Reablement care is aimed at promoting functional abilities among care recipients, especially with regard to activities of daily living [9, 11]. The healthcare professionals in this study used several strategies to promote reablement among older people living at home in Norway. they performed needs assessments to evaluate older people’s functional status and needs, identified older people’s wishes and priorities with regards to reablement services, and designed care plans based on the assessments. They also assessed the safety of older people’s home environments. Assessing clients’ needs prior to providing healthcare services is important for delivering appropriate and timely care [42,43,44]. Additionally, older people receiving reablement care may be at a vulnerable stage in the life course with changing health and functional status. Such that regular and ongoing needs assessment becomes central to supporting them well [42,43,44]. Such assessments can help professionals and older people identify the type, frequency/duration and intensity of the reablement activities to be implemented [9, 42,43,44]. The professionals in this study reported that conducting needs assessment was a standard procedures that helped them plan for reablement care.
Working closely with older people and identifying/asking them about what is important to them, and then taking that into consideration when planning care activities, is a key part of reablement care that aids with goal setting [44,45,46]. It recognizes and safeguards older people’s sense of agency, empowerment, and right to self-determination by giving them the opportunity to collaborate with healthcare professionals to make informed decisions about-, manage-, and take responsibility for their own health [47,48,49,50]. Findings in this study and others [51,52,53] indicate that giving older people the opportunity to participate in decisions about their care is empowering and motivating for them. Professionals in this study also used motivational interviewing techniques [54,55,56] to encourage older people’s engagement in reablement training. Motivational interviewing is defined as “a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve ambivalence” (p. 91). Through their skilled conversations with older people, professionals were able to uncover and better understand older people’s interests and priorities, their motivation for reablement, and potential barriers therein that needed to be addressed.
The healthcare professionals worked with older people on reablement activities and training at a pace suitable for the older person, and applied the principle of ‘showing/doing with’ versus ‘doing for’ [9, 41, 57, 58] the person. They discontinued services no longer needed to avoid enabling disablement among older people. Tailoring care to older people’s needs is an important element reablement care [9, 24], and should ideally exhibit a holistic understanding of- and responsiveness to older people’s changing health and social care needs [5, 47,48,49,50]. Well-tailored care is therefore key to providing appropriate services that are well aligned with older people’s functional status, abilities, and potential for improvement. Such care respects the older person’s wishes, priorities, and right to self-determination—including deciding the extent to which one is involved in reablement training [47,48,49,50].
The professionals in this study designed care plans based on their assessments of older people’s needs, and made efforts to tailor reablement activities accordingly. Reablement care has only more recently been conceptualized as “… an inclusive approach irrespective of age, capacity, diagnosis or setting” (p.12), and in two Australian studies, reablement care was delivered to people with dementia [59, 60]. Norway’s municipal healthcare services are generally universal, available to all residents in need of care. Professionals in this study did not report on reablement processes for specific clients. For example, especially vulnerable older people who, in addition to needing reablement care, are also struggling with social isolation/loneliness, mental health problems, or recovery from a major illness (e.g., stroke, cancer treatment). This is an area that would benefit from further research attention.
A main goal of reablement care is to maintain/promote independence in activities of daily living, broadly defined [5, 9, 42, 45]. Older people receiving reablement care are encouraged to engage in reablement activities as much as possible, they receive appropriate support during those activities, and sometimes ‘being done for’ by professionals is the appropriate and compassionate support to receive [9, 45]. In addition, older people’s engagement in reablement activities should not be coerced, and their right to self-determination should be respected and safeguarded [9, 19, 47, 49, 50]. A central feature of reablement care practiced by professionals in this study was ‘showing/doing with’ versus ‘doing for’ older people [9, 41, 57, 58]. In this way, the professionals helped promote older people’s sense of empowerment and agency to regain/maintain (some) control over their lives and functioning [47,48,49]. In one Danish study , healthcare professionals balanced between actively encouraging and facilitating older people’s engagement in reablement, but also gave them room in other cases to not engage: “faced with older people at the last stage of life, often characterized by bodily and cognitive decline, professionals often allow older people to sit back or spend their remaining time on doing what they enjoy, which is rarely cleaning”p.2037. Such reports point to the multifaceted landscape within which reablement care is delivered, and our own findings here would have been enriched by further input from professionals describing how they work with older people who, in their opinion, could be more engaged in reablement activities but chose not to do so.
Older people are best supported when provided with care that is appropriate, timely, and well-coordinated [19, 47,48,49, 61]. The professionals in this study made efforts to collaborate and share knowledge within and across care units (e.g., reablement teams and homecare services). Such collaboration enabled them to learn from one another, improve their competencies in reablement care, and support older people by providing them with more consistent care and messaging regarding reablement. Other studies have also reported similar benefits of collaboration in reablement care [12, 51]. Professionals in this study also reported challenges that undermined the reablement way of working and collaboration across care units, including: heavy workloads, under-resourced/insufficient training in reablement, and poorly coordinated services. One feature that commonly underlies these challenges is finances. Reablement care, with its strong emphasis on person-centeredness, may be expected to increase user satisfaction and quality of life, although the research evidence is inconclusive [11, 44, 46, 50]. It is also less clear whether reablement reflects better use of scarce primary care resources [11, 46]. Reablement, including as described by the professionals in this study, requires solid investments in adequate and skilled professionals, good and consistent routines (e.g., ongoing needs assessments and tailoring services to users’ specific and changing needs), well-coordinated services, and user involvement and empowerment, to mention a few . It can therefore put professionals in a squeeze between the expectation to deliver appropriate care on one hand, and scarce municipal resources with which to do so on the other hand.
Aspects in the provision of healthcare services described by professionals, such as time constraints, inadequate staff training, high turnover, and poorly coordinated services are related to resources/capacity. Addressing needs related to capacity would therefore remove important obstacles in providing care that promotes reablement. To this end, well thought-out ways of designing and implementing the services are key. For example, if reablement is integrated with municipal care services, the reablement team can provide staff in homecare services (e.g., home nursing, practical assistance) and other care units with education and training in the reablement way of working. Then, with mentoring and consultation from the reablement team, homecare staff can provide older people with reablement training; and staff from other units can be cognizant of and apply principles of reablement when working with older people in other capacities. Thus, over time, key principles in reablement would become general knowledge: an orientation applied more broadly, and not only by a select, specially skilled few.
Reablement represents a new way of practicing rehabilitation in a home healthcare setting; and tighter financial and organizational constraints could potentially make it difficult for leaders to prioritize and promote reablement care. One reason for this is that home healthcare is required by law for Norwegian municipalities, while reablement is not. Tighter financial and organizational constraints could also affect the boundary between helping and enabling by derailing the shift towards enabling (and not ‘doing for’) older people. While the features of reablement reported in our findings are in line with existing reablement literature [9, 11, 41, 62], there is variation in what is understood as reablement care, its components and implementation [5, 11, 45]. Findings from this study and others, and The recently developed and more unified definition of reablement , should help advance research and practice in the field [9, 11], including in the areas of process and outcomes evaluation. A key question for further research is whether the effects of reablement warrants diverting resources from other areas to reablement care? Does reablement care create additional increases in functioning that would not have otherwise been realized given the same resource use? Is reablement care a worthwhile investment from users’, providers’, policy makers’ and taxpayers’ perspectives? Findings from this study indicate that the strategies and care processes applied by healthcare professionals to promote reablement reflected many aspects of person-centredness. This is as it should be considering that person-centredness is central to reablement care [9, 47,48,49]. Person-centredness “[focuses] care on the needs of individuals. Ensuring that people’s preferences, needs and values guide [care] decisions—and providing care that is respectful of and responsive to [those needs and preferences]“  section 1. A main challenge of reablement care appears to be that of capacity, and working from a person-centred framework is resource demanding: it emphasizes providing care that is: responsive to the changing health and well-being needs, wishes and preferences of people; and that is holistic—attentive to the physical, emotional/mental and social well-being of people . Solving the capacity challenge in reablement care, including those reported by the professionals in this study, will require increased spending among other strategies.
While there are several promising studies done on the effects of reablement [11, 22, 23], it is uncertain whether there can be a general answer to whether or not increasing resources for use in reablement will represent a better option than other alternatives. This might be a question that has to be answered on a case-by-case basis. Even so, promoting the potential and quality of life of citizens as they move through the life course, which are important aspects of reablement and active ageing [9, 11, 16, 19], should be worthy of support.
Our findings have limited generalizability given our sample of six municipalities. We made efforts to remedy this by conducting interviews in diverse municipalities (e.g., size, urbanicity). This study was part of a larger research project evaluating the Norwegian the ‘Care plan 2020’ that, through interviews, gathered data on a broad range of topics including reablement care. Our findings therefore lack the richness and specificity that in-depth interviews accord. Even so, the results add to the knowledge base on reablement strategies and processes from real practice settings. Municipalities in Norway generally provide primary healthcare services, including homecare services—of which reablement is a part, in a manner they consider appropriate given their local needs, priorities and conditions . Therefore, due to variation in the implementation of reablement care, we caution against drawing strong conclusions from our findings. The municipalities included in this study were sampled from a list of municipalities that took part in projects for developing services for people with dementia living at home. Therefore, it is possible that the municipalities in this study have a strong focus on developing primary care services, which might have positively affected reablement services (e.g., components, delivery processes). Future studies conducted in different municipalities will help confirm whether the foregoing is the case. Reablement care has an attractive ideological basis given its emphasis on person-centeredness and the ethos of ‘showing/doing with’ versus ‘doing for’ the care recipient. The professionals in this study might have therefore been positively biased in their reports of reablement services.
Data collection for this study was constrained by the availability of research funding, and by the capacity/available time of healthcare staff to participate in the project. For example, the eight focus groups in the study had between 2 and 5 participants and lasted between 41 and 89 min. Some topics, such as the importance of needs assessment in reablement care, were discussed across the focus groups; whereas the subtopic of ‘regular re-assessment of older people’s needs’ was not consistently addressed across the groups. Time and resource constraints thus affected the depth/breadth of data collection in a way that may have hindered data saturation in some cases. We recognize this as a limitation of the study.