Older adults’ experiences of a reablement process. “To be treated like an adult, and ask for what I want and how I want it”

ABSTRACT

This is a follow-up study of intensive home-based rehabilitation from older people’s perspectives. The aimwas to explore older adults’ descriptions of interactional needs related to autonomy in life. The purpose was also to explore the importance of significant others in the reablement process. The sample consisted of 23 women aged 72–92 who were included consecutivelyin the first project year. Data were collected through face-to-face semi-structured interviews that were recorded, transcribed, and analyzed using qualitative latent content analyzes. The results show that regaining autonomy through reablement was achieved by the interviewees although not always to the same extent as before. Three themes related to interactional needs were identified: (1) Transitional relations, referring to encounters with staff in time-limited relations. (2) More stable relations with significant others without limitation of time. (3) The acceptance of growing older and of death as a “natural departure”. Transitional relations with professionals, and more stable relations with significant others, are important parts of the reablement process according to older adults. In conclusion, professionals within gerontology need to recognize the social and historical context including the symbolic meanings each older person gives to life’s necessaries. Older adults appreciate reablement which includes rehabilitation goals related to the person’s stable relationships and larger life context.

Introduction

Reablement has emerged as the 21st century’s tool to manage the aging population, identified by time-limited goal-directed rehabilitation delivered by an interdisciplinary team (Whitehead, et al., 2016). The purpose of a reablement intervention is to strengthen the individual’s functional capacity and quality of life, while home-care hours and thus municipal expenditures are reduced. The intensive home-based interdisciplinary rehabilitation is designed to extend the time of independent and autonomous life and decrease municipal costs for eldercare, although evidence is lacking that can provide answers about the effect (Cochrane et al., 2016; Legg, Gladman, Drummond, & Davidson, 2016). In Sweden reablement has been highlighted as a way to integrate users’ perspectives on municipal home service into community care (National Board of Health and Welfare, 2014), aiming at strengthening or preserving the health and functional ability of older adults.

Depression and loneliness are often mentioned when describing problematic old age. Several studies show that a more nuanced view needs to be taken into consideration when focusing on older adults’ needs. Despite declining physical health and abilities of different kinds, satisfaction with life may still be expressed (Anbäcken, 2015; Andersson, 2002; Hagberg, 2002; Tornstam, 2007). Moreover, part of being human is to experience existential loneliness (Moustakas, 1961) not least in the aftermath of grieving for loved ones who have died, or other, perhaps less dramatic losses, of working life, of the former home, of the ability to travel or the ability to participate in contexts one could freely chose (Whitaker & Anbäcken, 2012). While loneliness is obvious, it does not mean that old age has to be characterized by loneliness. There is little research from the perspective of older persons themselves on loneliness (Ågren, 2017). Rather the discourse on older people’s loneliness seems accepted as legitimate reason for addressing loneliness as a big problem in old age and in social work for older people. Ågren (2017) found that when Swedish media (during 2013–2104) wrote about loneliness among older people it was with the main purpose of persuading welfare and care actors to use more resources on eldercare. Ågren further highlighted the importance of volunteer organizations in alleviating the assumed loneliness among older people.

To facilitate older people to live with independence, autonomy and dignity is a main goal in industrial societies all over the world. With demographic changes and economic recession, continued needs for qualified care services are seen on the one hand, while on the other hand the precarious society (Phillipson, 2016) in which older adults are at risk appears to add further challenge to care services. Ageist stereotyped views of old age tend to compromise older adults’ ability to be in control of their own lives. Therefore, professionals need to integrate older adults’ perspectives when developing new treatment methods and in research as valid evidence to enhance scientific knowledge. Earlier research on the user perspective in reablement has focused on medical reablement, which describes the process of rehabilitating patients to be independent with their medication in the transition between intermediate health and social care services (Gerrish, Laker, Wright, & Stainrod, 2017). There is also research of relevance for home-based rehabilitation such as older adults’ perspectives on daily life when returning home from hospital (Bontje, Asaba, Tamura, & Josephsson, 2012). However, few published qualitative studies have focused on older adults’ perspectives of home-based reablement interventions. One Norwegian study, though, was found which for example claimed that follow-up is important, since not every older adult has enough motivation to continue reablement practices on their own (Hjelle, Tuntland, Førland, & Alvsvåg, 2017). Older adults, mostly women, are the major group of users within welfare services delivered both by the state and the public, and we need to know more about users’ views of community social care and services, such as reablement initiatives delivered by an interprofessional team at home.

The aim of this study was therefore to explore older adults’ descriptions of interactional needs related to autonomy in life. The purpose was also to explore the importance of significant others in the reablement process.

Theoretical frame

The meaning of home especially in older age has been elaborated on in terms of feeling “at home ness”, which can be experienced as wellness despite illness or disease (Öhlen, Ekman, Zingmark, Bolmsjö, & Benzein, 2014). Three aspects of “at home ness” appeared in the study by Öhlén et al.: to be safe and secure, to be related, to be centered, i.e. to have an inner center of calm which is equivalent to the individual’s sense of being herself. Villko (2001) described the feeling of “home enough” that could be experienced in institutional care homes if the individual’s integrity was respected. Thus it is both material and immaterial aspects that blend in the meaning(s) of home. This can also be linked to a feminist philosophy perspective which draws on the meaning of having a home, a place to live where you are able to find your own space (de Beauvoir, 1973; Young, 2005). Young furthermore argues that aging people can maintain a sense of self through engaging with objects that have symbolic meaning; “my things and my dwelling place support and display who I am” (Young, 2005, p. 157). The home is where your identities are grounded by keeping connection and contacts with the world outside through valued objects such as furniture, paintings, pictures and clothes; you can reflect on and reinforce who you are.

In addition, Tornstam (2011) has developed knowledge about how role confusions and loss of roles in later life and old age influence health and well-being. This is where the interprofessional team in particular can make a change in finding suitable reablement goals for the individual, not confusing personal loss of loved ones with loss of roles in life. As we age we lose parts of the self based on competences, relationships, memories, private space and objects. The present study addresses what factors may nurture well-being for older adults after and during receiving home-based rehabilitation, known as reablement (Cochrane et al., 2016; Legg et al., 2016).

Methods

This interview study is a follow up of a reablement intervention, i.e., a time-limited intensive home-based rehabilitation of older adults delivered by an interprofessional team. The intensive home-based rehabilitation project (IHR) was set up and pilot-tested in 2015, and during 2016 the participants that had completed the intervention were invited to take part in individual follow-up interviews. The sample consists of 23 women aged 73–92; five persons declined to participate (four women and one man). The variation in age is due to the study design: all cases of older persons in central areas of one municipality who came to the care managers for a first assessment during a certain time period were included. Few men were included in the sample of the IHR project, which was beyond the control of the study design, since most of the participants during the first study year were women.

The Care manager identified consecutive people who were eligible for inclusion in the study before assessment and during planning for discharge after going home from a hospital admission and when needing home care for the first time. All participants were informed by the care manager about the research project and could decide whether or not to take part. The intervention involved intensive everyday rehabilitation visits by an interprofessional team that included nurse aides, occupational therapists, physiotherapists, a nurse and a social counselor. Together the team and the user decided on rehabilitation activities and practices based on user-specific goals focusing on regaining autonomy in life. All members of the team worked toward the same individualized rehabilitation goals. In the first project year participants included in the intervention group were asked a second time both by care managers and by the prospective interviewer before deciding on being interviewed and taking part in the follow-up study. The IHR project and the follow-up interview study were approved by the Regional Ethics Committee (Dnr 2015/350).

The interviews

An interview guide was constructed that included questions about work experiences, everyday life dilemmas, experiences of reablement, preparedness for aging and death, and ended with an evaluation of the interview. The interview guide (which can be requested from the first author) was inspired by critical incident technique (Woolsey, 1986).

Data analyzes

The interviews were recorded, transcribed verbatim and qualitative content analyzes was used in the interpretation of the results (Graneheim, Lindgren, & Lundman, 2017). The interviews were read and the meaning units that included content related to the aim of this study were abstracted to tabular form. From these tables preliminary subthemes and themes were identified by one of the coauthors (GÖ). Later on, another coauthor (E-MA) reread the interviews and further developed the themes. The first sorting of the empirical material was done under the heading “the IHR intervention”, “encounters with staff”, “experiences of municipal service”, “social integration” and “loneliness”. The table with quotations from each interview facilitates the analyzes of data and the comparisons of contents within all transcribed interviews, but the labeling of themes was continuously developed while going back and forth working with the whole material, and in preparing the manuscript. During these analyses the research group further discussed the interpretations. Thus the analyzes combines the manifest content and hermeneutical interpretations, known as latent qualitative content analyzes (Graneheim et al., 2017). The preliminary results were also presented at national and international social work conferences.

In the results section when quoting the women, pseudonyms are used and age is stated in parentheses.

Results

Although the aim was to explore older adults’ descriptions of needs and interactions related to autonomy in life after the intervention, the answers showed variations. While some of the women talked in specific terms of the professionalism of the staff and their support to reable, others had difficulties recognizing specific situations that were included in the IHR intervention. They preferred talking about what gave life meaning, such as relationships. Based on the women’s descriptions of everyday relationships, three themes were found:

• Transitional relations with interprofessional staff

• Stable relationships with neighbors, relatives, and loved ones

• Acceptance of aging and death as a natural departure

When exploring the interviewees’ descriptions of what they include in their reablement process we found that they talked about the need for autonomy in everyday life and the importance of being able to keep on living at home. Everyday worries concerned autonomy in managing self-care, shopping, stairs, and heavy doors in the accessibility and housing complex, and finding ways to get fresh air. Everyday pleasures included recurrent or daily talks with neighbors and relatives. In addition, for some a dog can be viewed as a best friend. Daily pleasures also include preparing or receiving nice food and coffee, preferably in company with others, along with being able to go outside.

Transitional relations with interprofessional staff

Being independent and able to manage daily life was the overarching objective of both the interprofessional team and the users, although the negotiated rehabilitation goals were directly tailored for each woman (see Table 1). The maximum time of the IHR intervention was three months, but if a person had regained enough of her goals it could be less. Svea (90) was disappointed because she had counted on getting help from the team for three months but due to her fast recovery the intervention ended sooner.

1. Svea: Yes, they said that I would have their help for three months, but that ended sooner, it was shortened. [They said] You can make the bed, you can clean, we don’t have to be here, but I thought it was a shame when I like them so much.

Table 1. Older adults’ rehabilitation goals in the reablement intervention from interviews in Sweden 2016.

Age	The will to regain independence – rehabilitation goals	Days in the project	Fictional names
80	Walk to the bus stop and travel without support	73	Telda
75	Shower, vacuum, do the washing and take out the garbage	39	Carmen
87	Go outdoors independently and do the washing	75	Elsa
90	Go for a walk on your own	67	Berta
91	Be able to dress and use a walker indoors without company	59	Gun
87	Use a walker indoors without company	53	Rut
76	Dress and undress, walk indoors, sit on a kitchen chair when eating	68	Karin
78	Walk with walker and support to the park, remove stockings	62	Iris
86	Use travel service for shopping, and take out the garbage	67	Stina
86	Judge safety and walk without indoor aids, go outdoors with the help of crutches and go shopping	101	Anna
82	Take a bus to the cemetery and buy flowers while traveling, dust and vacuum	44	Malva
92	Prepare meal, remove support socks, get out with a walker, be able to use travel service	59	Britta
73	Go outside with the walker to bingo using the stairs. Put on a coat to walk the dog as well as safely pick up after it	61	Martha
91	Shower and go shopping with shopping cart	50	Maja
87	Go with a walker indoors, lay the table and make simple meals, support talks to find motivation and energy in life	97	Siv
90	Take the walker to the store and shop	84	Svea
81	Improved walking and using stairs	85	Gerda
75	Go to the toilet, get in and out of bed, prepare easier meals, go shopping on your own	58	Vera
86	Put on socks, walk short distance outdoors and be able to use the stairs	73	Fina
87	Shower and manage go shopping	95	Tora
89	Shop with a walker as company, use the stairs and pop out to the mailbox	87	Doris
83	Evaluate safety when walking with a walker, dress and undress, was glasses, plates and cutlery	60	Hilda
72	Dress independently and cook meals 2–3 times a week.	61	Priscilla

*Quantitative rehabilitation goals were found in half of the users, such as how many weeks were calculated to reach a specific goal, although, these are not shown here.

The intention was to tailor rehabilitation goals to physical disability and social needs and wants. Gerda’s (81) rehabilitation goal was to improve walking and using stairs. However, she would have liked more communication rather than focusing on physical practices, because she manage to exercise on her own, but felt lonely and would have preferred to get company and support in outside activities. Sometimes, however, a rehabilitation goal was a perfect match and overlapped with other desires. For example, social needs and wants such as visiting her husband’s grave at the cemetery on her own made Malva (82) particularly keen on practicing walking. Carmen (75) was supported to attend social activities by the social counselor in the team and she managed to meet new friends and enjoy more social integration as part of this intervention, although this was not articulated in her rehabilitation goal.

• (II) Carmen: Well, I tried to embroider on my own when I had the plaster, I was sad, it was sad. I tried once, I felt, I went to it from one room to another room and into the kitchen, I felt like a [prisoner], yes. I sat in my bedroom and I tried to raise my embroidery, and I eventually, yes, a little slow. And I told her [the social counselor of the IHR team], I will be embroidering and in the afternoon I go to my brother, I will at nine, sometimes half past nine, and other activities no. I told her, I don’t know if I have any interest in those activities, I’m … I’m not [feeling safe] to go. It depends on the language. Feeling outside the group, but she just [backed me up, so] I tried something from the computer that we checked [together].

Another migrant woman was very critical of the IHR intervention because she had clear expectations from a medical point of view: “I can say honestly that I am very sad since I did not receive the rehabilitation (…) physiotherapy”, Priscilla (72) exclaimed. She felt the team did not understand her needs and she expressed feelings of powerlessness and indignation. It was obvious that her views on what rehabilitation means, and the intervention goal of being able to get dressed and cook independently, did not match. In contrast, Anna (86) expressed general contentment with her home rehabilitation, and appreciated the training that she still continues to do, so that she can keep the goal of walking indoors without aid, and walking outdoors with crutches – thus enabling shopping.

On the other hand, Iris (78) wanted to be more prepared, saying that not only the name of the intervention but also the team’s regular visits made the intervention too intense: “Yes it was intense! That’s the word, ‘intense’ … you know what that means … mobilization with intensity.” More voices were raised against the early demands from the team to let the user to show off how much they were able to perform in relation to self-care and domestic work. Stina (86) said that the demands of the team felt tough initially because she had been malnourished and therefore had no strength at all to do these exercises when she came back home. Ruth (87) and Britta (92) argued that their poor physical condition limited their appreciation of the team’s rehabilitation activities to start with.

The IHR team seemed to act a bit differently than other caring personnel the women had meet, since they involved the person in the practice of rehabilitation directly. However this pressure from the personnel could be understood as patronizing the individual, especially by well-educated women. Marta (73) said that she wanted to be treated as an adult possessing experiences and knowledge as opposed to having demands made of her by the personnel. In contrast, Karin (76) liked and agreed with the team’s way of pushing her forward and not helping her out too quickly.

• (III) Karin: [They were] lighthearted and (…) wanted to help me, no, not all the time, they contradicted me [sometimes] when I said I could and I kept holding on. “Mm, you should do it yourself,” they said. Interviewer: Mm, so they have also pushed you. Karin: Yes, “we’d really like to help you,” they said, “but we won’t, you should do it yourself.”

The way the team let the women try to perform every activity for themselves contributed to giving them insights into their own abilities, as reported by Hilda (83): “They let me try and thought I could do some things, but not all, and I thought that was positive. Because then I got insight into what I could or couldn’t do.” Karin (76) and Telda (80) were sad when the intervention was finished.

• (IV) Telda: Yes, yes. No, to be treated like an adult person, and ask for what I want and how I want it. They did it all the time, you decide to tell them. So that was, no, that was a good deal. It was a bit sad when I did not get them anymore, it was a little like departing. They were here, my contacts and said goodbye and so on.

Tora (87) appreciated the time that IHR had to talk, and she described herself as doing what they told her, because she really wanted to get going. Fina (86) was very clear about the team’s professional skill especially, mentioning both nurse aides and physiotherapists, and clarified also that it included not being on too familiar terms with each other. When asked by the interviewer what does professional skills mean? Fina said:

• (V) Fina: well you’d better ask them in their work what it means but it means going back to life” Interviewer: Going back to life, yes, but can you give any specific example of a situation when you felt they encountered you in a very good, specifically good way? Fina replied: The whole time, every hour. They kept the integrity and were careful about my integrity, they were fantastic.

The one interview that was done together with the spouse of Vera (75) differed not only due to the dialogic pattern of this showing the “we-ness” (Nilsson, 2018), but it contrasted with the others in displaying a very clear knowledge about health and social care systems and professions, the county council’s and the municipality’s roles in delivering care and support. This couple’s account bears witness to the equal balance between them and the professional staff, and they especially praised the occupational therapists. The couple was supported in their social identity in an interplay between IHR staff and themselves: “We went to a café, it may have been the first walk with the municipal people for them to see how far I could walk and how long it took and if I needed to rest. Actually it was a first test.” Vera and her spouse talked very much about their hitherto active life and how they continued it, using support from the IHR team, but they also talked about their social network.

Although maintaining motivation for reablement seemed to be related to social relationships of different kinds, the relationship with nature and the environment also shaped the individual’s involvement in the process. Recognizing one’s surroundings make one feel secure and comfortable about testing new challenges. Gun (91) told us how important daily mood was and described how the sun inspired her to reach her rehabilitation goals, such as fetching the mail down the road. Gun says: “I check how it is out there. If the sun is shining, it is easier.” If the sun is shining she clings to the garden fence to find her way to the mail box; without sunshine she did not bother to practice.

Stable relationships with neighbors, relatives, and loved ones

Several interviewees described how they phoned relatives regularly at the same time, once or twice a day. Phone calls were like meetings. One women told of how her sister had died and how she and the niece now continued the phone calls the sisters previously had made twice a day. According to Malva (82) both of them benefited from these calls, but she also kept her connection with the past by using everyday knowledge, such as sayings passed on from parents and grandparents, as if the significant others were still present in life. Malva also talked about how her mother always said: “Happiness is being able to get up in the morning.” She also concluded with: “I don’t know if this is something that has followed me, I only think about it every night.”

Doris (89) explained that she had been raised by her grandparents, which was normal for children of single mothers in Sweden a century ago. She still used her grandfather’s saying: “You should not be in a hurry when the evening comes”, and this strategy gave her guidance in life. Another woman described how she was haunted by her late husband’s aggressive and threatening words, especially at bedtime, making it hard to fall asleep: this shows how the inner world also can have a negative influence. Siv (87) described a complex situation having difficulties walking on her own, having sight problems, and still caring for her husband who has dementia. When she had the accident and went to the hospital one of her neighbors took care of the husband. Siv found life difficult and kept most of her melancholy thoughts to herself, but she coped with the situation through a supportive neighbor. “I have a lady over there in this neighborhood, she has lived in these apartments before. She was really nice when I was in the hospital, my husband stayed with her because he’s a little worried when he is alone.”

Several of the women had lived in the same apartment for many years and socialized with neighbors on a daily or weekly basis, meeting over morning coffee or afternoon tea and sharing newspapers. Being rooted in the same place is something that these women of age value highly. Many of them also address concerns about not being able to keep their apartment if they can no longer manage to open heavy doors or climb the stairs. Social integration with neighbors was important for structure, security, satisfaction and joy in life. Neighbors’ presence related to one’s sense of belonging, but also to safety in terms of trusting someone to be there. Several of the women told how the neighbors sided with them and helped out when the accident occurred that led to the need for hospital care. One of them was Gerda (81).

• (VI) Gerda: And then I have neighbors, we are as one, like this … Interviewer: Like a small family? Gerda: Yes. Interviewer: Well, that’s great. Gerda: Yes. We have been. Interviewer: You bring your hands like this [to the chest] and keep them there. Gerda: Yes, yes that is what I mean. But they are beginning to get a bit old, they can’t help out so much anymore. Gerda: But it’s good to have them anyway.

The women’s former independent lifestyle had changed, and while the interprofessional team was around some independence was restored, but without backup uncertainty was there again. Telda (80) says that, above all, she wishes to have the freedom to decide tonight whether to go to the movies, or a concert or something, and not just sit at home. Several of the women worry about their mobility; public transportations are important conditions of healthy aging, making it possible to maintain social contacts and interests. They worried about public transport and disregarded the social welfare transportation service since it does not work when it comes to keeping the scheduled time. Being isolated and lonely is a major fear for several of the interviewed women. Berta (90) talked of how nice it was when she could do things with her friends.

• (VII) Berta: Yes, just go and go to the woods and pick berries, yes, get on a bike and go there … I thought all my friends were gone. That’s the worst, I think. She lived to be 87, no, 97, before she passed on. It’s sad, I think. We had a lot of fun together.

Acceptance of aging and death as a natural departure

Worries for the future were described as not wanting to be dependent on others and being forced to move from a familiar context, or fear of having to stay in bed. Ruth (87) said she was afraid of being bedridden since her father had wound up like that. She also worried about not being able to cope with stairs, heavy cellar doors and not being able to keep her beloved dog. Existential matters were spoken about in the interviews in different ways. Some, such as Ruth (87), gave a straightforward answer that she thinks of death, “sometime every day”.

• (VIII) Interviewer: Anything special you think of then? Ruth: No, it is not like that. It’s, well, that you don’t want to disappear. You want to be in the game … And I am so thankful as long as we can be together, yes, yes”

Ruth talks affectionately about her family, that while they cannot do anything about her health condition, it feels better when she can talk with them about it. “Interviewer: Is it the worry about what will happen, or what? Ruth: Yes, yes. I want to be in (with them) … until the end (laughter). For Ruth existential health is intertwined with her relation to her family: grandchildren, children and husband. To be together, to be related, to be connected in life is central to her life as a whole and daily life now. She lives knowing that death can come any time because of her heart failure, but she may also live on for a longer time. Loneliness is not mentioned, but the thought of death could be described as fear of utter loneliness – being cut off. And it is all related to her strong will to be in life together with her family. In other interviews loneliness was also described indirectly: the loss of friends, and loved ones, the loss of ability to travel … loss of things and activities to long for. The overall impression from the interviews was that to a greater or lesser extent they had accepted it. Not wanting to be a burden to the family at the end of life was mentioned explicitly by some.

Hilda (83) describes death as a “natural departure”, and that she wants to keep on living at home until the end. Another existential nuance expressed concerned not having the strength to do things she used to like, such as baking buns: having lost the desire to do it, she still did it for the sake of her grandchildren. This is a different way to talk about the importance of family relations: to be needed. Yet another aspect of growing older is acceptance of one’s limitations.

• (IX) Elsa (87): I don’t think of things I would like to do but cannot, no, no … .no I have accepted. Now I am as I am. So now it is only, I am glad to be at home, and that I can lie in my bed and [just] be, yes I am glad about that [living], one of these days, bang. My heart might just strike and then there you are.

Loss of family members, as mentioned in several cases, gave awareness of death being part of life. For Britta (92) the situation was reversed since one of her children now had cancer and this was what Britta showed her concern for and how to arrange all practical details that had to be taken care of.

• (X) Interviewer: How do you think about the matter of becoming older? Britta: That is … Well, I think it is a bit creepy and a bit hard. I: yes … B: Yes, yes, it comes mostly in the evenings. I: I see. B: Mm. I: How do you think then? B: Oh, “well, we’ll see if we get up tomorrow” [referring to her mother’s way of talking about death].

Karin (76) has kept going until recently, not being ill at all, and could not imagine that things like this [her husband’s death] could happen. So when the long relationship to her partner was broken and her own health was challenged by a stroke, it provoked her to think … On the other hand, as Karin muses: “As long as … everything functions and … I mean, I am alive … ”

Anna (86) is a bit “low” after three strokes; she would not mind getting old if she was a bit more healthy: “I have got what I want from life and I’m not so hungry to live that long with this handicap.” Approaching end of life, however, is something she has “been on friendly terms with”.

Discussion

This interview study has been conducted as a follow-up of an intensive home-based rehabilitation intervention for older adults received after having experienced a new situation where they were assessed for the first time by a social worker (care manager) about the need for home care based on physical health conditions. The women found transitional relations with the IHR team members rewarding, though sometimes too challenging, and they preferred talking about everyday life in general. While the lived life of each person was present in their conversation, the present time seemed also to be in focus in the talks with the interviewer, from the small joys of everyday life that one could accomplish to reflections on social interactions with next of kin, and neighbors or team members, when asked about the IHR intervention. Sometimes anecdotes and sayings that relatives had used were present in their descriptions of what everyday life included, even if the person passed away a long time ago. Past, present and future life, including the last part of it, was thus the life context they shared in the interviews. The quality that was commented on in various ways could be related to both the feminist view of home as a base for oneself, due to material things (Young, 2005), but perhaps equally home being the place where “at home ness” is experienced (Öhlen et al., 2014). To keep one’s identity, to be able to live at home, maintaining a healthy enough everyday life, was made possible thanks to support through informal and formal care and help. Also a “we-ness”, of keeping the relationship and one’s shared life going (Nilsson, 2018), was expressed in an interview with a couple; that gave life meaning and made reablement worthwhile. Related to identity we also found that the specific training and support from the IHR team strengthened the identity of some of the participants, who described themselves as actively aging persons. The women verbalized the appreciation they felt for the IHR team members as professionals who supported them to take part in rehabilitation activities and continue their reablement process despite reduced abilities.

In sum, all the interviewees in different ways showed awareness of aging and approaching the end of life. None of them talked about loneliness explicitly, but they did indirectly or through talking about the end. Perhaps Moustakas’ (1961) description of existential loneliness as an essence of life is a suitable way of describing and labeling their reflections, thoughts and feelings about life, aging and death. While loneliness was not problematized by the participants, it can be seen embedded in a few sayings. Loneliness was in such cases of an existential kind: the loss of loved ones, the loss of abilities, the loss of control, the loss of a life lived (Hagberg, 2002; Moustakas, 1961; Whitaker & Anbäcken, 2012). Here loss of roles is an intertwined aspect, and Tornstam’s (2011) discussion of loss of roles in later life is applicable to our findings especially when referring to qualities related to the professional work role. Caring roles in the family were mentioned but not as a dominant feature, as might have been expected, since women of this generation(s) are often thought of as being caregivers, to children, to spouses, to their own parents (Sand, 2010). Perhaps role confusion could be seen in relation to IHR intervention: What is expected by the older person receiving this intervention? To be a patient? To be a person living at home receiving care and support, a so-called “user” (of care)? Some of the women voiced uncertainty about what was expected of them and what they could expect from the IHR team. This could be related to role confusion experienced when suddenly being treated as equal contributors in rehabilitation and care, and not as patients.

It is noteworthy though, that the expected discourse on the problems of loneliness of older people (Ågren, 2017) is not detected in our study. The loneliness that shines through can be described in terms of normal aging, the existential loneliness of being a human being, experiencing various losses within the phases of life (Moustakas, 1961). The loneliness that shone through the two interviews with people from ethnic backgrounds other than Swedish could be related to a feeling of alienation in their life stories and that they did not feel “at home ness” (Öhlen et al., 2014) due to either language problems or experiencing that one’s own struggles in Swedish society were not rewarded.

To what extent the reablement, or intensive home rehabilitation, made a difference to the women’s experienced life satisfaction, or was conducive to alleviating feelings of loneliness, and supportive in relation to mental health aspects cannot be deduced from this interview study. Although, we might be able to address that as well as other similar questions based on our analyzes of a forthcoming randomized control study. Nonetheless, from the transcripts we can see that the interviews seem to have offered a good opportunity to reflect on life and death. Perhaps the interview offered a positive opportunity for many of these women to verbalize thoughts about the finite character of life, and in this respect alleviated feelings of loneliness (Anbäcken, 2015; Hagberg, 2002).

The participants in the present study talked about social relations and social interactions in many ways. Primarily family but also friends and neighbors were important for their well-being, for social self-recognition and to facilitate enriched social interactions. The older woman’s experiences in the reablement process are particularly linked to the notion of home: having a safe place to return to where you could identify yourself as a person through interactions in recognizable surroundings (Young, 2005). Two of the women emphasized the professional skills and the relationship between themselves and the IHR team as “public” and not “social”, although social skills were obviously part of their professionalism.

The interviewees’ relational needs and social interactions with significant others recurred through the interviews as a central value of life, although in different ways. For some the partner, children and grandchildren seemed to be the very foundation for the existence of the older persons, while for others they were indeed important individuals but the older person had the ability to sustain a meaningful life herself. The daily social interactions often described were socializing with neighbors, sharing coffee and exchanging newspapers. However, the interviewees did not only give examples of daily interactions, but could also show a capacity for critical thinking and ability to take charge. These older woman reflected in their minds on how “life experiences and social reality” were interpreted and given symbolic meaning in everyday life (Young, 2005). Indeed, this is a message to professionals in social care and reablement, to recognize the social and historical context, e.g. the larger picture of each older person.

Moreover, for some participants reablement interventions have to be developed by follow-up contacts for those that have enough motivation on their own to continue exercises as claimed by Hjelle et al. (2017). From our present study a somewhat different perspective emerged, since some of our participants were upset by the huge difference between the intensive contact with the team, and then the experienced abandonment when the time for the intervention was up. In future research and practice the interprofessional team might need to investigate more thoroughly which individuals would benefit most from follow-up contacts after reablement. Another difficulty that the interviewees addressed was matching team goals with participants’ goals. Some of the participants receiving reablement did not understand what to expect from the intervention. This highlights the need for the team to be more imaginative in helping people achieve what they really want to achieve.

Acknowledgments

Firstly, many thanks to the older adults that took part in our interviews, and the social care managers that helped us out with or research. Secondly, thanks to the social work master’s student Carl Johansson for inspiring theoretical discussions of older adults’ mental health and his master’s thesis in social work (2017), which is based on quantitative data in the IHR project.

Disclosure statement

No potential conflict of interest was reported by the authors.