Abstract
Statement of context
Occupational therapists and physiotherapists in a Swedish municipality answered a web-based survey about their reablement interventions.
Critical reflection on practice
There were overlapping areas as well as differences regarding the focus of occupational and physiotherapy interventions. Regarding the duration of interventions, occupational therapy was implemented over a short time span in contrast to physiotherapy, which had a longer duration. Both professions used valid and reliable instruments to a very limited extent.
Implications for practice
If other areas than self-care and mobility are to be addressed within reablement there is a need to critically reflect on the focus, content and duration of reablement interventions. Valid and reliable assessments can be utilised to a greater extent to guide goal-setting, the focus of interventions and to evaluate effects.
Statement of context
Reablement is a multi-professional intervention implemented for people at risk of functional decline. The focus is on optimising peoples' ability to perform activities of daily living, remain in their home and live independent and fulfilling lives, and so reducing the need for social care services (Aspinal et al., 2016; Cochrane et al., 2016; Tessier et al., 2016). While a recent review identified the positive effects of reablement on a range of outcomes (Tessier et al., 2016), other reviews highlight that the intervention has been poorly defined (Legg et al., 2016), indicating that little is known about what various different professionals actually do and how they collaborate within reablement (Pettersson and Iwarsson, 2017; Sims-Gould et al., 2017). In Sweden, reablement is mainly implemented in a municipality context in close collaboration with home care services. Occupational therapists and physiotherapists are the core of the reablement team. Thus, to provide a basis for critical reflection on the content and design of reablement, there is a need to expand knowledge of the content of each profession’s contribution (Craig et al., 2008). With this in mind, the purpose of this practice analysis was to describe occupational and physiotherapy interventions within the context of reablement in a Swedish municipality.
Critical reflection on practice
Research ethics
Participants were occupational therapists and physiotherapists and the data used were collected as part of normal routines for quality assessment within the organisation. Written informed consent was therefore neither required nor sought. All potential informants (n = 31) were informed about the procedures for data collection, both verbally and by email. Participation was voluntary, and five therapists chose not to participate. Ethical approval was not required because no health measures, sensitive personal data or any other individual information concerning informants was collected. Approval to conduct the data collection was granted by the Head of the Health and Social Care Administration in the municipality.
Method for data collection
Data was collected during 2016 in a middle-sized Swedish municipality. Reablement was provided by 16 teams that included occupational therapists, physiotherapists, district nurses, social care managers, home care managers and home care staff. Two profession-specific questionnaires were developed by the second author and a group of experienced occupational therapists (n = 3) and physiotherapists (n = 3) working with reablement. The questions addressed aspects of assessments (for example, asking if and which outcome measures had been used), the actual intervention (for example, the main focus, content), the frequency of contact (that is, a maximum of three contacts or more than three contacts) and the duration of the intervention. Information about the survey was provided by the second author at one meeting attended by the majority of occupational and physiotherapists in the municipality. An internal web-based platform was also used for sharing information with occupational and physiotherapists within the municipality. The questionnaires were distributed through the web-based tool Easyresearch (https://www.questback.com/se/). The informants were asked to answer the survey for each case in which assessment and/or interventions had been initiated during the time period 3 October 2016 until 21 October 2016. The survey was filled in either at the time that the intervention was ended or, at the latest, on 16 December 2016.
At the time of the data collection there were 16 occupational therapists and 15 physiotherapists working with reablement in the municipality. In all, 14 occupational therapists and 12 physiotherapists answered the survey. On average, the experience for working with reablement among occupational therapists was 7.2 years (1–17 years), and 7.3 years (3–17 years) for physiotherapists. All therapists who worked in the community had received basic education on routines for reablement in the municipality.
All data from the survey were summarised with descriptive statistics. Each question is presented by number and percentages (in relation to the reported cases for each question). In all, occupational therapists reported 111 cases and physiotherapists reported 88 cases.
Focus and content
Main focus and content of assessment and intervention.
N represents the total number of reported cases for each area of investigation.
More than one answer could be reported, thus resulting in a sum exceeding the sum of reported cases.
Goal areas of the intervention.
N represents the total number of reported cases for each area of investigation.
More than one answer could be reported thus resulting in a sum exceeding the sum of reported cases.
Within physiotherapy, valid and reliable instruments (such as the Berg Balance Scale (Berg et al., 1992), the Short Physical Performance Battery (Guralnik et al., 1994) and the Falls Efficacy Scale (Yardley et al., 2005)) were used in 15 cases (22%). The main focus of the physiotherapy intervention was on body function and walking indoors (see Table 1). The most common area of intervention was provision of technical aids and training in walking and climbing stairs.
Frequency and duration
Duration of the intervention.
N represents the total number of reported cases for each area of investigation.
Summary
Our results indicate that, for most clients, occupational therapy was focused on mobility indoors and self-care, the intervention was mainly based on adaptive approaches, involved only a few visits and was implemented during a time span of 3 weeks or less. This is similar to a study in which older people applying for home help with bathing received three home visits by an occupational therapist resulting in that seven out of 10 clients regained their independence (Zingmark and Bernspang, 2011). Thus, on one hand, short-term occupational therapy seem to be sufficient to regain independence but, on the other hand, one could question if occupational therapy should be terminated once initial (self-care) problems have been addressed. An alternative perspective could be that when basic occupational needs have been addressed, a new discussion together with the client could focus on whether other prioritised occupations should be addressed. Thus, initial goal achievement could be seen as one link in a chain of goals, subsequently focusing on, for instance, leisure and social participation toward supporting the person in living a fulfilling life, also stated as the goal of reablement (Aspinal et al., 2016).
One possible explanation for the narrow focus of occupational therapy intervention may be the fact that valid and reliable assessment instruments were used only to a very limited extent. In recent reablement trials, the COPM (Carswell et al., 2004) has been used both to ensure a person-centred, goal-oriented reablement process, as well as to evaluate the outcome of reablement (Langeland et al., 2015; Tuntland et al., 2015). When the COPM was used in a recent study, the prioritised activity limitations identified during initial assessments included not only self-care and mobility, but also productivity (such as household tasks) and leisure (Tuntland et al., 2015). In contrast to the studies by Langeland et al. (2015) and Tuntland et al. (2015), the basic education provided for informants involved in this practice analysis did not include the use of outcome measures such as the COPM. Since the COPM might be a potentially effective tool to guide occupational therapists and the reablement team in goal-setting, to focus the intervention toward areas that are relevant for the person and to evaluate the effects of reablement, our practice analysis indicates that the basic education of therapists should include the use of outcome measures.
The emphasis on walking and body function within physiotherapy is not surprising. Sufficient physical function to climb stairs and to walk indoors and outdoors are important to be able to perform valued activities at home or outside the home and to participate in the society. However, the existing evidence regarding the effect of reablement on physical function is inconclusive. While some trials (Lewin and Vandermeulen, 2010; Parsons et al., 2013) have shown positive effects on physical function, others have not (Tuntland et al., 2015). Since the physiotherapist is a central factor in the reablement team (Pettersson and Iwarsson, 2017), the specific design of physiotherapy intervention need to be further explored in order to identify how optimal effects can be reached. Given the infrequent use of valid and reliable assessment instrument among physiotherapists in our study, we underline the importance of identifying and using appropriate outcomes measures in relation to physical function. One such measure, which has been used in recent studies (Langeland et al., 2015; Tuntland et al., 2015), is the Short Physical Performance Battery, which provides a feasible approach to evaluate lower extremity function including balance, gait speed and chair-stand. Furthermore, for most cases, physiotherapy included more than three contacts with the client and was implemented over a long time period; for more than half of the clients, the intervention was still ongoing at the time that data collection was terminated.
Our results indicate that there were differences between occupational therapy and physiotherapy (such as the duration of the interventions), but there was also overlap (such as the focus on mobility and provision of technical aids). In order to further develop evidence-based reablement services, there is a need to clearly specify the core components of each profession’s assessments and interventions and how the interventions are delivered (for example, in relation to duration). Further, the link between different intervention components and how they affect health outcomes needs to be established, as well as the size of these intervention effects. While our results provide a first picture of what occupational and physiotherapists do within the context of reablement, the overlaps and differences requires further in-depth investigation conducted using larger samples. In addition, there is also a need to explore the contribution and the effect of interventions delivered by other professionals involved in reablement and the outcomes of team collaboration. As Hjelle et al. (2016) recently stated, there is a need for a clear framework for communication and collaboration, both in terms of more efficient cooperation toward the client’s goals and in terms of acknowledging all team members and making the most of the reablement team.
In general, reablement has been implemented as a time-limited service over a maximum of 12 weeks (Aspinal et al., 2016; Tessier et al., 2016). In one recent study, the reablement period lasted 10 weeks and after follow-up, no new goals were set (Tuntland et al., 2015). The time limit of reablement likely has an effect on what problems are identified and addressed. The results from a qualitative study illuminated that motivating support would have been needed for some participants and that a prolonged follow-up period could lead to additional gains (Hjelle et al., 2017). Although there was no pre-set time limit in our study, occupational therapy can be described as a short-term intervention focused on primary needs whereas physiotherapy is implemented over a longer time period. Thus, in further development of reablement, critical reflection on the focus, content and duration of interventions is needed. The necessity of a specific time limit should be balanced in relation to the person’s need for progressive goal-setting toward optimum levels of activity and participation and how each profession can contribute to reach such goals. Even though the ability to walk as well as managing self-care is important for many older people, other occupations, such as leisure, are also considered important (Vik and Eide, 2014). In fact, ongoing engagement in occupation, in the context of relationships with others, has been described as central to the experience of health during old age (Bryant et al., 2001). The idea of focusing on occupation that the person identifies as important was recently identified as an essential component of reablement (Hjelle et al., 2017), and therefore, the process of identifying such occupation is a critical feature of the intervention. A guiding principle could be the one recently proposed by Langeland et al. (2015), ‘What are the most important activities in your life right now?’. Taken together, there is a need to critically reflect on the design of reablement intervention components and how the reablement team collaborate to promote the experience of living a fulfilling life for those clients receiving reablement. Although this practice analysis reflects a small distinct study in a Swedish municipality, it has relevance for a wider audience across the international arena of reablement. Further research into the purpose, roles and components of reablement would add to the knowledge base for this fast-developing area of therapy.
Limitations
Our data is limited to one Swedish municipality and therefore the results should be interpreted with caution. However, as reablement is developing fast in many countries, this practice analysis provides a basis for reflecting on the key components of occupational therapy and physiotherapy that can be of relevance in other reablement contexts, both national and international.
Key findings
Occupational therapy was mainly implemented as a short-term intervention
focused on indoor mobility and self-care, whereas physiotherapy mainly
was implemented over a longer time period and focused on walking and
body function. Valid and reliable assessments were used to a limited extent.
Footnotes
Acknowledgements
We would like to thank all occupational therapists and physiotherapists who contributed to this study. This study was conducted within the context of the Centre for Ageing and Supportive Environments (CASE) at Lund University, funded by the Swedish Council for Working Life and Social Research (FORTE).
Research ethics
Ethics approval was not required because the data used were collected as part of normal routines for quality assessment within the organisation. No health measures, sensitive personal data or any other individual information concerning informants was collected. Approval to conduct the data collection was granted by the head of the health and social care administration in the municipality.
Consent
Due to the nature of the data, informed consent was neither required nor sought. All potential participants (n = 31) were informed about the procedures for data collection, both verbally and by email, and participation was voluntary.
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
The authors received no financial support for the research, authorship and/or publication of this article.
Contributorship
Magnus Zingmark and Bodil Evertsson contributed to the methodology of the project. All authors contributed in interpreting the data. Magnus Zingmark and Maria Haak wrote the draft of the manuscript. All authors reviewed, and edited the manuscript and approved the final version of the manuscript.