Working with short-term goal-directed reablement with older adults: Strengthened by a collaborative approach

Introduction

The increased number of older adults who experience longevity is a positive development, but it also means higher requirements on homecare and reablement initiatives. General policy goals state that older adults should live independently and have an active and meaningful existence in a community with others. Previous reports show that reablement has a good effect on municipal economies in the form of reduced hours of homecare.^1,2 However, there is not enough research focusing on the professional’s perspective regarding the meanings of short-term goal-directed reablement from a multi-disciplinary view on health, described by the care staff working with these new interventions. Municipal home healthcare is a growing field of interest for nurses. More and more patients are staying at home or being sent home from hospital in an earlier stage in recovery than before, which requires more and more multi-professional cooperation in order to manage this growing challenge. Nurses have an obvious role in these multi-professional teams. This article explores some aspects' of working in this type of collaborative team that could be used to widen the picture of how this is experienced and to know how nurses’ confidence of their profession within this collaborative approach could be strengthened. An illumination of the phenomenon can deepen understanding about working with reablement within municipal care developments and research at a national as well as international level.

Background

The National Board of Health and Welfare in Sweden ³ highlights in its report the importance of working with everyday rehabilitation, which has the goal of strengthening and maintaining the health and functional capacity of older adults. International research^2,4,5 uses the term reablement to describe targeted home-based rehabilitation. Reablement interventions are sometimes used synonymously with the Danish term ‘hverdagsrehabilitering’ ¹ or the Swedish concept of everyday rehabilitation and describes the purpose of supporting and assisting older people to learn or relearn the necessary skills to cope with their daily lives. Reablement refers to an intense form of rehabilitation that is limited in time and carried out in people’s homes or in assisted living. It is often inter-disciplinary and focuses on supporting people to regain the ability to perform and participate in daily activities which are decided by the older adult. ⁵ It must be noted, however, that the evidence regarding reablement is limited.

Older adults often have a multiplicity of age-related needs which implies that a key element is to empower and enable professional care-givers to work with person-centered care. ⁶ Person-centered care can be seen as an approach to practice and establish therapeutic relations between care-givers, patients and other important people in the older adult’s life. Caring is built on values such as respect for the person, the person’s right to self-determination and equal understandings. ⁷ Janssen, Snoeren and Van Regenmortel ⁸ point out the importance of interdisciplinary cooperation between professionals working with older people in community care. They describe professional cooperation as a prerequisite for providing strong and integrated care since older people living at home often face complex, multi-faceted problems that cannot be solved by one profession alone. The foundation of interprofessional teamwork can, according to Berlin ⁹ be seen as a) to be able to offer help to others b) to be able to receive help from other professions. Robben et al ¹⁰ emphasize that the care for older frail adults is often fragmentized, involving many professionals from various disciplines. Their study suggested a specific program with interprofessional education (IPE) and collaboration, and concluded there is a need to get to know each profession’s viewpoint, though it is known that interprofessional communication is not without problems. Norman and Peck ¹¹ found four key reasons for interprofessional team problems in community care: loss of faith in systems within which they work; strong adherence to uni-professional cultures; absence of a strong shared philosophy; and a mistrust of managerial solutions to problems. These problems can lead to disputes about the area of practice and to mistrust of the interprofessional idea, according to the WHO’s Framework for Action on Interprofessional Education and Collaborative Practice. ¹² Robinson and Cotell ¹³ found that successful interprofessional collaboration includes both enhanced structural coordination, and the establishment of a cultural commitment that overcomes different professional attitudes. Studies^14–16 also show that different professionals who experience involved in reablement are also encouraged to interact interprofessionally.

The confidence of healthcare staff, both in their own capacity and their professional role, is crucial for the quality of care and should receive more attention. ¹⁷ Leadership plays an important role in ethical qualitative care, supplying tools, confirmation and recognition such as common space and structures for the staff to be able to act in an evidence-based way. ¹⁸ Previous research with municipal healthcare staff shows a lack of confidence in their own capacity to apply such things as evidence to their own daily work.^18,19 Empowerment of healthcare staff and their influence are significant factors for such things as keeping cultures in healthcare that create high quality of care. ²⁰ Severinsson and Hummelvoll ²¹ claim that factors such as time to spend with the elderly contribute to job satisfaction or dissatisfaction and are related to each nurse’s ethical system. Trojan and Yonge ²² also showed in their research that spending more time with the patient may be more cost-effective, as the patients experienced that their needs were cared for and experienced a sense of confidence. This also might lead to a situation where the patient may not enter the healthcare system as frequently.

Methods

The overall short-term goal-directed reablement project has a multi-method design, where a randomized intervention project was combined with qualitative studies with both older adults and staff as research persons to follow up the intervention. The intervention was a goal-directed, home-based, time-limited (three months) reablement, organized by an interprofessional team in which the controls received traditional homecare. The overall research design included measurements of the older adult’s multi-dimensional health, and the ability to perform daily activities as well as their physical ability. Measurement was performed at inclusion when the older adult applied for homecare as well as after three and six months to study the effects of the intervention. Qualitative data were collected after the intervention via interviews with the older adults about their experiences, and from personal letters from the staff. In this particular study an analysis of the interprofessional rehabilitation team’s narrated experience of the meaning of working with this type of short-term goal-directed reablement is presented.

Data collection

The interprofessional team involved in the project consisted of one registered nurse and 13 enrolled nurses, three occupational therapists, two physiotherapists and one social worker (20 team members) who were invited by an invitation email after approval from the chief administrative officer. More specific team demographics can be seen in Table 1. The staff were recruited by the municipality office to work full time with the intervention project for two years. They had been previously employed in ordinary homecare areas in the same municipality. Before this intervention project came into action, all team members were trained at the university for five weeks to create team cooperation, to enhance the theoretical framework about health, to educate them in the rehabilitative approach and to encourage mutual working goals for the planned person-centered intervention. Data for the present study were collected by sending an email to all staff in the team after approximately one year from the start of the interventions. The invitation email stated that research participation was on a voluntary basis. Those who agreed to participate were invited to continue with answering the demographic and open-ended questions. The main question was: ‘Can you tell me about your experience of working with short-term goal-directed reablement with older adults within the framework of this project?’ After two reminders, all invited staff had emailed us back with their written narratives in attached as Word files.

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Table 1.

Demographics.

Background variables	n
Sex
Female	20
Male	1
Age (years)
23–30	2
31–40	9
41–50	9
51–60	1
Profession
Nurse	1
Enrolled nurse	13
Physiotherapist	3
Occupational therapist	2
Social worker	1
Experience in the profession (years)
3–5	3
6–10	7
>10	11

Results

The staff in the interdisciplinary team working with short-term goal-directed reablement described their experiences, ambitions, and motives for performing their mutual work. The findings are presented in the order of the described methodological phases of phenomenological hermeneutics to make the process of interpretation as visible as possible.

Structural analysis

In the structural analysis, four major thematic structures were identified in the narratives as experienced by an interprofessional team: 1) Reliable relationship; including the following aspects: ‘Confidence between the older adult and staff’, ‘A sense of security’ and ‘Continuity’, 2) Empowered participation, including the following aspects: ‘Listen to the older adult’s desires’ and ‘Put the person in control’, 3) Team with a negotiated approach, including the following aspects: ‘Closeness’, ‘Same direction and overarching goal’ and ‘Learning from interprofessional dialogue’, 4) Time for growth, with the aspects ‘Creating harmony’ and ‘Building the older adult’s self-confidence’. (See Table 2).

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Table 2.

The meaning of working with short-term goal-oriented reablement with older persons.

Theme	Sub-themes
Reliable relationship	Confidence between the older adult and staff
	A sense of security
	Continuity
Empowered participation	Listen to the older adult’s desires
	Put the person in control
A team with a negotiated approach	Closeness
	Same direction and overarching goal
	Learning from interprofessional dialogue
Time for growth	Creating harmony
	Building the older adult’s self-confidence

Reliable relationship

The relationship with the older adult, according to the team members, was characterized by confidence, security and continuity. The staff emphasized that the creation of a trustworthy, dependable, and continuous relationship facilitated reablement work.

Empowered participation

In relation to the reablement process, the team underlined the need for the older adult to be engaged and empowered in her or his own participation. Empowered participation was supported by listening to the older adult’s wishes, and giving the person control over goals and activities in the reablement process.

A team with a negotiated approach

This thematic structure is about interprofessional relationships and their outcomes. Working full time in a team with a negotiated approach was not something any of the team members had done before. Their descriptions about team cooperation focused on team closeness, working with the same overall directions and the opportunity of learning from an interprofessional dialogue.

Time for growth

According to the interprofessional team, the older adult’s development and progress were supported by reliable relationships and trust, and creating harmony instead of contributing to stress and time pressure.

Discussion and comprehensive understanding

The present study is based on narratives written by the members of an interprofessional team working with short-term goal-directed reablement with older adults. According to these staff, the basic foundations of the team’s reablement work are: creating reliable relationships, finding ways to empower older adult’s participation, giving enough time for growth, and developing a team with a negotiated approach in the work situation. The interprofessional team further underlined that basic elements of person-centeredness included respect for the person’s values and rights to self-determination in deciding on goals and staying in control over the reablement process. Offering reliable relationships supporting confidence and trust where there is time for the older adult’s growth of self-esteem and self-efficacy in regaining autonomy was important. The concept ‘being in a relationship’ as part of patient-centeredness can be compared with the present study where the staff in the interprofessional team put forward the staff as offering reliable relationships. Exploring the person’s own values and desires is described as a starting position of person-centered care ⁷ and another central concept is ‘being with oneself’, which show a similar understanding of how staff can contribute to patients’ empowerment. The present study illuminates how the older adult’s engagement influences the reablement process from two different angles. The first angle concerns when the person becomes empowered through gaining control of own goals of reablement. The other angle relates to the development of trust and confidence gained through the relationships with staff and their capacity to deliver supportive homecare promoting reablement.

The members of the interprofessional team in the present study describe trusting their own competencies and working methods and believe that through their way of working they manage to make major contributions to older adults’ reablement processes. Previous research has shown that staff confidence in working methods is a factor that contributes to job satisfaction and is likely to affect the care of the patients. ¹⁸ The staff in the present study believed in working within a negotiating team that facilitated finding mutual goals and directions that improved both work quality and older adults’ multi-dimensional health. The staff in the present study also underlined how their interprofessional teamwork included being able to offer help to others and being able to receive help from other professions as has previously been described, ⁹ but they also recognized the contribution concerning a broader development of reflected knowledge that the team delivered. The interprofessional team members in the present study described the importance of learning from interprofessional dialogue in a two-way communication where no hierarchy ruled the outcome of discussions or decisions made. Negotiating and communicating within the team was described as contributing to a culture commitment that overcame personal or uni-professional differentiated attitudes. ¹³ The team in the present study also argued that teamwork gave them confidence both in their general knowledge of homecare but also as a specific confidence of one’s profession. According to Norman and Peck, ²⁷ four key components are needed to succeed with cooperation in interprofessional teams in community care: faith in systems within which they work; rejection of uni-professional cultures; strong shared philosophy; and trust in managerial solutions to problems. When comparing our team’s descriptions they seem to have created a working culture with a shared theoretical framework, rehabilitative approach and trust in managerial solutions of problems through communication and negotiation of professionals’ values. However, the staff did not reflect on trust related to their organization, and we as researchers did not ask about this. A possible interpretation is that the staff in the present study have faith in the organization, since they volunteered to take part in this two-year project to develop and test a new method in elderly care.

Time also held a high level of importance in working with short-term goal-directed reablement of older adults as experienced by an interprofessional team. Time for the older adult to grow was discussed, which is comparable with Trojan and Yonge’s ²² descriptions that spending more time became more effective as the older adults experienced that their needs were cared for and that seemed to create a sense of confidence in care. Earlier research often brings up leadership as having an important role in structures for the staff to be able to act in an evidence-based way. ⁸ Surprisingly little was mentioned about leadership’s role in work with short-term goal-directed reablement. This could be understood as a result of the non-hierarchical team spirit the team had already developed in the introduction phase of the intervention.

Methodological issues

A strength of the study including the team composition is that the participants were predominantly enrolled nurses. This might have empowered this profession, given they experienced more equal colleague relationships within the team, and strengthened the team spirit (e.g. work satisfaction and trust in ability to mediate reablement). However, it might be that even with this composition in the team, occupational therapists or physiotherapists might have more influence in reablement work, since they are the professions which usually are responsible for the rehabilitation strategies. In addition, this team was built up from an idea that even if rehabilitation is explicitly the responsibility of the aforementioned professionals, enrolled nurses are the ones who meet older adults the most in municipal homecare and, as a result, who have the greatest opportunity to make change.

It may seem strange that everyone in the team answered positively to being asked to participate in this study, but the fact is that members of this team have voluntarily applied to work within a development project linked to research from the beginning. These research participants were also particularly interested in developing their work, which is likely to have affected the results in a positive way. In addition, the short-term goal-directed reablement was a voluntary intervention for the older adults to participate in. Anyone could easily choose traditional homecare if they wanted to. Therefore the older adults joining the intervention were very engaged in their reablement, which perhaps not would be the case if short-term goal-directed reablement became a more common approach. Thus the team work with a motivated group of older adults, and that might have influenced their positive views of how the reablement intervention turned out.

Moreover, the staff were asked to contribute with written narratives by the research group that also had been involved in educating them at the university in preparing them for the new method. The email correspondence did not allow the narratives to be anonymous since they attached their narratives to an email to one of the researchers. However, we found it important to label the narratives as soon as we received them and not connect them to a specific person in the team. It might perhaps be interesting to see whether the different professions included in the team experienced participation differently, but we chose not to perform any analysis of differences as we were, according to Ricoeur, ²³ searching for the common meanings of the phenomenon. In further research it could also be interesting to see whether such positive results would result from an in-depth interview study with the interprofessional team where some members have been replaced by new colleagues.

Conclusions and relevance to clinical practice

The findings highlight the process of short-term goal-directed reablement that can be understood as being strengthened by a collaborative approach and the efforts of different professions. Having an increased amount of time over a shorter period created, according to the team, harmonic confidence between the older adult and staff. Goal-directed reablement has the potential to build the older adult’s self-esteem and empowerment and thereby independency if listening to the person’s wishes, and giving the older adult control over goals and activities in the reablement process. An implication to praxis is that short-term goal-directed reablement has the potential to be experienced with a sense of calmness, a feeling of not being abandoned and therefore not claiming more homecare hours. These results can function as a way of widening understanding, and form the basis for decisions regarding planning for reablement processes that enable interprofessional teams to plan for home-based rehabilitation of older people as well as to widen the picture of how nurses’ confidence in their profession within this collaborative approach could be strengthened.