Optimising Capacity – A Service User and Caregiver Perspective on Reablement

Cathrine Moe, Nord University, Norway
Berit Støre Brinchmann, Nord University, Norway

Abstract

Reablement focuses on offering individuals the opportunity to regain independence and thus stay longer in their homes. Few studies have looked at service users and caregivers’ perspectives on reablement. There is also a lack of theories grounded in this relatively new field of practise. This study aims to generate a grounded theory of service users’ and their caregivers’ experiences of reablement. The empirical data are based on interviews with 17 service users and 10 caregivers and observations of reablement provision. For seniors to manage as well as possible in their own homes emerged as the main concern. The core category is optimising capacity. The grounded theory builds on the core category, integrating identified strategies and concepts of health and coping.  The conditions of reablement are grounded in the social and cultural life of the recipient. We conclude, therefore, that including the individual’s life history and existing coping strategies is essential to the success of reablement.

Keywords: grounded theory, reablement, service user, caregiver, optimising capacities, open concept of health, coping.

Background

Reablement (also known as restorative care) is an approach focused on offering individuals the opportunity to regain independence and thus stay in their own homes longer. The goal of reablement is for service users to re-learn skills and find new ways to perform daily activities, be active, socialise, and participate in society. The method consists of using physical training and adaptive equipment to strengthen actions the individual defines as important (Tuntland, Espehaug, Forland, Hole, Kjerstad, & Kjeken, 2014.; Winkel, Langberg, & Wæhrens, 2014). Reablement is time-limited, person-centred, and typically delivered by an integrated team consisting of various health professionals such as nurses, occupational therapists, physiotherapists, and nurse assistants (Kjerstad & Tuntland, 2016; Wilde & Glendinning, 2012). Reablement services are increasingly offered to everyone who meets local eligibility criteria for home-care services. Still, aging persons (65+) are the most common recipients of reablement. The targeted populations are individuals with diverse mortality and morbidity risks, multimorbidity, and diverse prognostic outcomes, symptoms and disabilities. Exclusion criteria are typically advanced cognitive impairments and end-of-life care (Legg, Gladman, Drummond, & Davidson, 2016; Wilde & Glendinning, 2012). Reablement is supposed to represent a shift from reactive home care services to preventative and proactive models based on early intervention and active engagement (Legg et al., 2016).

The evidence for reablement is growing, but the ill-defined intervention towards a heterogeneous service user group means that it is complicated to get an overview of the state of knowledge (Legg et al., 2016). Reablement is found to improve the ability of aging persons receiving reablement services to engage in daily activities (Lewin & Vandermeulen, 2009; Winkel et al., 2014) and to have positive impacts on their health-related quality of life and social care outcomes (Glendinning et al., 2010). Reablement is often presented as a solution to future health service challenges. However, there is still very little knowledge about what recipients of this service view as important. Few studies have looked at service users and caregivers’ perspective on reablement. It is not clear who benefits most from reablement and which barriers to independence arise (Glendinning et al., 2010; Ryburn, Wells, & Foreman, 2009; Wilde & Glendinning, 2012). Barriers may be compounded when service users live alone or have few social contacts, or when they have a limited understanding of the purpose of reablement. It is unclear how reablement affects relatives and whether their involvement influences the outcomes (Glendinning et al., 2010; Wilde & Glendinning, 2012). Insights into service users’ and relatives’ experiences provide important feedback about the delivery and content of the reablement services (Wilde & Glendinning, 2012). A Norwegian study of older adults’ experiences of reablement concluded that the support must be adapted to the older adults’ resources and health and that municipal healthcare services need to consider individualised programmes of follow-up after reablement (Hjelle, Tuntland, Førland, & Alvsvåg, 2015). Another Norwegian study found it important to look beyond how activities are performed when examining participant satisfaction with homecare services (Witsø, Eide, & Vik, 2012).

The present study seeks to explore how service users experience reablement services. The study also includes the informal caregivers in order to build knowledge about their involvement and experiences. The goal of the study is to generate a grounded theory of service users’ and their caregivers’ experiences of reablement services. The following research question guided the study: What is the participants’ main concern and how do they resolve it?

Methodological Approach

A grounded theory approach was considered suitable for exploring reablement from a service user and carer perspective with the aim of generating theory (Glaser, 1978; Glaser & Strauss, 1967). We use the data to discover the participants’ main concern and the social processes to explain how the participants resolve it. Grounded theory focuses on human action and interaction. The aim of grounded theory is to discover patterns emerging in the data, and to formulate theories that are grounded in the world of the participants (Glaser, 1978; Walsh et al., 2015). Grounded theory is a constructive process in what Glaser and Strauss (1967) called the constant comparative approach. The approach involves a building process from descriptions to theory.

Study Context and Participants

The present study is a part of a Norwegian project investigating various perspectives on reablement (Moe & Gårseth-Nesbakk, 2015). The study was initiated by the municipality in order to evaluate its reablement service. The study took place in a Norwegian municipality located in the Arctic region. The reablement service has been established relatively recently and includes participants from rural and urban areas. The reablement practitioners recruited participants for the study. We asked for variations in age and gender and for participants from rural and urban areas. We also asked the reablement practitioners not to be selective. All service users receiving reablement were potential participants in the study. The target group for the reablement service was home-dwelling residents requesting municipal health care. They could also be existing service users receiving conventional home-care who were assessed to have rehabilitation potential. The exclusion criteria were significant cognitive impairment, mental health problems, or substance dependence, all of which hamper the reablement process. The reablement practitioners assessed the service users’ competence to give consent before asking them to participate in the study. They gave the participants written and verbal information about the study. Participants consented to participate in research interviews, to the researcher observing the provision of reablement services in their home, and for the researcher to contact a care giver (a carer). An information letter was sent to caregivers, and they replied to the researcher by post. Altogether, 17 service users and 10 caregivers participated in the study. All service users had received reablement for at least three weeks before the interview (the average time spent in reablement was 6 weeks).

Data Collection

Data collection took place in 2014 and 2015; the data consist of individual interviews and field observations of reablement service provision in participants’ homes.  Six service users had completed the reablement service before participating in the study. The other 11 consented to the researcher being present while they received reablement services at home. Field observations of reablement service provision were undertaken to gain knowledge of “what is going on” in a reablement situation and to observe the service users’ spontaneous responses and utterances. Notes were taken during and after the observations. Interviews were conducted in service users’ homes. Each interview was prepared based on ongoing analysis, but all participants were encouraged to speak openly about their experiences and conditions related to the reablement process. Interviews were audio recorded and notes were taken after each interview. Caregivers were interviewed by telephone. The researcher took notes during the conversations. A six-month follow-up interview was conducted with service users in order to gain knowledge of the period after reablement and its process from a more distanced point of view. Follow-up interviews were scheduled after the first interview, and took place by telephone or in interviewees’ homes.

Data Analysis

In accordance with grounded theory (Glaser, 1978; Glaser & Strauss, 1967), analysis and data collection were carried out simultaneously. The first 10 interviews were transcribed verbatim. The transcripts were read line-by-line and analysed several times using a system of open, selective, and theoretical coding (Glaser, 1978). The open coding focused on coding incidents in the data. QSR International’s NVivo 10 software (QSR International Pty Ltd., 2012) was used to store data properly and as a coding tool. Codes were printed, sorted, and examined on a whiteboard. Field notes were coded and added to the whiteboard. Codes were sorted in categories and memo writing focused on the relationships between codes and categories.  Memos were hand sorted as a part of the process of searching for participants’ patterns of behaviour. Patterns are what the participants do to resolve their main concerns (Walsh et al., 2015). After identifying the participants’ main concern, a core category was conceptualised. Categories related to the core category were identified (selective sampling) and sorted into subcategories. After the first 10 interviews, the main concern and the core category emerged. We conducted seven more interviews in the theoretical sampling phase until we reached saturation, meaning the new data fitted the concepts and properties. By writing memos on memos, we developed the theoretical codes further.

Research Ethics

The study conforms to the principles outlined in the Declaration of Helsinki. The Norwegian Data Inspectorate approved the study (reference 36770). The study was presented to the Regional Committee for Medical and Health Research Ethics in Norway. The committee found approval to be unnecessary (2013/2145/REK Nord). All participants received written and verbal information about the study and gave informed consent. All data has been treated confidentially.

The Theory of Optimising Capacity

The main concern of seniors receiving reablement and their caregivers consists of experiences of a challenging everyday life. The challenging life of seniors is composed of functional impairments, frailty, several health professionals, assistive technology, loneliness, medication, and environmental barriers. The life as caregivers consists of responsibility, practical tasks, support, multiple health agencies, and negotiating. For the seniors to manage as well as possible in their own homes emerged as the main concern. Even though the seniors and the caregivers are heterogeneous and diverse groups, they share this main concern. Seniors have the need for public health services because of functional impairments. However, there is a significant range in age, functional states, and goals for the reablement process. The main concern is congruent with the municipal goal for the reablement service, though the municipality’s focus on independence is stronger. To manage as well as possible means not to aim for total independence or to find help from others as a defeat. It involves managing important, daily activities such as maintaining personal hygiene, preparing meals, and manoeuvring safely inside. Managing daily life is also about doing meaningful activities outside the home.  To manage as well as possible involves an acceptance of the life situation and a wish for a qualitatively good life within available capacities.

The theory of optimising capacity builds on the core category and summarises the process of how study participants act to resolve their main concern. Optimising capacities means making the best out of each person’s resources, despite functional impairments. Optimising capacities by such strategies as appreciating a push, physical strengthening, adapting the environment, and building confidence explains how the seniors become able to live in their own homes. Appreciating a push is accepting the motivational work of reablement professionals. The strategy relates to the core category by being the first step in the reablement process. It is also a prerequisite for the other strategies. Physical strengthening relates to the core category by being a significant factor in optimising service recipients’ physical capacities. By training muscular strength and flexing joints, the capacities of the body increase. Adapting the environment highlights the role played by the external surroundings.  The home situation can become manageable if adaptations and changes are made. The last strategy, building confidence, is a process that goes on in parallel with the other strategies. Building confidence takes time and is based on repetitions of exercises and activities, increased knowledge, and support from others. All together, these strategies lead to an optimising of capacities during the reablement process, making the seniors able to live as well as possible in their own homes. The strategies are presented in the following sections.

Appreciating a push

Appreciating a push means accepting the motivational work done by the reablement practitioners. Seniors residents, like most others, sometimes need motivation and a helping hand to start and sustain physical activity. The push is mentioned as “a kick in the butt”. The appreciation of a push is the start of the reablement process. The strategy includes trusting the practitioners, experience meaning, being viewed as a capable person and valuing the social dimension of having someone coming to your home every day. The strategy does also include perceiving there is no choice and filling the expectations of citizenship.

Trusting the practitioners means finding them to be qualified, and the knowledge concerning the rehabilitation potentially valuable in advanced age, and the benefits of being active understandable. Experience meaning involves that the goals and methods of the reablement service are meaningful. If they are not, the reablement service will be a hassle. The idea of experience meaning depends on what the individual finds important. Seniors are being viewed as capable persons when the practitioners point out their resources and rehabilitation potential. The fact that someone outside the family view you as a capable person is emphasised as important. Valuing the social dimension is a significant property of appreciating a push. The intensive training of reablement includes home visits every day. Valuing the social is appreciating the aspect of doing activities with someone.

I believe this is good. It might also be because I enjoy the company. The fact that they are coming every day is a big motivational factor. It is so much easier to do exercises together with someone. Everyone needs a “kick in the butt”. I needed someone to get me started (Woman, age 78).

The idea of perceiving there is no choice is about feeling obliged to accept the reablement service. It is about experiencing the message of “this is what is being offered to you”, which does not involve a possibility to choose. In that way, appreciating a push also includes the external aspect of being a recipient of public services. Filling the expectations of citizenship consists of predetermined roles as being a part of society. Media and other societal discourses build on the impression of how hard it is to receive proper elderly care. This leads to a resident gratitude for everything being offered.

Appreciating a push leads to a new glow, better mood, and an increased spark of life. Even though the appreciation of a push is based on external factors rather than inner motivation, the result is accepting the reablement service. Therefore, this strategy lays the foundation for the other strategies.

Physical strengthening

Physical strengthening is performed by doing strengthening exercises and activities of daily life at home and in the neighbourhood. As reablement is activity-based, physical strengthening is a core aspect of optimising the physical capacities. Exercises and other therapeutic activities are based on a detailed screening that identifies activity goals and functional impairments. The screening also reveals other factors contributing to functional losses such as pain, malnutrition, and medication use.

The physical strengthening primarily involves remedying muscular weakness evoked through long-time passivity or immobility after disease and surgery. The muscular weakness causes walking difficulties, unsteadiness, and pain. Walking difficulties and unsteadiness cause fear of falling and immobility. Even though physical strengthening is a well-known strategy in the society, the idea of being active to counteract frailty of old age is new. A 93-year-old woman stated:

This is completely different from home-care. I have exercises. I can feel it in my back, my thighs and my legs. This is good. I walk without my rollator. I have not dared to do that before. I am so happy I rejoice at every step forward.

Surgery, injury, or years of immobility, lead to insecurity of burdening injured body parts, for instance a broken hip. Having professionals facilitate the process with repetitive practice of activities gives security. Security is therefore a condition and a result of physical strengthening. Another condition is the knowledge of the benefits of being active in late age. Even though physical activity not necessarily increases the quality of health, it is good for building muscles, digestion, appetite, sleep, and cognitive function. The physical strengthening does also condition on a clarified health situation as a promotor of regularity and harm avoidance. A clarified health situation means that the health situation is assessed, illness is treated, and the functional situation is relatively stable and predictable. Advanced age causes risks of getting sick or having new functional impairments, which cause a fragile stability of the health situation. Still, the physical strengthening process helps prevent new problems.

The physical strengthening leads to a strengthen body and thereby an optimising of the physical capacities. The strategy also influences the stamina to manage even more activities. Feelings of being too old or too frail are reduced and replaced by increased self-confidence in managing. The latter creates a concern about the seniors’ ability to assess the intensity of training. The stamina to manage even more activities can lead to overload and repetitive strain injuries.

Adapting the environment

Adapting the environment means adjusting to external conditions. In order to optimise the capacities, the environmental conditions must be right. Adapting the environment involves modifying the homes and the outdoor facilities.

Adapting the home means making it suitable for aging residents. A benefit of receiving reablement service at home is that the exercises relate to everyday life and well-known surroundings. Adapting involves reorganising furniture, removing objects, and using welfare technology and assistive devices.

Reorganising furniture means modifying their placement to reduce barriers. For example, a crowded bathroom may be tidied up to give place for a rollator, or a more appropriate chair can be placed by the dining table. Removing objects means getting rid of carpets, doorsteps, or others barriers for safer movement inside. By testing various models of assistive devices and welfare technology, the care given can find a functional solution to deal with the barriers in managing everyday life. Such devices can be a safety alarm, a rollator, a chair in the shower, or handles. By receiving reablement in their own homes, seniors value the practitioners for seeing new solutions. Reorganising also involves removing existing assistive devices being improperly used. Adapting environment therefore leads to a change in habits and patterns of action. Instead of organising the home in such a way that things can be reached without moving, reorganising aims to make it safe and easier to manoeuvre inside. The indoor adaptions depend on the willingness of the senior to make changes and his or her ability to learn how to use new devices.

Adapting the outdoor facilities means to reduce barriers for outside activities. The weather has a significant impact on the lives of seniors living in the Arctic. Especially in winter, the conditions (snow banks and icy roads) can be inhibiting. A condition for adapting the environment is whether municipal agencies can handle the winter environment to make the outside conditions optimal, or whether private agencies (such as family members or volunteers) can shovel snow and sand stairs. Handles and proper placements of the mailbox and trash also make outdoor adaptions. Adapting the outdoor environment involves safe walking paths, benches to rest, and easily accessible supermarkets and pharmacies.

Several assistive devices are funded by the welfare agencies but the individuals’ economic capability does sometimes influence the ability to adapt the environment. The consequences of adapting the environment is the opportunity to live longer at home.

Building confidence

Building confidence means to trust the own ability to manage everyday tasks.  Confidence increases as a result of physical strengthening and adapting the environment, and as a result of social support, knowledge, and safety. The loss of confidence emerges from several aspects. After a long life of hard work and economic scarcity, some seniors feel tired. The traditional view of aging is for many residents to rest and withdraw from activities, which leads to an understanding of “this is as it should be”. A grief from a loss of function contributes to a lack of confidence. Building confidence is therefore a way of thinking, involves an acceptation of the reablement practitioners’ encouragement, and are repetitive experiences of managing. Accepting the practitioners’ encouragement involves doing things—even if you do not believe that you will succeed. One woman (age 73) says:

I feel valuable and they see me. They can see it is hard to age. When you break your femoral neck and get a setback, it does something with your mind. The reablement practitioners make me believe in myself again.

Repetitive experiences of managing means experiencing and managing exercises and activities. By doing activities repeatedly, facilitated by the reablement practitioners, confidence builds. Despite the fact that reablement practitioners focus solely on physical activities, confidence increases during the reablement period. The strategy of building confidence does not represent a dualistic view of the human body, but emphasises the reablement role of optimising the mental capacities: “Reablement has helped me in two ways. I have gained the courage to do things that I have not been able to do earlier. I can also feel that my body has become stronger” (Woman, 71 years old). Confidence building is conditioned by social support. Social support explains how the social network encourages and keeps the faith in managing. The support is provided by pushing, challenging, and encouraging. The entire social network—reablement practitioners, family members, a partner, friends, other health personnel, or volunteers—offers support. The consequence of building confidence is safe and empowers seniors to be able to take control over their own lives.

Discussion

The theory of optimising capacity explains how participants act when and after receiving reablement. The main concern is perceived to be “for the seniors to manage as well as possible in their own homes”. It became clear that the participants did not long for big, unattainable goals. They want to make the best out of their situation. In this way, the theory represents a relatively optimistic view of elderly care and might provoke service users, caregivers, and health personnel who have different and difficult experiences of elderly care. The authors are aware that many seniors are not included in the reablement service. The study therefore does not include those excluded from reablement or those who say no to reablement. This limitation makes the study an investigation of the patterns of action of a small segment of the senior help-seeking population and of senior residents with sufficient capacity to act.

Four subcategories conceptualise actions for optimising capacity, which is how the participants solve their main concern. By optimising their capacity, seniors and their caregivers utilise the available possibilities. The theory explains what is identified as the most important pattern of behaviour and does not cover all the actions of the participants. The subcategories explain the theory and the integration of these concepts in our theory contribute to a greater understanding of what is going on when seniors receive reablement services.

The integration of extant literature

We conducted a literature review after the emergence of the theory and this review revealed a lack of theories exploring the experiences of reablement service users and their caregivers. Our theory contributes to explanations of the social patterns of the reablement service from the seniors and their caregivers’ point of view. The theory of optimising capacity emerged through careful analysis. During the theoretical coding process, we became aware of the open concept of health and the idea of coping; we found our theory to be closely related to these concepts.

Wackerhausen (1994) introduced the open concept of health as a humanistic alternative to the existing concepts of health. According to Wackerhausen, health is “the individual’s capacity to act” (p. 43) within the framework of the individual’s goals and values, conditions of life and their physiological and psychological abilities to act. The individual’s goal is made visible through dialogue; it is not set by the health practitioner as an objective expert. The reablement service is directed to the senior’s own goals for reablement. The focus is on re-learning skills and finding new ways to perform daily activities, being active, socialising, and participating in society. The service users increase their capacity to act through physical training and adaptive equipment, as described in previous studies (Tuntland et al., 2014; Winkel, Langberg, & Wæhrens, 2014). This study relies on Wackerhausen (1994) to expand the understanding of the reablement processes by integrating the conditions of life and personal factors. The personal factors that constitute the abilities to act include motivation and personal resources. Through the open concept of health, the focus changes from health as a bodily or mental state to the relationship between the goals, conditions of life, and ability to act.

Western cultures generally define a healthy person as someone who is active and dynamic (Wackerhausen, 1994). This cultural expectation has also reached seniors. The World Health Organization (2002) and the European Parliament (2010) promote active aging as a strategy for social and economic sustainability (Walker, 2008). Our study shows the importance of allowing seniors to define their reablement goals themselves rather than having the reablement team define service goals. The expectations of being active might be overwhelming. The motivation and will to carry out the reablement process depend on the participation of the service users. The participants value the time the reablement service provides. This appreciation enables the practitioners to ask participants about their life situation, their life history, where they worked, and how they solved important issues earlier in their lives. Optimising capacity emphasises the importance of continuing existing coping strategies. Still, adapting the environment and physical training might introduce new strategies of actions. This adaptation requires a great awareness of seniors’ motivation and ability to integrate new patterns of actions in their daily life. The focus on adapting the environment is in line with Michael, Green and Farquhar’s (2006) conclusion that environmental adaptions influence activity among older adults.

The relationship between goals, life conditions, and ability to act makes participants aware that they cannot reach the same activity goals throughout the year. Their ability to move outside in winter depends on how other agents remedy the conditions and their own ability to buy adequate clothing.  Sometimes the outside activity goal is temporarily on hold because the senior realises it will be too challenging to go outside. To sustain the reablement process, it is important that seniors experience a relationship between inside and outside activity goals. They can maintain strength and balance by doing activities inside to maintain their ability to go outside later.

The capacity to act relates to psychological and physiological factors, including motivation and personal resources. Anxiety and depression are recurring phenomena for some seniors. This study reveals that reablement has an impact on participants’ mental health (on building confidence) and we may consider this a secondary benefit. Mental health improves, even as there is less focus on it. The improvement of the mental health, still depends on the degree of mental illness. Reablement, as a short-term intervention, fails to support individuals in need of longer-term support. Through physical training, reablement participants strengthen their body and their ability to do activities that matter to them. They become able to walk longer distances than before, to do kitchen chores, to walk safely up and down stairs, or other important daily activities. Being able to engage in activities can also lead to new activity goals. Managing one’s own in a specific area might thus transfer to other areas. Building confidence can make a person believe there are developmental possibilities even in old age and can also make him or her motivated to carry on after reablement. The latter is considered the most precarious part of the reablement service. A majority of the senior participants expressed a great enthusiasm for reablement during the first interview. The follow-up interview, on the other hand, revealed a greater diversity of views on the period after reablement. Identifying the conditions for the theory of optimising capacities will have implications for the reablement practice. These implications will be elaborated in the following section.

Implications for Practice

The theory of optimising capacity explains how a successful reablement process leads to increased senior health. The focus is not on health as a bodily or mental state, but as a relationship between the goals, conditions of life, and ability to act. The achieved health is not static, but changes in accordance with new goals, conditions of life, or abilities to act. To sustain the reablement process, it is therefore necessary to have flexibility and stability. This study names the identified conditions for the grounded theory “stability agents”, necessary for the reablement process to promote positive health outcomes.  We will elaborate on the implications of these conditions for practice. First, it is important that the professionals focus on the seniors’ own goals. The professionals involved must have a high level of ethical awareness. They must be sensitive to each individual’s life history in order to find each individual’s goals and strategies. This is supported by the open concept of health: the goal must be free of coercion (Wackerhausen, 1994), and the Hjelle, et al. (2016) study concluding that the support must be adapted to the older adults’ resources and health. Otherwise, the aging person will find the reablement activities to be a hassle and the intervention to be paternalistic. It is also important that the seniors participate in the design of the reablement plan. The principle of respect for autonomy is foundational to the open concept of health and a condition for a successful reablement process.

The second condition is an understanding of the goals and methods of reablement. It is essential for service users’ motivation and participation that they understand the goals and methods of reablement and find them meaningful. This is closely related to Antonovsky’s (1996) concept of “Sense of Coherence” where the crucial component is meaningfulness. Individuals who experience a high level of coherence despite a difficult situation can still experience good health. The salutogenic model supports the emerging theory of viewing reablement as a health promotion service optimising the participants` capacity—if the seniors experience sense of coherence. Salutogenesis is defined “as the process of movement toward the health end of a health ease/disease continuum” (Antonovsky, 1993, para. 9). It is crucial that service users and caregivers see the connections between interventions, activities, and the defined goals.

The third condition is having knowledge of the advantages of being physically active in old age. Knowledge also promotes confidence. Information and repetitive practice build confidence for the seniors that is necessary for their ability to act. The reablement process depends on seniors’ ability to make an effort for themselves. Frailty and discouragement are barriers to the ability to act. Finally, the present study shows the importance of social support. Support from significant others can make a big difference in the outcome and maintenance of the reablement process. The theory of optimising capacity shows that the family situation and social support are important. Several seniors live alone and their nearest family members are most likely to support them through the reablement process. It is therefore important that there is a dialogue between the service users, the caregivers, and the reablement practitioners. The reablement process might lead to a change of lifestyle, and it is essential that the family culture is supportive.

The theory of optimising capacity integrates elements of the open concept of health by emphasising the relationship between the individual goal, the ability to act, and life conditions. This relationship supports the study findings that a holistic approach is a key to success. The participants highlight the importance of focusing on the entire life situation, not only a specific functional loss. Service users and caregivers emphasised the importance of the reablement team’s focus beyond the physical achievements. The focus on nutrition, medication, social needs, and support were highlighted as significant factors. The theory of optimising capacity therefore embraces the individuals’ physical, mental, environmental and social life conditions in a holistic reablement service.

Study Limitations and credibility

The authors are aware that there are different levels of theoretical abstraction within grounded theory. Grounded theory is based on a third-level conceptual perspective analysis. Most published grounded theory research uses the third level of analysis, representing an overall integration of data into a theory through data sorting. The fourth level is a more general conceptual level that relies on constantly comparing substantive theory articles (Artinian, 2009; Glaser, 1998). The grounded theory in this article relies on the third level. We have made this choice to stay closely related to the practice field. In this way, we aim to create a theory applicable to practice.

To ensure the credibility of the study, we used the constant comparative method (Glaser & Strauss, 1967). This involves always comparing new data with the existing data, which helps us validate our preliminary findings during the research process. The constant comparative method also requires the researchers to keep on track and makes the research process rigorous.  Ongoing analyses have been presented to the municipal Council for the Elderly for feedback and external checks on the research process. A representative from the Council for the Elderly also participated in the early stages of the study to ensure peer/service user participation.

To assess the quality of the grounded theory, we used the criteria of fit, work, relevance, and modifiability (Glaser, 1978). The categories must fit the data. The concepts were constantly modified as new data emerged and all concepts and properties can be tracked to the empirical data. By “work”, we mean that we need to ensure that the theory explains what is going on in the substantive area. Our theory evolved as data and concepts emerged and was constantly crosschecked to the existing analysis. The constant reanalysis gave us confidence that the theory worked as an explanation for what is going on in the reablement situation. The theory is relevant to the participants as it evolves directly from the data and is found in nearly all the participants’ patterns of action. Modifiability means that the theory changes during the research process, as the collection of new data requires modifications of what came before. Furthermore, it means that the generated theory is always modifiable. New data that may be collected from other areas may modify the theory in further studies.

Implications

The reablement process is dynamic and the open concept of health is a relationship between dynamic factors. The study helps visualize patterns of action and conditions that allows a reablement service to optimise capacity. The study will contribute to the evaluation and development of such a service, and will be beneficial for service users, caregivers, reablement practitioners, and policy makers. There is still a need for more in-depth knowledge about how service users and caregivers experience reablement services.  More theories that are applicable to practice should also be developed.

Conclusion

With this study, we aim to contribute to existing knowledge about reablement. We believe there is a need for theory development in this area, as it is a relatively new field of practise. Reablement is to large extent a part of the innovation strategy in the public health sector in Norway and the other Nordic countries. The feedback from the service users and their careers is an important factor when evaluating such a service. The purpose of the study was to explore the service users’ experiences of the reablement service and reflect upon these experiences. To optimise capacity was identified as a core category and a main strategy allowing the senior participants to live in their own homes. The results of this study revealed four strategies connected to the core category. The participants highlight the focus on the goals of each individual, the practitioners’ motivational work, the holistic approach, and the social as conditions of a successful reablement. We believe these elements are grounded in the social and cultural life of each individual. Including the individual’s life history and existing coping strategies are therefore essential to a reablement service. The grounded theory of optimising capacity integrates the empirical data and the concepts of coping and health.

However, active aging cannot be the only solution in future elderly care. It is important that seniors do not get the impression that being healthy is only a matter of choice. Reablement can contribute to health promotion, but there are still many seniors living with complex health issues. They are in need of a longer-term follow up by the municipal health service.

Acknowledgements

We are grateful to all study participants for openly sharing their experiences. We would also like to thank the reablement team for recruiting informants and for allowing the researcher to participate during reablement sessions in participants’ homes. The Regional Research Funds Northern Norway (grant number 220754) funds the study.

 Declaration of conflicting interests

The authors declare that there is no conflict of interests.

Authors’ contributions

Both authors contributed to the research design. The first author collected data from interviews and participatory observations, performed the data analyses, and drafted the manuscript. The second author participated in data analyses and provided comments on the manuscript. Both authors read and approved the final version of the manuscript.

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