Working with ‘hands-off’ support: a qualitative study of multidisciplinary teams’ experiences of home rehabilitation for older people

Understanding frailty: a qualitative study of older heart failure patients' frail experience and perceptions of healthcare professionals with frailty

BACKGROUND

Although frailty is highly prevalent in hospitalized older heart failure (HF) patients, its management is often delayed. Understanding the unique experiences of frail elderly HF patients and the perceptions of healthcare professionals (HPs) regarding frailty can facilitate the integration of frailty prevention and intervention into clinical practice. This study aimed to use a descriptive qualitative approach to obtain the experiences of frailty in older HF patients and the perceptions of HPs concerning frailty.

METHODS

Qualitative interviews were conducted with 16 frail elderly HF patients and 13 healthcare providers. Data were analyzed using thematic analysis.

RESULTS

The interviews yielded several themes with associated subthemes: "a state of predicament," "hope is gone and social isolation," "daily adjustment and attempts to do something," "thoughts on factors contributing to frailty," "the need for transformation of stakeholders' mindset regarding frailty," "management is imperative, but there is still a way to go".

CONCLUSIONS

Both elderly patients with HF and HPs described frailty as a state of predicament, involving being caught in life difficulties and falling into a treatment dilemma. Due to the overlap of symptoms and evaluating indicators between frailty and HF, it's essential to thoroughly understand modifiable risk factors that could worsen frailty and develop a specific frailty assessment tool for HF patients. Adequate social support, multidisciplinary collaboration, and a frailty education program for patients, caregivers, and HPs are essential to facilitate frailty management and improvement.

Re/connecting with "home": a mixed methods study of service provider and patient perspectives to facilitate implementing rehabilitation in the home for reconditioning

PURPOSE

To explore the views of healthcare professionals and patients about the advantages and disadvantages of rehabilitation in the home (RITH) for reconditioning, and identify factors that should contribute to the successful implementation of a consensus-based RITH model for reconditioning.

MATERIALS AND METHODS

Interviews with 24 healthcare professionals and 21 surveys (comprising Likert scale and free text responses) of inpatients undergoing rehabilitation for reconditioning provided study data. Interpretive thematic analysis was used to analyse interview data; descriptive statistics analysed Likert scale responses; patient written responses assisted with the interpretation of themes developed from the interview data.

RESULTS

Two major themes were elicited in this study: the home is a physical setting and the home is a lived space. Advantages and disadvantages of RITH for patients, carers and healthcare professionals were identified within these themes. Appropriate patient selection; effective communication with patients and carers, and within RITH teams; adequate patient and carer support; ensuring the safety of patients and staff; and education of patients, carers and healthcare professionals are essential for the satisfactory implementation of RITH.

CONCLUSION

The concept of home shapes the delivery of RITH. Recognising the advantages and disadvantages of RITH highlights important considerations needed to successfully implement RITH for reconditioning.

Exploring Goal-Setting and Achievement Within Reablement: A Comparative Case Study of Three Countries

Purpose

Over the last two decades, reablement programs have been studied and implemented internationally. Goal-setting and multidisciplinary collaboration are central elements of reablement. Unfortunately, limited intervention descriptions leave questions on how they are applied in practice and how goals set by the user are achieved. As a consequence, healthcare providers and organizations often lack knowledge to implement and align reablement to their national and local context. This study aimed to collect data on goal-setting and achievement, and multidisciplinary collaboration within reablement services to provide insight into how these processes inform reablement practice as well as to explore the experiences of healthcare professionals in Norway, New Zealand, and the Netherlands.

Material and Methods

A qualitative exploratory design was used comprising three focus group interviews with 20 healthcare professionals (nursing and allied health) involved in reablement programs from the three countries. Purposive sampling was employed considering a mix of gender, age and educational level.

Results

Findings reflected healthcare professionals' experiences and reablement processes in three main themes: (1) Goal-setting processes; clearly demonstrating goal-setting as an essential part of reablement and contributing to better understanding of users' motives; (2) Impact of goal-setting on multidisciplinary collaboration; promoting a sense of community, learning climate, job satisfaction and task-shifting; and (3) Behavior change techniques used to reach users' goals, promoting self-reflection and changing users' perspectives.

Conclusion

This study offers valuable insights from three countries. Goal-setting serves a crucial role enabling effective reablement implementation across diverse contexts. More specifically, to facilitate tailoring of reablement programs to the user's needs as well as establish more effective multidisciplinary collaboration by promoting trust, shared vision, and utilizing each other's expertise. However, despite the acknowledgement of the significance of reablement, it was reported by all that a cultural shift is necessary for users, informal caregivers as well as healthcare professionals.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Frail community-dwelling older persons' everyday lives and their experiences of rehabilitation - a qualitative study

BACKGROUND

The number of older persons with frailty is increasing, and rehabilitation to improve the consequences of frailty are important for both the individual and society. However, the perspective of older persons themselves in research and planning of interventions is scarce.

AIM

The aim of this study was to describe frail older persons' everyday lives and their experiences and views of rehabilitation.

MATERIAL AND METHODS

Twenty older persons were interviewed, and analyses were performed using a qualitative content analysis method.

RESULTS

The two main categories were 'Frailty impacts everyday lifé and 'Experiences and perceptions of rehabilitation'. The participants described that they had to adapt their everyday lives in line with their health conditions. They all used strategies and were dependent on support in their activities of daily living. Their social network had decreased. All participants strived to stay active and independent, and wanted rehabilitation and support from professionals, experiencing decreased access to rehabilitation.

CONCLUSIONS AND SIGNIFICANCE

Frail older persons are a vulnerable group who often need support in everyday life. There is room for improvement when it comes to helping frail older persons to stay active and facilitate participation in both individual and group interventions.

Exploring the delivery of community rehabilitation services for older people in an urban Canadian setting: Perspectives of service providers, managers and health system administrators

As the global population of older people increases, policies aimed at improving health care delivery for older people often include supports for ageing in place. Living in the community not only reduces institutionalisation but also improves quality of life and reduces health care costs. For older people, community rehabilitation offers the opportunity to preserve and maximise function while maintaining the ability to live in the community. However, limited research examines the delivery, coordination and integration of community rehabilitation services in health systems. Our case study explored the perspectives of service providers, managers and health system administrators on the strengths, limitations and gaps in community rehabilitation for older people in one Canadian urban health region. Using interpretive description and thematic analysis, we analysed interview data from: 16 service providers, eight managers and five health system administrators. Three themes were identified: (a) Limited Access to Programs and Services; (b) Need to Emphasise Promoting, Maintaining and Restoring Function; and (c) Lack of Flow Across the System. Participants highlighted that restrictive eligibility criteria limited access to services. Services were organised around health conditions that did not address the needs of older people. Long waitlists meant that services were delayed. Transportation costs limited participation of individuals from lower socioeconomic status (SES). Age restrictions did not reflect differences in the ageing process and the health inequities individuals from lower SES groups experienced. There was a lack of emphasis in community rehabilitation programs on maintaining or restoring function in older people, which is the primary focus of rehabilitation. Furthermore, key stakeholders stressed the need for strengthening the integration of service delivery across the continuum of care. The findings underscore the need to develop a conceptual framework for community rehabilitation to promote greater system integration, access and availability of services and to optimise functional outcomes for older people.

Reablement - relevant factors for implementation: an exploratory sequential mixed-methods study design

BACKGROUND

Reablement is a multi-professional and internationally established home-based health care service for mainly older people with the aim to reduce the need for long-term care and to promote self-determination. However, it is unknown which factors would facilitate the implementation of reablement in health care services. Therefore, the aim of this work was to identify relevant factors for the implementation process and to elucidate their importance based on the perspectives of experts.

METHODS

Within an exploratory sequential mixed-methods design, a literature search followed by framework analysis was carried out using the five domains of the Consolidated Framework of Implementation Research (CFIR) to collect potentially relevant factors for implementation of reablement. A survey was then drawn up encompassing the factors identified. Within the survey international reablement - experts were asked to rate the relevance of these factors .

RESULTS

The literature search identified 58 publications that served as sources for the framework analysis, where 40 potentially relevant factors were clustered into the five CFIR domains. These 40 factors were rated by experts in an online-survey. Based on the analysis of survey-data, 35 factors were considered as relevant for implementation of reablement services. The CFIR-domain characteristics of individuals, including teamwork and communication skills, was seen as most relevant.

CONCLUSIONS

The implementation of reablement services is complex and requires the consideration of numerous factors, especially regarding the CFIR-domain characteristics of individuals. From the perspective of the survey´s participants one important factor of a successful implementation was the engagement of the persons involved. It requires team members with a strong, shared vision. Communication skills are highly important to promote teamwork and intensive training is needed to establish these skills. Further research on the implementation of reablement services is essential to realize its full potential.

A qualitative study on promoting reablement among older people living at home in Norway: opportunities and constraints

BACKGROUND

Healthcare services that traditionally have been provided in long-term care institutions in Norway are increasingly being delivered at home to a growing population of older people with chronic conditions and functional limitations. Fostering reablement among older people is therefore important if they are to live safety at home for as long as possible. This study examines how healthcare professionals and managers (staff) in Norwegian municipalities promote reablement among community-dwelling older people.

METHODS

Face-to-face, semi-structured interviews lasting between 21 and 89 min were conducted between November 2018 and March 2019 with healthcare managers (N = 8) and professionals (N = 8 focus groups with 2-5 participants) in six municipalities in Norway. All interviews were audio-recorded, transcribed, and thematically coded inductively and analyzed with the aid of NVivo 12 software.

RESULTS

Overall, healthcare staff in this study used several strategies to promote reablement, including: carrying out assessments to evaluate older people's functional status and needs (including for safe home environments), and to identify older people's wishes and priorities with regard to reablement training. Staff designed care plans informed by the needs assessments, and worked with older people on reablement training at a suitable pace. They promoted among older people and staff (within and across care-units) the principle of 'showing/doing with' versus 'doing for' the older person so as to not enable disablement. Additionally, they supported older people in the safe and responsible use of welfare technology and equipment. Even so, staff also reported constraints to their efforts to foster reablement, such as: heavy workload, high turnover, insufficient training in reablement care, and poor collaboration across care-units.

CONCLUSION

Older people may be supported to live safely at home by meeting them as individuals with agency, identifying and tailoring services to their needs and wishes, and encouraging their functional abilities by 'showing/doing with' versus 'doing for them' when possible. The healthcare professionals and managers in this study were positive towards reablement care. However, meeting the resource demands of reablement care is a key challenge.

Reablement professionals' perspectives on client characteristics and factors associated with successful home-based reablement: a qualitative study

BACKGROUND

To understand what is needed to achieve a successful Danish home-based reablement service from the perspective of reablement professionals.

METHODS

Semi-structured interviews and observations were conducted with nine professionals within a municipal visitation unit in the Northern Denmark Region. Thematic analysis was used to analyze the interviews.

RESULTS

Four major themes emerged during this study: "Heterogeneity of clients and mixed attitudes towards the reablement intervention", "Shared understanding and acknowledging the need for help as the first step in reablement", "Commitment and motivation are essential for successful reablement", and "Homecare helpers as most important team players". The findings indicate that the clients had both mixed characteristics and attitudes about participating in the reablement intervention. Essential factors for successful reablement included a shared understanding of the reablement intervention, commitment, and motivation in terms of client involvement and staff group collaboration.

CONCLUSIONS

Shared understanding of the reablement intervention, commitment, and motivation was found to be essential factors and the driving forces in relation to successful reablement.

Enablers and barriers in adopting a reablement model of domiciliary care

Purpose

The purpose of this paper is to explore the effectiveness of reablement as an outcome-focussed commissioning model within the English domiciliary care market from the perspective of two private domiciliary care agency (PDCA) managers/owners within one local authority (LA) in the North West of England. Specifically, it focusses on owner/managers' perceived ability to effect change from a dependency to a reablement model within the English domiciliary care market.

Design/methodology/approach

Qualitative interviews with two contrasting owners/managers of PDCAs within one LA in the North West of England were carried out. Explorative analysis followed a constructionist grounded theory methodology.

Findings

Findings revealed how two main factors interacted to effect change from a dependency model to a reablement model of domiciliary care: internal organisational structure and individual emotional investment of the owners/managers. Additionally, fiscal and external organisational systems impact on these drivers, and are perceived to act as potential barriers to the adoption of a reablement model of domiciliary care by PDCAs.

Originality/value

Although based on only two idiographic accounts, the findings shed light on the policy and practice of commissioning models of domiciliary care within England and suggest further studies in this area of practice.

Control as a Core Component of User Involvement in Reablement: A Qualitative Study

BACKGROUND

Reablement, also known as restorative care, supports older adults in regaining or maintaining their independence in daily life through the optimization of functional ability. Users' goals and healthcare professionals' use of a "hands-off" approach are key, thus user involvement is central to reablement logic. The aim of this study was to explore user involvement in reablement from users' perspectives from the beginning of an intervention.

METHODS

The study has an explorative qualitative design and includes thematic content analysis of data from repeat, individual semi-structured interviews with ten users accepting reablement intervention services in an urban Norwegian municipality.

FINDINGS

Control emerged as a core component. Users handed control over their time and body to professionals, balanced by drawing on an inner strength to control own limits, retain the right to make own judgements and decisions, and dream. Five themes were seen: Positive, but with a "wait and see" attitude; Professionals have goals, users have dreams; Desire to control schedule and activity; Regaining faith in one's own capacity and strengthening one's dreams; and Keep going, hold on to your dreams.

CONCLUSION

User involvement interpreted as user-set goals may be over-emphasized. Users possess the information that professionals need to set goals, consider these the goals important for professionals, and seek to facilitate professionals in their work. Based on a belief in own competence and a trust in professional's expertise, users invite professionals into a co-creation process. User involvement has previously been defined as a willingness and positive attitude toward reablement activities, but we find it can be expressed in different ways. Reablement logic does not always match users' understanding or desires, and it may be time to rethink user involvement in reablement. The reablement concept should be developed further, so that it better suits the individuals it should serve.

Evaluation of the Factors that Promote Improved Experience and Better Outcomes of Older Adults in Intermediate Care Setting

The aim of this article was to identify the main contributing factors to optimising improved experience and better outcomes for older adults participating in intermediate care setting. Background: Intermediate care is an integrated team intervention for patients experiencing an acute change in their function and well-being. Crisis intervention is one of several intermediate care pathways and provides a timely, person-centred, goal setting assessment to determine appropriate care and support for patients in the community. Method: This systematic review was conducted using key search terms and Boolean operators. A Critical Appraisal Skills Programme (CASP) tool was used to evaluate the studies and the data was extracted and synthesised systematically to develop themes relating to the research question. Results: Seven qualitative primary research studies and one mixed methods study were identified. The main themes were ‘communicating with patients’ and ‘patient participation’. Results showed neither themes are parallel entities but co-dependent. Patient-centred approaches to communication by professionals encouraged active patient participation, in turn optimising patient outcomes. Conclusion: This review showed that patient participation in intermediate care requires professionals using advanced communication skills and taking time to actively listen to what is important to the patients. In addition, poor professional communication resulted in passive patient participation. Implications for future practice are discussed.

What constitutes 'good care' and 'good carers'? The normative implications of introducing reablement in Danish home care

As populations worldwide are ageing, Western welfare states are currently implementing welfare reforms aimed at curbing the rising need for social and healthcare services for ageing populations. A central element in home-care reforms in several welfare countries is reablement: short-term home-based training programmes aimed at re-enabling older people to live in their own homes independently of care. In this paper, we explore how transitioning from compensatory care to reablement care is not merely a practical process, but also a deeply normative one. Drawing on Annemarie Mol's concept of 'ontonorms' we analyse the normative dynamics involved in transitioning from one form of care to another as reflected in reablement professionals' practices and discourses. The paper draws on 10 months of multisited ethnographic fieldwork carried out from April 2015 to February 2016 in a Danish municipality, including participant observations of reablement practices as well as qualitative interviews with 13 professionals working with reablement. We demonstrate that professionals generally consider reablement to represent a desirable shift in home care from 'bad care' practices of making people passive through compensatory care, towards 'good care' practices of 'keeping people going' despite their limitations. Moreover, we demonstrate that while therapists are valued as 'good carers' due to their ability to focus on development and training, nurses and in particular home helpers are devalued as 'bad carers' due to their 'caring genes' and lack of technical and theoretical skills necessary for documentation work. Finally, we discuss the implications of these normative dynamics, which may risk stigmatising compensating care practices, although this form of care to a large extent continues to coexist with reablement practices. In conclusion, we argue for a more nuanced approach to care, recognising compensatory care and reablement as complementary forms of care, each doing good under different circumstances.

Home care as reablement or enabling arrangements? An exploration of the precarious dependencies in living with functional decline

The threat to welfare societies posed by population ageing has urged high-income countries to rethink the provision of social and healthcare services for the ageing population. One widely implemented policy solution is 'reablement': short-term home-based training programmes focusing on re-enabling older people to carry out activities of daily living independently. Drawing on empirical material from multisited ethnographic fieldwork of reablement practices in a Danish municipality we explore how the assumptions about independence embedded in the concept's linguistic parts - 're', 'able' and 'ment' - map onto lives characterised by functional decline. We find that home care applicants: (i) are often too deeply dependent on the capacities of others in order to have their independence restored; (ii) negotiate individual meanings of independence to maintain their identity as able human beings; and (iii) might possibly gain new capacities through reablement, yet these are not individual and stable achievements, but rather temporary effects of the care relations with eldercare professionals. Rather than reablement we, therefore, suggest the term 'enabling arrangements' as more appropriate for capturing independence as a distributed, negotiated and continuous accomplishment. Finally, we discuss the practical and ethical implications of this term.

Ideal and reality; Community healthcare professionals' experiences of user-involvement in reablement

Many welfare states offer reablement, also known as restorative care, as an intervention to promote healthy ageing and support older adults in regaining or maintaining their independence in daily life. Reablement is a time-limited, intensive, multidisciplinary, person-centred and goal-directed rehabilitative intervention. Reablement emanates from the user's goals, thus user-involvement is a key factor. The aim of our study was to explore healthcare professionals' experiences of user-involvement in reablement. The context for the study was an urban municipality in south-eastern Norway where reablement had been implemented into home-care services 1.5 years prior to the study. Eighteen healthcare professionals recruited from home-care services participated in focus groups. The material was analysed using qualitative content analysis. The findings resulted in one main theme: Transforming user-involvement from ideal to reality-a demanding process, and four sub-themes: (a) An ideal of self-determination and co-operation; (b) Diverse ability to commit to what user-involvement requires; (c) Continuous co-creation processes; and (d) Challenged by old traditions. User-involvement is a valued ideal that professionals strive towards when providing healthcare. Two main strategies that professionals use to enable user-involvement were identified here: spending sufficient time and having patience with users during the initial stage of an intervention, and starting an intervention by introducing small tasks that users can master. It was also seen that if the time and arenas for interdisciplinary meetings were lacking, professionals could demonstrate traditional attitudes and practice when faced with limited user-involvement in the intervention. There is a need for follow-up over time at the structural, personal, and cultural levels to develop reablement as an intervention with a strong person-centred approach. The findings of this study have relevance for practice development in several reablement settings.

Perception of integrated practice in home care services

Purpose

As a result of demographic changes, older people are increasingly living at home, with multi-morbidity and complex care needs. This calls for enhanced integration of homecare nursing and social services. The purpose of this paper is to describe the clinical collaboration, scope and impact of integration from the perspective of staff in a setting identified as fully integrated.

Design/methodology/approach

In this qualitative study, data consisted of interviews with managers and care workers in social services and homecare nursing (n=14) in daily clinical collaboration, followed by five focus group discussions (n=28). Data were analysed using framework analysis.

Findings

Although the homecare services studied were ostensibly fully integrated, the study showed that the process of integration was incomplete. Interdisciplinary coordination between nursing and social services team managers was described as strong and efficient, but weaknesses were identified in collaboration between care workers. They lacked acquaintance with one another, opportunities for communication and knowledge of the contribution of members of other teams. They felt unclear about their own role in coordinated teamwork and lacked a shared vision.

Originality/value

This paper’s originality lies in the model of integrated care studied and its focus on actual care practices. The findings highlight that integration does not automatically permeate between different levels of service. Time and space must be allowed for conversations between health and social service teams to promote integration.

Physiotherapy supervision of home trainers in interprofessional reablement teams

Physiotherapists (PTs) in reablement are responsible for the supervision of support personnel, referred to as home trainers (HTs), who carry out training and initiatives. There is a lack of knowledge about the significance of physiotherapy supervision in reablement. The aim of this study was to explore the content of PTs' supervision of HTs in reablement teams. We conducted fieldwork in seven reablement teams in Norwegian municipalities. The methods included observations of practice and individual in-depth interviews with PTs and HTs. We analysed data thematically through an iterative inductive-deductive process. The results were generated in a social constructionist perspective and situated learning theory guided the analyses. Analyses revealed that supervision included elements of instruction, demonstration and reflection. However, practices varied widely across different teams, especially regarding the reflection aspect, which was highlighted as essential for learning. Frequent meetings, both formal and informal, were essential to enable learning through reflection. This paper identifies and discusses fundamental elements of PTs' supervision practice in reablement teams, which is also relevant for similar interprofessional settings. Managers of reablement programs should be aware of the powerful impact that organizational conditions have on the practice of supervision.

The practice of support personnel, supervised by physiotherapists, in Norwegian reablement services

OBJECTIVES

Reablement is a relatively new service targeting people with or at risk of functional decline. The approach is team based, and physiotherapists (PTs), occupational therapists, and nurses have the responsibility to guide and supervise the support personnel, referred to as home trainers (HTs). The aim of this study was to explore how the HTs follow up instructions and supervision by PTs in reablement.

METHODS

This qualitative study included video recordings of practice and individual interviews in seven Norwegian reablement teams. The analysis involved a triangulation of all data.

RESULTS

The results identified that HTs had the main responsibility to carry out interventions in reablement and were also expected to report back to the therapists if they recognized further need for assessment or adjustments. The content of the practices varied considerably along a continuum from rigidly standardized practices to individually tailored approaches emphasizing quality of movement. This paper presents analyses of two examples representing the two widely different approaches.

CONCLUSION

Practitioners and health authorities should be aware of the broad variation in reablement services in Norwegian municipalities. The results indicate that a standardized approach may be more efficient in the short term, targeting a large population, whereas a tailored approach, valuing quality of movement, is essential to provide high-quality movement training for users with complex rehabilitation needs. The target groups receiving the different reablement methods should be clearly identified.

A qualitative study of patient-centered goal-setting in geriatric rehabilitation: patient and professional perspectives

OBJECTIVE:

To characterize how rehabilitation goals of older patients change over time and to explore professionals' attitudes toward patient-centered goal-setting and their perspectives on rehabilitation goals.

DESIGN:

Qualitative interview study.

SETTING:

Three geriatric rehabilitation centers.

SUBJECTS:

Ten patients (aged ⩾ 80), who had recently received inpatient geriatric rehabilitation, and seven professionals were purposively recruited.

METHODS:

Semi-structured interviews. Patients were interviewed in the third or fourth week after discharge from inpatient rehabilitation, to reflect on their inpatient goals and to investigate long-term goals now that they were at home. A thematic analysis was performed.

RESULTS:

During inpatient rehabilitation, participants' main goals were regaining independence in self-care activities and going home. Post-discharge, patients were not at their baseline functioning level. Rehabilitation goals appeared to shift over time, and once at home, patients formulated more ambitious rehabilitation goals that were related to regaining full independence and being able to perform activities. Although professionals thought goal-setting together with the patient is important, they also stated that older individuals often are either unable to formulate goals or they set unrealistic ones. In addition, professionals indicated that goals have to be related to discharge criteria, such as performing basic self-care activities, and rehabilitation revolves around getting patients ready for discharge.

CONCLUSION:

During inpatient rehabilitation, patient goals are related to going home. After discharge, patients have ambitious goals, related to their premorbid functioning level. Rehabilitation services should distinguish between goals that are important while patients are inpatient and goals that are important after discharge.

Reablement teams' roles: a qualitative study of interdisciplinary teams' experiences

Introduction

Reablement is a service for home-dwelling older people experiencing a decline in health and function. The focus of reablement is the improvement of the person’s function and coping of his or he valued daily activities. The health care professionals and the home care personnel are working together with the older person toward his goals. In reablement, health care personnel are organized in an interdisciplinary team and collaborate with the older person in achieving his goals. This organizing changes the roles of home care personnel from working almost alone to collaborating with different health care professionals. There is little scientific knowledge describing the roles of different health care professionals and home care personnel in the context of reablement. This study’s objective is to explore and describe the roles of interdisciplinary teams in reablement services in a Norwegian setting.

Method

Two interdisciplinary teams consisting of 17 health care professionals (i.e. occupational therapists, physiotherapists, nurses, and social educators) and ten home care personnel (auxiliary nurses and nursing assistants) participated in three focus group discussions. In addition, three interviews were conducted with occupational therapists, physiotherapists, nurses, and auxiliary nurses. The focus group discussions and the interviews were all digitally recorded, transcribed verbatim and analyzed using the qualitative content analysis.

Results

The health care professionals’ main role was to be consultants and advisors, consisting of (1) planning, adjusting, and conducting follow-ups of the intervention; (2) delegating tasks; and (3) supervising the home care personnel. The home care personnel’s main role was to be personal trainers, consisting of (1) encouraging and counseling the older adults to perform everyday activities; and (2) conveying a sense of security while they performed everyday activities. The role of interdisciplinary collaboration was a common role for both the health care professionals and the home care personnel.

Conclusion

The health care professionals established the setting, and had the main roles of supervision, delegating tasks, and main responsibility for the intervention. The home care personnel accepted the delegations and had a main role as personal trainers. Their work changed from body care to encouraging and counseling the older person to perform activities themselves in a safe way. The health care professionals and the home care personnel collaborated closely across roles. The home care personnel experienced a shift in role from home care to a person-centered care. This was perceived as strengthening the health care identity of their role.

Potentiality made workable – exploring logics of care in reablement for older people

In the face of population ageing, Western health-care systems are currently demonstrating an immense interest in mobilising older people's potentials. With this agenda in mind, several countries have introduced reablement: a type of home care aimed at mobilising older people's potentials for independence by means of short-term training programmes. Based on extensive ethnographic fieldwork conducted in Denmark's home care sector, this paper explores how elder-care professionals translate the abstract notion of ‘potentiality’ into practice. Theoretically, the paper draws on Annemarie Mol's term ‘logic of care’. I demonstrate that professionals draw on two co-existing logics of care: a logic of reablement encapsulating ideals of successful ageing and life-long development; and a logic of retirement, which in contrast allows people at the end of life to retreat and engage in enjoyable activities. Professionals manage to balance these logics in order to live up to policy obligations while at the same time complying with moral standards of good care. However, very little is achieved in terms of increased independence. I argue that by narrowly focusing on bodily and quantifiable potentials, the ‘potentiality paradigm’ holds the risk of deeming older people to lack potential. In conclusion, I therefore encourage a more inclusive approach to elder-care and ageing that recognises the complexities of ageing, including older people's potentials for retreat and leisure.

Workplace learning through collaboration in primary healthcare: A BEME realist review of what works, for whom and in what circumstances: BEME Guide No. 46

BACKGROUND

Changes in healthcare practice toward more proactive clinical, organizational and interprofessional working require primary healthcare professionals to learn continuously from each other through collaboration. This systematic review uses realist methodology to consolidate knowledge on the characteristics of workplace learning (WPL) through collaboration by primary healthcare professionals.

METHODS

Following several scoping searches, five electronic bibliographic databases were searched from January 1990 to December 2015 for relevant gray and published literature written in English, French, German and Dutch. Reviewers worked in pairs to identify relevant articles. A set of statements, based on the findings of our scoping searches, was used as a coding tree to analyze the papers. Interpretation of the results was done in alternating pairs, discussed within the author group and triangulated with stakeholders' views.

RESULTS

Out of 6930 references, we included 42 publications that elucidated who, when, how and what primary healthcare professionals learn through collaboration. Papers were both qualitative and quantitative in design, and focused largely on WPL of collaborating general practitioners and nurses. No striking differences between different professionals within primary healthcare were noted. Professionals were often unaware of the learning that occurs through collaboration. WPL happened predominantly through informal discussions about patient cases and modeling for other professionals. Any professionals could both learn and facilitate others' learning. Outcomes were diverse, but contextualized knowledge seemed to be important.

DISCUSSION/CONCLUSIONS

Primary care professionals' WPL is multifaceted. Existing social constructivist and social cognitivist learning theories form a framework from which to interpret these findings. Primary care policy makers and managers should ensure that professionals have access to protected time, earmarked for learning. Time is required for reflection, to learn new ways of interaction and to develop new habits within clinical practice.

Tailoring reablement: A grounded theory study of establishing reablement in a community setting in Norway

Reablement is an interprofessional, home-based rehabilitation service that aims to enable senior residents to cope with everyday life and to prevent functional impairments. Systematic accounts of what practitioners actually do when establishing reablement are lacking. This study aims to generate a grounded theory of practitioners' patterns of action when establishing reablement. The study is located in Norway, and grounded theory is the methodological approach. Data were collected from January 2014 to August 2016 through participant observations, focus group interviews and individual interviews. Informants are municipal healthcare employees in different organisational areas associated with the process of establishing reablement services (managers of conventional home care and representatives from the administration and service-provider offices). Altogether, 17 individuals are interviewed. The empirical data are analysed several times using open, selective and theoretical coding. The grounded theory, "tailoring reablement," includes three phases-replicating, adapting and establishing-and the strategies of collaborating, developing knowledge, habituating and filtering. The theory of tailoring reablement also includes the impact of the contextual factors. The study seeks to bridge the gap between research and practice. The theory of tailoring reablement emerges from an inductive approach and theorises participants' actions. The theory focuses on the phases from innovation to implementation. Establishing a new service model in a complex welfare setting requires a wide range of actors and agencies. Tailoring reablement also requires flexibility and professional autonomy. It is important to create terms and conditions for this within a stringent health and care service. The insights of this study have implications for practice development of reablement and can fit other public sector fields.

Interdisciplinary collaboration in reablement - a qualitative study

BACKGROUND

In-depth knowledge regarding interdisciplinary collaboration, a key feature in reablement, is scarce.

OBJECTIVE

To elucidate how the interdisciplinary collaboration in reablement worked in a Norwegian context.

SAMPLE AND METHODS

Seven focus group interviews were conducted with 33 health care providers working in interdisciplinary reablement teams in seven municipalities across the country. The focus group interviews were transcribed and an hermeneutical analysis was conducted.

RESULTS

The analysis resulted in four main themes: "participant's own goals as a common interdisciplinary platform", "a positive professional community", "learning from each other's skills and competencies" and "new roles and joint efforts but specific competencies". The results show that interdisciplinary collaboration in reablement depends on participants defining their own rehabilitation goals, which function as a professional unifying platform for the interdisciplinary collaboration. The challenges for participants in reablement are often complex and include assessments, effort and a need for close collaboration between several different professionals. A tight interdisciplinary collaboration causes major changes in roles, often from a particular role to a more general role with broader job tasks. Although different professionals perform the same rehabilitation tasks, it is important that each professional contributes their unique competence and thus together they complete each other's competencies.

CONCLUSION

Factors that have a positive impact on interdisciplinary collaboration in reablement are participants' definitions of their goals, number and variety of professionals involved, how closely these professionals collaborate, the amount of time for communication and shared planning and decision making.

The reablement team's voice: a qualitative study of how an integrated multidisciplinary team experiences participation in reablement

Background

Reablement is an early and time-limited home-based rehabilitation intervention that emphasizes intensive, goal-oriented, and multidisciplinary assistance for people experiencing functional decline. Few empirical studies to date have examined the experiences of the integrated multidisciplinary teams involved in reablement. Accordingly, the aim of this study was to explore and describe how an integrated multidisciplinary team in Norway experienced participation in reablement.

Methods

An integrated multidisciplinary team consisting of health care professionals with a bachelor’s degree (including a physiotherapist, a social educator, occupational therapists, and nurses) and home-based care personnel without a bachelor’s degree (auxiliary nurses and nursing assistants) participated in focus group discussions. Qualitative content analysis was used to analyze the resulting data.

Results

Three main themes emerged from the participants’ experiences with participating in reablement, including “the older adult’s goals are crucial”, “a different way of thinking and acting – a shift in work culture”, and “a better framework for cooperation and application of professional expertise and judgment”. The integrated multidisciplinary team and the older adults collaborated and worked in the same direction to achieve the person’s valued goals. The team supported the older adults in performing activities themselves rather than completing tasks for them. To facilitate cooperation and application of professional expertise and judgment, common meeting times and meeting places for communication and supervision were necessary.

Conclusion

Structural factors that promote integrated multidisciplinary professional decisions include providing common meeting times and meeting places as well as sufficient time to apply professional knowledge when supervising and supporting older persons in everyday activities. These findings have implications for practice and suggest future directions for improving health care services. The shift in work culture from static to dynamic service is time consuming and requires politicians, community leaders, and health care systems to allocate the necessary time to support this approach to thinking and working.

Interdisciplinary collaboration experiences in creating an everyday rehabilitation model: a pilot study

Background

When functional impairment occurs, assistance to achieve self-help can lead to qualitatively more active everyday life for recipients and better use of community resources. Home-based everyday rehabilitation is a new interdisciplinary service for people living at home. Rehabilitation involves meeting the need for interprofessional services, interdisciplinary collaboration, and coordination of services. Everyday rehabilitation is a service that requires close interdisciplinary cooperation. The purpose of this study was to gain knowledge about employees’ experiences with establishing a new multidisciplinary team and developing a team-based work model.

Method

The study had a qualitative design using two focus group interviews with a newly established rehabilitation team. The sample consisted of an occupational therapist, two care workers with further education in rehabilitation, a nurse, a physiotherapist, and a project leader. Data were analyzed by thematic content analysis.

Results

The data highlight three phases: a planning phase (ten meetings over half a year), a startup phase of trials of interdisciplinary everyday rehabilitation in practice (2 months), and a third period specifying and implementing an everyday rehabilitation model (6 months). During these phases, three themes emerged: 1) team creation and design of the service, 2) targeted practical trials, and 3) equality of team members and combining interdisciplinary methods.

Conclusion

The team provided information about three processes: developing work routines and a revised team-based flow chart, developing team cooperation with integrated Trans- and interdisciplinary collaboration, and working with external exchange. There is more need for secure network solutions.

Home Help Service Staffs’ Descriptions of Their Role in Promoting Everyday Activities Among Older People in Sweden Who Are Dependent on Formal Care

The study aimed to explore how home help service staff described their role in improving the abilities of older people, in particular, older women with chronic pain who are dependent on formal care, to perform everyday activities. Three focus group interviews were conducted, and a qualitative inductive thematic content analysis was used. The analysis resulted in one theme: struggling to improve the care recipients’ opportunities for independence but being inhibited by complex environmental factors. By encouraging the care recipients to perform everyday activities, the staff perceived themselves to both maintain and improve their care recipients’ independence and quality of life. An important goal for society and health care professionals is to improve older people’s abilities to “age in place” and to enable them to age independently while maintaining their quality of life. A key resource is home help service staff, and this resource should be utilized in the best possible way.