transitions. Developing transitional care plans is a critical step in ensuring people's active participation and it treats older people as human beings with inherent worth and dignity. It also brings the person in transition and the social worker together to prepare for the transition and offers older people an opportunity to voice their individual expectations, wishes, interests, and needs. Developing transitional care plans would allow social work professionals to interact with older people before their admission to LTC and discover the factors that may affect their well-being after admission.
Social work being an innovative profession, it should find novel ways to promote service user involvement in decisions about transitions amidst the rise of neoliberal and managerial policies, working within those policies and institutional guidelines to find the best solutions for their service users. Social workers can, for instance, advocate for their clients through forming associations or think tanks to promote policy reforms in the transition of older people to LTCs. Similarly, social workers need to empower older people to engage in self-advocacy and raise their own voices during the transition, rather than merely speaking on their behalf. To promote the voices of older people, social workers should collaborate with older people's organizations to advocate for their voice and rights during the transition to LTC.