Older adults’ experiences and expectations after discharge from home-based occupational therapy

Abstract

Introduction

Home-based occupational therapy can improve older adults’ occupational performance, but maintaining improvements presents challenges, and service development is needed. In this study, older adults’ experiences and expectations concerning their occupational performance after discharge from home-based occupational therapy were examined and used to develop suggestions for improved practice.

Method

Semi-structured qualitative interviews were conducted with 11 older adults living alone or with a spouse. The interviews were analysed using inductive qualitative content analysis.

Findings

The older adults still strove to improve and maintain their occupational performance using various strategies; their desire for independence was strong, but some could accept a lesser degree of independence.

Conclusion

From the findings and existing literature, ideas were developed to improve home-based occupational therapy and support maintenance of occupational performance after discharge. These ideas include: (a) finding strategies to achieve satisfactory occupational performance that does not necessarily entail full independence, (b) increased focus on the use and transfer of problem-solving strategies, (c) acknowledging and addressing possible reluctance to use assistive devices, and (d) individually scheduled follow-up visits post occupational therapy. Future research should examine the effectiveness and applicability of these ideas.

Keywords

Content analysis elderly home occupational performance occupational therapy older adults

Introduction

This qualitative study explores older adults’ experiences of their occupational performance in everyday life post discharge from home-based occupational therapy. Occupational performance, the primary focus of occupational therapy, is defined by Townsend and Polatajko (2013) as ‘the ability to choose, organize, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life and contributing to the social and economic fabric of a community’. Many older adults with chronic health issues experience declining occupational performance, and since the proportion of adults aged 65+ is growing rapidly, there is societal interest in restoring and maintaining their independence and wellbeing (Christensen et al., 2009). In Denmark, 72% of registered occupational therapists work in the municipalities, where the majority of their clients are older adults in need of rehabilitation (Ergoterapeutforeningen, 2015). Occupational therapy often takes place in older adults’ homes, to ensure transfer to everyday life (Fisher, 2009). While evidence shows that older adults’ occupational performance can improve through home-based occupational therapy, the improvements are not always maintained in the longer term (Nielsen et al., 2017). It is not clear why some older adults have problems maintaining the achieved improvements, while others succeed to a greater degree. Problems may be due to deteriorating or fluctuating health (Fried and Guralnik, 1997), changes to the older adults’ everyday lives or environments post occupational therapy, or factors directly related to occupational therapy processes and outcomes.

Literature review

The Person–Environment–Occupation (PEO) model (Law et al., 1996) explains occupational performance as an interaction among the PEO components and occupational performance problems as the result of a misfit between two or more PEO components (Law et al., 1996; Townsend and Polatajko, 2013). Rehabilitative measures to improve older adults’ occupational performance address one or more PEO components.

Previous studies, mainly from Western Europe, North America and the Middle East, show that occupation-based occupational therapy for older adults, delivered in the home and other contexts, has the potential to improve occupational performance in the short term, but the long-term maintenance of achieved effects presents challenges as the improvements tend to diminish at follow-up (Nielsen et al., 2017, 2018, Steultjens et al., 2004). The same pattern is found in studies of multi-disciplinary interventions (Fleischmann et al., 2012; Hershkovitz et al., 2012, Tuntland et al., 2015). Participants have reported being unprepared for discharge from occupational therapy and feeling that they could have achieved more, had they been given a greater number of sessions (Boutin-Lester and Gibson, 2002). Older adults, living alone or with a spouse, have reported strategies for maintaining and improving occupational performance including planning and continuing important activities, maintaining bodily functions, receiving help from spouses, family or others, maintaining social networks, and moving into accessible housing (Bergström et al., 2015; Vik and Eide, 2014; Yuen et al., 2007). To our knowledge, no qualitative studies have examined specifically how older adults with various chronic health issues experience and maintain their occupational performance post home-based occupational therapy. The aim of this qualitative study was to extend current understandings of older adults’ experiences and expectations concerning their occupational performance post home-based occupational therapy, as this may inspire occupational therapists to plan and perform home-based interventions aiming for greater long-term effectiveness.

Two primary research questions were posed.

How do older adults who have had home-based occupational therapy experience their occupational performance post occupational therapy?

What do older adults who have had home-based occupational therapy expect concerning their occupational performance in the future?

Method

Setting and intervention

The study took place in a Danish municipal home-care context, where older adults commonly live alone or with a spouse. Occupational therapy is delivered by registered occupational therapists to people with declining occupational performance due to illness, disabilities, injuries or more general ageing processes, with the aim to improve independence and quality of life. The study participants had received occupational therapy in their homes and local environments, where occupation-based interventions had engaged them in real-life activities for at least three weeks; assistive devices and minor home adaptations had been introduced free of charge, when necessary. Discharge had taken place 2–11 weeks before the interview.

Sampling

The inclusion criteria (Table 1) ensured that the sample mirrored the diversity among older adults typically referred to Danish home-based and occupation-based occupational therapy.

Table 1.

Inclusion and exclusion criteria.

Inclusion Age: 65+ years Housing: Private homes or sheltered (senior) housing Health: Experienced chronic health issues Occupational performance: At the time of referral to occupational therapy, the participant experienced problems that hampered his/her independence in everyday life Language: Danish speaking and able to talk about their everyday lives in relation to home-based occupational therapy Home-based occupational therapy: Discharged 2 to 12 weeks ago Exclusion Health: Alcohol or drug abuse, tetraplegia, dementia, or severe intellectual disability, rapidly progressive diseases such as cancer or motor neurone disease.

Purposeful sampling (Crabtree and Miller, 1999) aimed for maximum variation concerning gender, age, need for assistance, living arrangement, and referral route. Information concerning the study’s aim, inclusion criteria and procedures was given to managers of occupational therapy services in 19 municipalities chosen to broadly represent the country’s regions as well as rural and urban areas. The managers invited clients who matched the inclusion criteria. After inclusion of five participants, we decided which characteristics, typical for the Danish population, were missing or less prominent in the sample and adjusted the sampling procedure accordingly.

Participants

The 11 participants (9 women, 2 men) were aged 72–94 years. All the participants were born and raised in Denmark; nine lived alone while two lived with their spouse. They were diagnosed with various chronic health issues and had been referred to home-based occupational therapy due to occupational performance problems within self-care or productivity; eight were referred from a hospital while three had not recently been hospitalised. After discharge from occupational therapy, two participants did not receive any assistance, six received housekeeping assistance, while two received assistance with self-care and housekeeping. See Table 2 for details.

Table 2.

Demographic and clinical data of the participants.

Participant (anonymised)	Arne	Bodil	Camilla	Dorthe	Ellen	Fie	Gitte	Hans	Inger	Jane	Karen
Gender	Male	Female	Female	Female	Female	Female	Female	Male	Female	Female	Female
Age in years Mean 85 years	79	87	81	85	87	89	72	89	81	94	92
Living arrangement	With spouse Married	Alone Widowed	Alone Widowed	Alone Widowed	Alone Widowed	With spouse Married	Alone Widowed	Alone Always single	Alone Widowed	Alone Widowed	Alone Widowed
Housing	Single-family house	Apartment	Senior housing	Apartment	Apartment	Single-family house	Apartment	Farmhouse	Single-family house	Single-family house	Senior housing
Health issues	Hemiplegia (right side): impaired walking and use of arm Fatigue HOSP	Shoulder fracture Pain Circulatory problems HOSP	Hip fracture Osteoporosis Osteoarthritis Circulatory problems HOSP	Hip fracture Pain HOSP	Severe arthritis Osteoporosis Fatigue Pain NOT HOSP	Heart disease Fatigue Circulatory problems Hearing loss HOSP	Hip replacement Osteoporosis Diabetes HOSP	Heart disease Fatigue Circulatory problems Hearing loss NOT HOSP	Hemiplegia (left side): cannot walk or use arm Hemiagnosia COPD Pain NOT HOSP	Hip replacement Fatigue Pain Slight memory problems HOSP	Shoulder and pelvic fractures Arthritis COPD PMR HOSP
Assistance with self-care	No	No	No	No	No	No	No	No	Daily @	No	Daily @
Housekeeping assistance	Daily []	Less than weekly §	Less than weekly @	No	Less than weekly @ §	Daily [] §	No	No	Weekly @	Less than weekly §	Daily @

HOSP: the participant had been hospitalised prior to referral to home-based occupational therapy; NOT HOSP: the participant had not been hospitalised prior to referral; COPD: chronic obstructive pulmonary disease; PMR: polymyalgia rheumatica; @Home-care assistant; [] Spouse; § Private help

Data collection

Data were collected January–March 2017 using a semi-structured interview guide (Brinkmann and Kvale, 2015a; Crabtree and Miller, 1999) to investigate participants’ present occupational performance and expectations concerning their future performance, including participants’ individual experiences in relation to themes that were salient in their everyday life. The guide comprised briefing and debriefing, questions concerning biographic information, and five primary interview questions related to the two research questions as shown in Table 3.

Table 3.

Interview guide.

Research questions	Primary interview questions
How do older adults experience their occupational performance post occupational therapy?	Will you tell me about what happened when you had occupational therapy in your home?
	Did you gain something from having occupational therapy?
	Will you tell me about your present everyday life, now that the occupational therapist does not come any more?
	Will you tell me if something is now helping you or making it harder for you to do the things you would like to do in your everyday life?
What do older adults who have had home-based occupational therapy expect regarding their occupational performance in the future?	Will you tell me about what you think it will take for you to continue doing the things you like to do in your everyday life?

The interviewer (TLN) aimed at obtaining rich descriptions: detailed and nuanced, and thick: of sufficient quantity (Fusch and Ness, 2015) and followed procedures described by Brinkmann and Kvale (2015a) and Olsen (2003) to engage the participants and to capture their experiences and views. The questions were short, broad, open, non-directional and easily understandable. Participants were encouraged to describe as precisely as possible what they experienced and felt and how they acted. The strategies of active listening, periods of silence, and probing were used to encourage the participants to elaborate further. The PEO model (Law et al., 1996), which represented the occupational therapy professional preconceptions of the interviewer, helped to enable new perspectives to emerge through follow-up questions concerning personal, environmental and performance components. The interviews were conducted in the participants’ homes; they started with a briefing to establish relationship, lasted 30–100 min, were audio-recorded, transcribed verbatim by a student assistant and quality checked by TLN. Corrected versions and field notes were stored in NVivo (2015).

Data analysis

The transcribed interviews were analysed in five steps using inductive content analysis (Dey, 1993; Morgan, 1993; Schreier, 2012). First, TLN read transcripts of all interviews in full to gain an overall impression. Second, TLN built a data-driven coding frame, resulting in 21 codes (Table 4) (Schreier, 2012). Third, TLN coded all material, that is, sorted it by the 21 codes set up in NVivo (2015). Fourth, the codes (Morgan, 1993) were categorised into nine subcategories and summarised into three descriptive main categories (Table 4), which are presented in the article’s findings section, accompanied by illustrative interview citations for transparency (Brinkmann and Kvale, 2015a; Dey, 1993). Finally, looking for patterns and co-occurrences across categories at the interpretive level (Morgan, 1993; Schreier, 2012) led to two explanatory syntheses, which are discussed in the article’s discussion section. No new codes emerged after the first six interviews, and each code was represented in at least three interviews.

Table 4.

Coherence between research questions, subcategories and codes, main categories, and syntheses.

Research questions	Meaning units, citations in text	Subcategories and codes	Main categories	Syntheses
How do older adults who have had home-based occupational therapy experience their occupational performance post occupational therapy? (Research question 1)	A1 C1	Improved occupational performance 01) Improved performance related to occupational therapy aims 02) Untrained activities improved	Achieved improvements in occupational performance through occupational therapy	The importance of achieving and maintaining independence Strategies used to improve and maintain occupational performance
	B1 F1 K1	Strategies adopted through occupational therapy that enhance occupational performance today 03) Adaptation of activities 04) Assistive devices and environmental adaptations 05) Problem-solving
	H1 C2 E1 C2 C3	Consequences of improvements in occupational performance achieved through occupational therapy 06) Feelings of independence or freedom 07) Feelings of joy related to resumed occupations 08) Feelings of safety or comfort 09) Experiences of positive social impact 10) Negative consequences of improved performance
	K2	Unresolved performance problems related to occupational therapy aims 11) Unresolved performance problems	Unresolved performance problems related to the occupational therapy intervention
	I1	Consequences of unresolved problems 12) Feelings of unhappiness
	E2 E2 K3	Strategies adopted to deal with the unresolved problems 13) Accepting the situation 14) Receiving help 15) Working to improve occupational performance
What do older adults who have had home-based occupational therapy expect regarding their occupational performance in the future? (Research question 2)	J1 J2	Thoughts and feelings concerning future occupational performance 16) Confidence concerning future performance 17) Worries concerning future performance	Efforts to maintain occupational performance in the future
	D1 G1	Strategies used to maintain occupational performance 18) Continuing with important occupations 19) Keeping physically and mentally fit
	B2 G2	Strategies to deal with decline 20) Adapting to decline 21) Knowing whom to contact

Ensuring validity and reliability

The sample consisted of a heterogeneous group of former participants in home-based occupational therapy. The validity of the interview guide was strengthened through discussions among all involved authors, and through two pilot interviews. The primary investigator, TLN, is an occupational therapist experienced in home-based rehabilitation of older adults. To ensure the face validity and reliability of the coding frame, all authors were involved in developing it (Schreier, 2012). A trial coding was performed by TLN and KSP, and codes used inconsistently were improved (Schreier, 2012). To maximise validity of the analysis, all authors discussed the main aspects and interpretation of the findings. Steps 1–4 of the analysis were performed on the Danish transcripts; translation of the citations from Danish to English were made from the original by TLN in cooperation with a bilingual professional translator (Van Nes et al., 2010). We aimed at obtaining rich and thick descriptions through the reported procedures for sampling, data collection and analysis (Fusch and Ness, 2015).

Ethics

The study abided by the Declaration of Helsinki (World Medical Association, 2013). All participants were informed about the study and their rights, both orally and in writing, before giving written consent. The participants were anonymised in all documents used for further processing; original personal information was kept confidential and destroyed when no longer needed.

Findings

Three main categories were inductively derived from the coded material: ‘Achieved improvements in occupational performance through occupational therapy’, ‘Unresolved performance problems related to occupational therapy intervention’ and ‘Efforts to maintain occupational performance in the future’. Alphanumeric codes after citations refer to Table 4.

Achieved improvements in occupational performance through occupational therapy

Most participants stated that owing to occupational therapy they had improved their occupational performance. The improvements were within self-care, indoor and outdoor mobility, productivity and leisure.

Well, washing myself in the morning and all that, I manage that myself, you see. And taking a bath and all, that is also done quite automatically (Arne, A1).

Physical improvements were often related to improved occupational performance. Improvements in activities that had been practised during occupational therapy had enabled some to take up untrained activities like shopping, gardening or using public transport.

I can use a shopping trolley again; this is how well I walk now! (Camilla, C1).

The participants told how strategies adopted through occupational therapy were often still used to enable their occupational performance. Adaptation of activities was an important strategy; this could include resting intermittently, choosing ready-meals and using new techniques to compensate for impairments.

I take my rubbish bag, tie a knot on it, put it in my IKEA bag and carry this over my shoulder …. I can then descend the stairs, holding on to the railing. … I would never have thought about this myself (Bodil, B1).

Other useful strategies involved using assistive devices, for example rollators, reachers or stocking aids, using labour-saving household devices or making changes to the home environment. The participants found that such strategies improved their occupational performance, safety and mobility.

A small shower seat, it is so fine and small. It is not so polite to say this, but I find it hard to believe that it comes from the municipality [laughing], and they have also mounted a small grab bar that I can hold on to (Fie, F1).

Problem-solving in relation to activities had been discussed with the occupational therapist, and some of the participants continued themselves to find new, easier or safer ways of performing activities. Karen bought a small drying rack for her laundry and shared the laundry tasks with her daughter:

Now I can take it down. She hangs it up and I fold the dry clothes, I can do that (Karen, K1).

The participants had experienced mainly positive consequences from improving their occupational performance. Many highly valued that they could perform independently inside and outside the home again. Some emphasised not having to be dependent on others’ help any more, which they had perceived as a burden. Some had regained freedom to leave home when they wanted, to go wherever and whenever they wanted, and to decide independently what to do. Hans did not need help from a home-care assistant to get dressed anymore; this enabled him to make and keep early appointments in town again:

Now I do not need to stand [and wait] any more, I think I am freer now, with this [points at stocking aid] (Hans, H1).

Feelings of joy were related to resumption of occupations like going shopping, taking walks, cleaning, cooking one’s own food and gardening. Positive social impacts were experienced, too. Examples included visiting the family again, taking up walks with friends and meeting friends in the supermarket.

Actually, you get to talk to different people [in the supermarket], instead of everything being the same all the time (Camilla, C2).

Feelings of safety or comfort were expressed. Ellen, who had her occupational therapist observe her bathing, said:

She… found that I did it as safely as it could be… it was actually very good, that she was satisfied with the way I did it (Ellen, E1).

Some negative consequences were also experienced. Camilla missed the home-care assistant, who no longer came to help her to bed, since this person used to encourage her:

It was at the time when I could not yet climb to bed and all that myself. They [the assistants] always wanted to know: Have you been out walking today? Yes, Yes, I said, I surely have. Well, yes, that is good! (Camilla, C3).

Unresolved performance problems related to the occupational therapy intervention

In spite of improvements achieved through occupational therapy, the participants stated that a number of performance problems were still present. Unresolved problems existed in relation to self-care, mobility, productivity and leisure. Some activities were still not performed independently; other activities were performed independently again but with difficulty, with an (unwanted) assistive device, or less often than wished. Unresolved problems were linked to persisting physical problems like tiredness, impaired mobility or pain. Some refused to use assistive devices because they did not want to be reliant on them, although they acknowledged that they might be helpful. Sometimes, assistive devices did not fully solve the problems, and activities were therefore never resumed. Karen learned to dress herself, but, overall, it was too strenuous for her:

With much difficulty, when I had assistive devices, I could do it, but I cannot endure standing up for so long in the evening… it is painful (Karen, K2).

Unhappiness was felt in relation to unresolved problems like lack of energy due to extreme fatigue, feelings of helplessness due to immobility or lack of dignity due to an inability to dress and undress oneself.

Alone and helpless… I sit here and cannot move around (Inger, I1).

Accepting the situation was a way of coping with the unresolved performance problems, and some participants reported that their occupational therapist had helped them learn this. The participants compensated for unresolved problems by receiving help from spouses and other family members, private help or home-care assistants. Concerns about being too much of a strain on one’s spouse and family were also expressed as were feelings of relief.

The occupational therapist… could see it was very difficult for me to change the bed linen and hang up the washing, so I was allowed to have a home-care assistant do that. So in this way, she has been good (Ellen, E2).

Many participants continued practising activities to further improve their occupational performance and physical abilities. Some explicitly expressed a wish to improve to the extent that they could dispense with their assistive devices. Some mentioned specific, highly valued, yet untrained, activities performed outside the home that they wanted to resume like cycling, going to a beauty parlour, caring for grandchildren, taking up water aerobics, and visiting friends nearby or out of town.

She [the occupational therapist] urged me to do it [continue practising post occupational therapy] as much as I could, as that would be good for me, and I can feel that, too (Karen, K3).

Efforts to maintain occupational performance in the future

The participants shared their thoughts and feelings concerning their future occupational performance, their strategies to stay active and ways of dealing with decline. Confidence concerning future occupational performance was expressed in general terms by some, while others were more specific:

I do not know if I can continue to squat as I used to when I weed the garden, but then I just have to find another solution (Jane, J1).

However, several participants expressed fears of losing their abilities and independence, fears of falling and of possible consequences like having to use a wheelchair or move to a care home. Fears of losing momentum in life and becoming housebound were also expressed. Several participants were concerned that they would lose the structure of their everyday life, and that they would end up staying in bed or watching television all day instead of living an active life.

I am terrified by the idea of having to sit and just watch [television] (Jane, J2).

Striving to continue important occupations was generally expressed. Many participants emphasised the importance of staying active, continuing what they could do themselves, and using skills accomplished through occupational therapy.

I look at it this way: you have to do what you can do, you have to do it yourself, right? (Dorthe, D1).

It was important to maintain specific leisure and social activities like taking walks, being with friends, gardening and reading. Having binding appointments with others could support activity. Striving to keep physically and mentally fit was often mentioned as a means of maintaining occupational performance.

I do not get it done [exercising] by myself. I simply have to go to a gym, and this social thing, I like to be in the group (Gitte, G1).

Accepting that one has to change former standards and habits, especially by downscaling activities and workload, was one way of adapting to a lower performance level, as was arranging to have more help for household activities and gardening.

Such habits as tending the flowers Wednesdays and Sundays, why, if you are exhausted on Wednesday, let those flowers be! (Bodil, B2).

Participants were aware that the need for rehabilitative services could arise again. Several expressed feelings of safety and comfort linked to knowing how to contact their occupational therapist again, and knowing which other municipal services were available. Gitte’s occupational therapist had prepared her for discharge:

[She] has been excellent at preparing me… among other things she came with all these pamphlets about… everything the municipality offers… I can return to those any time (Gitte, G2).

Discussion and implications

From the analysis across categories, two explanatory syntheses (Dey, 1993; Morgan, 1993) were derived: ‘Achieving and maintaining independence’ and ‘Strategies used to improve and maintain occupational performance’.

Achieving and maintaining independence

Independence was highly valued and striven for by the participants. It was expressed as needing no assistance from others at all, as performing without assistive devices or in terms of performing specific activities by oneself. Achievements in occupational performance were linked to improved independence and to feelings of freedom and joy. When occupational performance had not improved as much as wished for, participants expressed concerns about unwanted dependence, and many therefore still strove to improve their occupational performance post occupational therapy. A similar emphasis on independence among older adults is reported by other studies (for example, Mack et al., 1997; Randström et al., 2013; Yuen et al., 2007). Also in line with our findings, previous studies have shown that receiving help from a public home-care service was associated with reduced self-determination (Hammar et al., 2016) and reduced life satisfaction (Johannesen et al., 2004). However, participants of the present study could also negotiate degrees of independence, where minor improvements and implementation of acceptable ways of working around persisting problems could be experienced as satisfying. Yuen et al. (2007) have found that community-dwelling older adults may redefine their perceptions of independence and dependence as their functional performance declines. Gignac and Cott (1998) have proposed trying to understand what physical independence and dependence means to individuals and what factors contribute to these perceptions. They suggest that in some areas of life, independence may be possible only by accepting some level of dependence in other areas of life. We suggest that occupational therapists employ these understandings to help older adults arrive at an acceptable trade-off between independence and dependence. Some participants in the present study performed housework together with family members or a hired help and found it more dignifying than passively receiving help. ‘Doing together with others’ has previously been reported (for instance, Bergström et al., 2015) and could be proposed when older adults cannot achieve independent performance of valued occupations. Setting occupational therapy goals that aim at ‘having no need for assistance’ may lead to discouraging results within home-based occupational therapy for older adults with chronic health issues. Instead, it can be addressed that full independence may not be achievable, by negotiating two degrees of the goal: (a) the desired level of independent performance, for instance, ‘cooking a family dinner independently’, and (b) the minimally acceptable degree of goal fulfilment, for example, ‘cooking a family dinner with help to drain the potatoes’.

Strategies used to improve and maintain occupational performance

The participants valued discussions with occupational therapists about solving various performance problems. Dawson et al. (2009) suggest that problem-solving strategies be implemented into daily occupational performance in three phases: acquisition (learning to use a strategy for a specific activity during occupational therapy sessions), generalisation (using the strategy for the same activity outside sessions) and transfer to other goals. Sufficient time is required for this process in order for problem-solving to become a fruitful strategy in older adults’ everyday lives. In the present study, some participants had continued problem-solving post occupational therapy, while others seemed less capable of this. Problem-solving comes more naturally to some than others, and teaching problem-solving strategies may be worth emphasising in occupational therapy programmes for older adults.

Assistive devices implemented during occupational therapy as a compensatory strategy were perceived by some participants as supporting the maintenance of occupational performance post occupational therapy. However, a number of participants worked on dispensing with their devices because they feared that using them would lead to further loss of abilities and to future reliance on them. Lund and Nygård (2003) describe users of assistive devices as pragmatic, ambivalent or reluctant users and link the descriptions to different adaptive approaches to achieving a desired occupational self-image. To the reluctant user, the undesirable consequences of using assistive devices may result in withdrawal from valued occupations. We find that occupational therapists should acknowledge and address older adults’ desired self-image and any reluctance when suggesting assistive devices as a means of enabling occupational performance. Use or non-use should be discussed and linked to the older adult’s general wish to be independent in everyday life. Practising activities was the main strategy used during occupational therapy, and it was obviously transferred by many participants to dealing with unresolved problems post occupational therapy. The participants expressed a strong wish and determination to continue performing important activities in the future. Previous research conveys similar results (Bergström et al., 2015, Vik and Eide, 2014). The high degree of motivation among our participants to improve and maintain occupational performance post occupational therapy is important, bearing in mind the challenges related to maintaining achieved improvements raised in the introduction. Yet, such high levels of motivation are not always present or sufficient to maintain the desired occupational performance. Some participants valued knowing how to contact their occupational therapist again, others were uninformed. Follow-up visits at individual intervals could be scheduled with the occupational therapist upon discharge to address any unresolved or newly arisen performance problems and to brush up on or adapt strategies. Healthcare professionals, including occupational therapists, involved in services for older adults should continue to look out for risks related to, or manifest declines in, occupational performance. Future studies may explore how to detect which older adults are in need of a follow-up visit.

Bodily strength and mobility were practised during occupational therapy and in physiotherapy, and many participants continued this activity, seeing it as a means of maintaining future occupational performance. This strategy has also been found in other studies among home-dwelling older adults (Vik and Eide, 2014; Yuen et al., 2007).

From our findings and this discussion, ways of accommodating older adults’ aspirations for improvement and maintenance of occupational performance post occupational therapy can be proposed. We posit that independence can be negotiated, goals that do not specify full independence can be formulated, and acceptable, alternative ways of accomplishing desired occupations can be explored. Emphasis can be put on problem-solving strategies during occupational therapy, giving the necessary time for generalisation and transfer. Occupational therapists should identify and address older adults’ possible reluctance when suggesting assistive devices. Follow-up home visits post occupational therapy may support occupational performance in the home. Such initiatives need to be evaluated in future studies.

Limitations

Only two men participated in the study, yet, their different living situations added to the variation. Some gender-specific differences apply to performance problems (Källdalen et al., 2012) and perceived satisfaction with participation (Vik and Eide, 2014), and had we been able to include more men, further aspects of older men’s experiences might have emerged. No participants lived with their family or were born and raised outside Denmark; we cannot be sure how the results and the suggestions have relevance in their situations. Those participants who had a lot of help from a spouse or from family expressed confidence concerning their future performance despite unresolved performance problems. Older adults with help close at hand may accept a higher degree of dependence which, in turn, may negatively affect their motivation for occupational therapy and the long-term effectiveness. The semi-structured individual interviews enabled us to achieve rich and thick descriptions of experiences of everyday life post occupational therapy. The reported positive influence of occupational therapy, unresolved problems, and useful and less useful strategies provided us with a breadth of experiences. The experiences can inform future practice about strategies for maintaining occupational performance. The present study did not evaluate long-term effectiveness of occupational therapy, as the interviews were performed 2–11 weeks post occupational therapy. The participants may have experienced improvements as well as deteriorations in their occupational performance during the following months. Follow-up interviews could further explore changes in occupational performance post occupational therapy. Our rich data and the focus on transparency in the analysis strengthen the internal validity of our findings. The syntheses and propositions concerning occupational therapy practice build on this evidence, as well as on previous empirical findings and theoretical work. According to Brinkmann and Kvale (2015b), ‘analytical generalisation involves a reasoned judgment about the extent to which the findings of one study can be used as a guide in another situation’. Our propositions cannot be transferred directly to occupational therapy for older adults who live with their family, are of non-Danish origin or have mental health issues or dementia. Yet we suggest that they may be generalised analytically to home-based and occupation-based occupational therapy for older adults with chronic physical health issues, who live alone or with a spouse in a Western welfare state.

Conclusion and recommendations

The research questions addressed older adults’ experienced occupational performance post occupational therapy and their expectations concerning their occupational performance in the future. The study sheds novel light on everyday life experiences among home-dwelling Danish older adults with chronic physical health issues, who live alone or with a spouse, and on how they self-manage and solve their problems. The desire to achieve and maintain independence as well as acceptance of different degrees of independence were key findings, along with strategies learned from occupational therapy that were still used to improve and maintain occupational performance. Our participants’ input can inspire occupational therapists to plan and perform home-based interventions for older adults aiming at greater long-term effectiveness as they point to new ways of maintaining improvements. The following propositions for service development need testing to ensure effectiveness and applicability: working with ways of achieving a satisfying occupational performance that do not necessarily entail becoming fully independent; increasing focus on the use and transfer of problem-solving strategies; acknowledging and dealing with possible reluctance to use assistive devices; and offering individually scheduled follow-up visits post occupational therapy.

Key findings

Independence was a core theme among older adults, but different degrees of independence were accepted.

Strategies learned from occupational therapy were used to improve and maintain occupational performance post occupational therapy.

What the study has added

This study suggests an increased focus on problem-solving strategies during home-based occupational therapy and follow-up visits post occupational therapy by occupational therapists to help enhance and maintain older adults’ occupational performance.

Footnotes

Acknowledgements

Gratitude is extended to the participants and to the staff who helped with the sampling.

Research ethics

Ethics approval was obtained from the Danish Data Protection Agency in 2017 (trial identifier J.nr. 2017-41-4995). The Scientific Ethics Committee of the Central Denmark Region deemed that no further approval was required (Query number 12/2017). All participants provided written informed consent.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Funding was received from the Danish Association of Occupational Therapists (Grant number FF 1 17 – R45-A1276); VIA University College; and Aarhus University, Department of Public Health.

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