Changes in everyday life after discharge from day care rehabilitation

Abstract

Community-based day care that provides rehabilitation (DCR) targets elderly people with physical disabilities. The goal of these programmes is mainly to improve physical ability in order to enable participants to remain in their ordinary homes. Knowledge of the outcomes of DCR is limited as well as knowledge of what it is that makes a difference for the individual. The aim of this study was to describe what changes in everyday life elderly persons experienced after discharge from a community-based day care rehabilitation centre and to give possible explanations for these changes. Fifteen elderly people were interviewed after that they had been discharged from DCR. A narrative approach was used for analysing the interview data. Four case stories constitute the findings, each of them with unique descriptions of changes in everyday life as well as possible explanations for these changes. The first case story described resumption of daily activities that made the days more eventful and meaningful. The second described how everyday life became an arena for exercising, which create confidence for the future. The third described how an increased sense of certainty and security in the movements led to an increased appetite for life. Finally, the fourth case story described both the stay at the DCR centre and the promise of a new period there as uplifting that made the days easier. Concerning possible explanations for these changes, the findings indicate that it was a combination of several events that together contributed to the changes. Examples were physical training, counselling about how to live in an active and healthy lifestyle, and socialisation with other patients in formal as well as in informal sessions.

In an ageing society there is an increasing number of people who are living with restricted function in their everyday life due to illness and disabilities. Many live in their ordinary homes (Socialstyrelsen, 2007). Facilitating aging in ordinary housing is a central principle of Swedish welfare policy (SFS, 2001, p. 453). The ability to perform activities of daily living (ADL) is an important factor contributing to the possibility of elderly persons remaining in their homes (Iwarsson, 1997) as well as enhancing their experiences of health (Iwarsson, 2003) and well-being (Hellström, Persson, & Hallberg, 2003).

To meet the health and social service needs of elderly persons with disabilities living in ordinary housing, different types of day care programmes are available. In Sweden, besides day hospital programmes run by the county council, rehabilitation is provided by community-based day care programmes run by the local authority (Andersson Svidén, Tham, & Borell, 2004; Samuelsson, Malmberg, & Hansson, 1998). There are different types of community-based centres and “day care that provides rehabilitation” (DCR) targeting elderly people who have physical disabilities after a disease or an injury. The goal of these programmes is mainly to improve physical ability in order to enable participants to remain in their ordinary homes for as long as possible. An individually tailored programme is offered to each participant according to a plan worked out by professionals (i.e., occupational therapists and/or physiotherapists). Activities provided at DCR centres, although they mainly concentrate on physical training, also aim to support social contacts. Attendance is usually restricted to about 3 months with the option to return for a new session (Samuelsson et al., 1998).

There is limited documented knowledge of day care programmes for elderly people, and the results from the studies that have attempted to evaluate the outcomes of day care are inconclusive. Gaugler and Zarit (2001) in their review of adult day services summarised that ADL functioning and related health variables were inconsistently, if at all, improved, while subjective aspects such as mood and satisfaction appeared to be positively affected. Pitkälä (1998) reported statistical significant differences between group changes on Katz ADL index when comparing day hospital with home care. Burch, Longbottom, McKay, and Prevost (1999) on the other hand, found only statistical significant differences within group improvements for Bartel index and Caregiver strain. Other studies have also failed to show improvements in performance of ADL (Fowler, Congdon, & Hamilton, 2000; Harwood & Ebrahim, 2000; Neufeld & Strang, 1992). A systematic review (Forster, Young, & Langhorne, 1999) that examined the effects of day hospital care for elderly people showed no statistical significant differences between day care and alternative services for the variables death, disability, or use of resources. However, the authors concluded that day hospital care when compared to no intervention appeared to have a possible advantage. Several researchers have discussed the difficulties involved when evaluating day care (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Bentley, Meyer, & Kafetz, 2001; Dabelko & Zimmerman, 2008; Forster et al., 1999). One major problem is comparability owing to the highly variable nature of interventions, facilities, and patient profiles (Bentley et al., 2001; Dabelko & Zimmerman, 2008; Forster et al., 1999). This makes it difficult to define treatment outcomes because the varying needs of the patients will result in the identification of different outcomes (Bentley et al., 2001; Dabelko & Zimmerman, 2008). The use of conventional standardised scales to measure outcomes of day care has also been reported as problematic (Baumgarten et al., 2002; Bentley et al., 2001; Dabelko & Zimmerman, 2008). The scales have been found to fail to include the full range of rehabilitation functions (Bentley et al., 2001) as well as not capturing the benefits of day care from a patient perspective (Baumgarten et al., 2002). In a qualitative study of perceived needs after discharge from a day hospital programme following stroke, the findings indicated that the participants' needs were being met through the activities of the programme. Their prime need was the opportunity to practice and improve skills for everyday living (Henderson, Milburn, & Everingham, 1998).

None of the studies cited above have contributed to an understanding of how the participants have experienced the benefits from day care in their everyday life. Suggestions have been made that future evaluating of the benefits of day care should have a more user-focused perspective (Bentley et al., 2001; Dabelko & Zimmerman, 2008) employing a qualitative research approach, for example, by following small numbers of users through treatment and by studying patients views of and preferences for care (Bentley et al., 2001). Dabelko and Zimmerman (2008) emphasised the importance of understanding what it is in a specific programme that makes a difference for the individual participant. Such knowledge could contribute to a better understanding of how day care programmes work. To capture the benefits of DCR from a user-focused perspective, we considered it important to investigate individual experiences of attending day care. The aim of this study was to describe changes in everyday life experienced by elderly persons after discharge from a community-based day care rehabilitation centre and to give possible explanations for these changes.

Method

Research approach

The present study was conducted within a narrative tradition in qualitative research. Narrative refers to a human's way of interpreting and making meaning from experience (Josephsson, Asaba, Jonsson, & Alsaker, 2006). Chase (2005) expressed that “narrative is retrospective meaning making—the shaping or ordering of past experience” (p. 656). Narrative research has been used in many fields of sciences, for example, in human sciences (Riessman, 2008) and health sciences (Josephsson et al., 2006). It has also been conducted in different ways. Polkinghorne (1995) makes a distinction between two uses of narrative in qualitative research: analysis of narratives and narrative analysis of eventful data. Analysis of narratives is based on storied narratives collected as data, which are analysis with a paradigmatic process. The result consists of descriptions of themes “that hold across the stories” or taxonomies of types of stories, characters, or settings. In narrative analysis of eventful data, the analysis is based on descriptions of events that are configured (by means of a plot) into a story that has a beginning, a middle, and an ending. The produced story can be in different forms, for example, a case study or biographic episode. The analysis of narratives moves from the stories to common elements unlike the narrative analysis of eventful data that moves from the elements to a story as the outcome of the analysis.

In the present study the narrative approach, narrative analysis of eventful data based on the work by Polkinghorne (1995) was used. This approach is useful when studying changes since the function of narrative analysis of eventful data is to produce explanatory stories about how and why a particular outcome has come about. In the analysis, the data elements have to be configured into a story that unites and gives a meaning to the data that is not apparent in the data themselves. A prerequisite for narrative analysis is that the data are diachronic; that is, they contain temporal information about the sequential relationship of events and the effect the events have on subsequent happenings. The analysis will result in a retrospective explanation linking past events together to account for how the final outcome might have come about (Polkinghorne, 1995).

Participants and settings

Participants were recruited from the 5 day care rehabilitation centres situated within a medium sized Swedish city. The main goal of the centres was to maintain or improve the patient's ability to perform activities of daily living. Another goal was to ensure that the patients were able to maintain a satisfactory level of health-related behaviours, for example, exercise. To be eligible for DCR, the patients had to be motivated to take an active part in the programme. The rehabilitation programmes lasted for 6–8 weeks and the patients attended on average 6 hours per day, 2–3 days per week. All centres were headed by an occupational therapist who was also responsible for each patient's individual programme. In addition, the personnel typically included assistant nurses and occupational therapy assistants and sometimes a physiotherapy assistant. No physiotherapists were employed full time, but all the centres had access to a physiotherapist on a part-time basis. Activities used in the programmes were different kinds of physical training; individually and in groups; mental stimulation games such as quizzes, crafts, and informal socialisation with other patients; and discussion groups with counselling about how to lead an active and healthy lifestyle. A government subsidised taxi service was available to bring the patients to the centres.

The criteria for inclusion in the present study were that the participants had completed day care rehabilitation, were at least 65 years old, did not suffer from memory problems, and were able to express themselves verbally in Swedish. The participants had taken part in two previous studies, which were carried out after their application to DCR but before they had started at the centre (Tollén, Fredriksson, & Kamwendo, 2007, 2008). Of the 22 participants who had been included in these studies, 16 had completed their rehabilitation at the centre. However, at the time of the commencement of the present study, one person had deteriorated and could no longer express himself verbally. As a result, 15 elderly persons, nine women and six men (mean age 80.7, range 74–91) were invited to participate. They all lived in their own homes. They had physical disabilities related to musculoskeletal problems, neurological problems, cerebrovascular disease, and cardiovascular disease.

Approval from the Ethics Committee at a Swedish university was obtained.

Data collection

All participants were interviewed in their homes by the first author about 3 weeks after they had been discharged from DCR. They were asked to describe their everyday life and what changes they felt had taken place when comparing their life before and after the rehabilitation programme. Follow-up questions were based on their previous descriptions of their everyday life before they attended DCR (Tollén et al., 2008). The participants were also invited to talk about how useful they experienced the day care rehabilitation to be. The interviews were audio taped and transcribed verbatim.

Data analysis

The analysis followed guidelines described by Polkinghorne (1995). In order to identify descriptions of changes in everyday life (outcomes) the 15 transcribed interviews were read through. Four interviews did not contain any descriptions of changes and were excluded from further analysis. The remaining 11 interviews were then scrutinised in order to find descriptions of changes in everyday life along with descriptions of possible explanations to these changes. When two or more interviews were found to describe similar changes, the most information-rich interview was selected. Polkinghorne (1995) stated that although it is possible to highlight a topic using only one case story, a set of case stories alongside each other provide greater insight and understanding of the same topic than any single case story. Consequently four information-rich interviews were selected for further analysis. In the following step of the analysis, the question: “What events contributed to these changes in everyday life” was put to the text. When events had been identified, they were arranged chronologically. Following this, a plot was constructed from each transcribed interview. A plot is the thematic thread in a case story and provides the systematic unit to the story. Finally, in order to produce a full and explanatory case story, the data elements in the plot were filled in with, and linked to, other data elements; that is, details and descriptions of the elderly person and the context in which the story took place. In this way it was possible to mark the beginning and the end of each case story and to elucidate the importance of the events as contributors to the changes in everyday life. Repeated comparisons between the plots and the transcriptions as well as between the case stories and the transcriptions were made in order to ascertain that the analysis was well founded in the empirical data.

The data analysis was performed by the first author, although each of the stages was discussed with the two other authors who systematically followed the process. The participants' names and other details of identifying aspects have been changed to protect the identity of the participants (Seidman, 1998).

Findings

The findings are presented in four case stories, each of them with unique descriptions of changes in everyday life (outcomes) as well as possible explanations for these changes. The first case story consists of changes in everyday life that was characterised as to resume previous activities. In the second case story the changes in everyday life were characterised as to use everyday life as an arena for exercising. The characteristics of changes in everyday life in the third case story were described as to perform activities in a safer way. Finally, in the fourth case story the changes in everyday life were characterised as to feel uplifted in everyday life.

To resume previous activities

Wilma was a woman who had been used to being very active. She described herself as a lively and social person who liked being surrounded by a lot of people. In her professional life she had worked as a shop assistant. At the time of her interview Wilma was 88 years old and lived on the first floor in a block of flats. She had been suffering from osteoporosis for several years. She injured herself badly from a fall a while back, breaking several ribs. Constant pain and pain relief medication made her tired and unenergetic. Wilma spent most of her time lying on her bed without having neither the energy nor the will to do anything. She received assistance in the form of domiciliary care and they helped her shower, do the laundry, and cleaning the house. One of her children helped her by purchasing ready-made meals that she would then heat up in the microwave. Even when the worst of the pain had subsided Wilma found it difficult to do the same kind of things she appreciated doing before the accident, like sitting down by the sewing machine to make something for herself or one of her great-grandchildren. She missed her old lively self and felt unhappy with her situation. An occupational therapist that Wilma had been in contact with urged her to apply for a place at the day care rehabilitation centre.

Physical exercises were a big part of the programme at the day care rehabilitation centre and Wilma took part in two different training sessions, group training and individual physiotherapy as well as outdoor walks. In her view, the physical exercising had done her a lot of good and had improved her health more speedily, which meant that she felt more energetic, the pain subsided, and she became more mobile.…and then they do gymnastics and they're intense about that and I've improved.

In addition to the physical exercises, Wilma also took part in social activities such as board games and quizzes. She felt that the company of the others and the positive atmosphere created by the staff contributed to her recovery.

And then there's the social thing there, they were so happy and positive and nice, so you felt happy inside and I think that heals quite a bit as well.

The physical improvements led to Wilma being able to do her own shopping and she did not have to eat the heated ready meals that she did not think tasted as good as her own home cooking. To make sure it was not too taxing, she came up with a new strategy for shopping and cooking. It meant doing the shopping one day, but waiting until the next day to prepare the food, making several portions that lasted a few days. Her improvements also meant that she could decline receiving help with showering and Wilma felt she retrieved control of her everyday life. You almost become like little children, you think like them, I can do this on my own!

Wilma felt more content with herself and took the initiative to do things she would not have wanted to or had the energy to do before. The discussion group at the day care rehabilitation centre with a focus on what the elderly can do in the home to improve and/or sustain their health and quality of life also contributed to Wilma resuming previous activities. She had become more aware of the importance of keeping active for ones general well-being. From more or less struggling her way through the day, after her stay at the day care rehabilitation centre her days became more meaningful. She filled her days with things that she found more enjoyable and more rewarding.

Even if it takes a long time with the sewing, at least I've taken the initiative to get the bits of fabric out and cut them out and then I sometimes get the idea to sew them together as well. So I must have gotten a little more out of that thing [DCR] about doing something. That way I have something to keep me occupied and then the day becomes more meaningful.

To use everyday life as an arena for exercising

John was 82 years old. Ten years ago he became a widower, but stayed on in the two story detached house that he and his wife built in the 1950s. He had spent his professional life working as a craftsman and had continued to do woodwork at home in the cellar as a hobby. He did not have any help at home and felt it was important to manage on his own and to get things done the way he was used to. He tried to take care of the house the way it was done while his wife was alive. He did, however, receive a little help with heavy cleaning from his son and his family who lived in the same town, and could get more help from them if he wanted to. John was an active participant of several clubs and associations. He had something scheduled for almost every day. John had a partner that he saw several times a week but apart from that his social circle consisted mainly of the other members of the various associations. He seldom had visitors to the house, aside from his son and his family.

John had joint problems. Both his hips had been operated and he had some difficulty walking, especially up and down stairs. Maintaining the ability to walk was important to John. Out of doors he used a wheeled walker and for longer distances he drove a car.

When your legs can't carry you, that's no fun. You could be as healthy as anything, but you can't walk or get anywhere, it's not so much fun then.

A heart attack a few years ago had made him a bit more careful, he did not dare exert himself too much for fear of it happening again. After a collision with a cyclist a while ago, he also suffered from pains and restricted mobility in one of his shoulders. During the time before John applied for day care rehabilitation he felt low and disheartened and felt that his life was slipping away from him, he did not really have the energy to live. John felt that his state of health was worsening, he felt his limbs stiffening, his balance worsening, and that walking was becoming more difficult. He started worrying about the future, about how long he would be able to keep living in his house, or if he would be forced to move.

Around that time John came across a member of staff from a day care rehabilitation centre. They had met before in a different context, but this time she felt that she could not really recognise John. She wondered how he was doing because she thought he looked unwell. On her recommendation he applied to and joined the day care rehabilitation centre.

At the rehabilitation centre John took part in different types of physical training, both individually with a physical therapist and together with the other participants and members of staff at the rehabilitation unit. The exercises were primarily for practicing balance, but there were also other types of movement exercises. For example, John exercised his damaged shoulder and cycled on an exercise bicycle. In addition to staff-led sessions, John also did exercises on his own, using the equipment available. He felt that he could follow the group training sessions well and was inspired to keep at it and to not give up on the exercises.

We got to sit down and do gymnastics, we did all sorts of movements, and it turned out, I could do more and more, and I could follow well if I really made an effort.

John also took part in a discussion-group led by an occupational therapist. The topics she raised to the group related to things senior citizens can do in the home to improve and/or maintain health and quality of life. The participants were encouraged to reflect on and discuss what they themselves could do to, as John expressed it, “try to stay in shape.” This resulted in among other things that John resumed the use of his exercise bicycle without feeling scared. Even his attitude toward daily activities changed. Having experienced them as something he had to do even when he did not want to, he now considered almost everything he did to be an exercising opportunity. From hanging the keys on the hook placed high on the wall instead of putting it on the lower shelf to happily watering the flowers without thinking of it as something troublesome.

Everything I do now has changed somehow. I think positively. So if I'm going to sweep the floor a little, then you just do it, because then I'm exercising.

John felt that he had improved physically in lots of ways, his sense of balance improved, the shaking of his hands decreased and the mobility of his shoulder increased. Combing his hair became easier and so did doing woodwork.

Got much better balance. Just walk off. I feel almost young again. Got back in shape and the confidence to walk.

One important change was that he, because of his improved balance and ability to walk, did not have any problems moving from one floor of his house to the other. Although John had already moved his bedroom downstairs, and so did not spend much time upstairs, the knowledge of being able to move between floors was important for his belief in his abilities and gave him hope for the future.

After finishing day care rehabilitation, John saw no reason to feel low. New ways of relating to his daily activities, viewing his everyday life as an arena for exercising, and his belief in himself together with an established relationship with the local authority healthcare services for the elderly made him feel less abandoned. The previously so draining worry about possibly having to move out of his house was gone.

I can walk properly now up the stairs and don't think about whether I can stay on in the house, because I'm completely self-sufficient.

To perform activities in a safer way

Henry was 80 years old and lived together with his wife in a flat near beautiful walking and cycling paths. He had worked as a bank clerk. Two years ago he had a stroke that left him partly paralysed. After the initial emergency phase, he took part in a rehabilitation programme at the hospital. He received a lot of support from the staff there and improved somewhat. After having been released from hospital, the responsibility for his continued recovery was transferred to the local authority healthcare services for the elderly. Occupational therapists employed by the local authorities contributed with assistive devices and adaptations of the residence. Henry felt a need for continued rehabilitation, which he had positive experiences of, so when one of the occupational therapists suggested he apply for day care rehabilitation, he did.

The complications after the stroke meant limitations to his everyday life, both in social situations and at home on his own. He felt a little isolated and confined to the house, especially during winter. He was still in touch with the members of the association where he had earlier been very active. He did not consider those acquaintances quite as meaningful anymore, because the conversations revolved mostly around old times. He did not think that his conversations with his wife were particularly stimulating anymore either. Henry was occasionally asked to undertake commissions for the association, but declined because it was too much of a strain for him to think productively.

The interaction with the others in the group at the day care rehabilitation centre was a truly positive experience for Henry. They had fun together, and there was a positive atmosphere in the group from the moment they met on the bus to take them there, to when they were driven back home in the afternoon. During group gymnastics Henry was spurred on by the presence of the others because he did not want to do a worse job than they. He experienced the same effect in the, what he called, “mental activities” that were part of the programme. They consisted of various games and competitions like quiz walks, other types of quizzes, and Bingo.

Sometimes, I guess, you felt a bit low because you were so bad at remembering things, and then you really wanted to pull yourself together. So then you wanted to try to think twice and things like that, so you really had to air out your brain to fish out your knowledge. Because, of course, you didn't want to be the worst.

Also the more informal socialising with the others, having coffee or food, or waiting for the organised activities, was perceived by Henry to be mentally stimulating. He considered it a collective responsibility to make sure the time spent with the group was enjoyable and rewarding. He tried to take part in the conversations with the others and was consequently forced to think of what to contribute with from his own thoughts and experiences. The group sometimes had different opinions on a subject, and these were also occasions for reflection in order to argue ones point of view. Through these conversations he learnt that interaction with a stranger could develop into something very positive.

Henry appreciated that the staff intentionally did not provide more help than necessary, because it gave him several opportunities to practice managing on his own to, for example, get up from the table. Henry also took part in crafts workshops at the day care rehabilitation centre. He painted a wooden rooster. To start off he had trouble painting the rooster exactly the way he wanted it because his hands were shaking so much, but he thought he managed to improve the stability of his hands and in time, was able to decorate the rooster exactly the way he wanted it. The finished rooster instilled in him a sense of accomplishment and sparked a desire to do things.

The physical improvements that Henry made through the rehabilitation centre lead to improved balance and dexterity, which in turn made it easier for him to undress and to perform other activities. Aside from the fact that many of the activities had become easier to perform, he also required less help from his wife.

I have a better grip on the fork in the left hand now than before, so that makes it easier to eat. [and] I don't have to wait for the wife in the evenings, I rip my clothes off myself.

An even more palpable change concerning Henry's physical abilities was that he experienced an increased sense of certainty and security in his movements, especially when it came to ambulation. What he used to do with a certain element of chance, he now did with considerably more confidence. As a result, he felt braver that, together with a greater desire to do things, meant that his appetite for life had increased, and he took more initiatives to do things than before.

I've surprised the wife with breakfast on the table, took food out of the fridge and bread out of the breadbin and plates and yoghurt and everything that belongs on the breakfast table. She didn't exactly faint, but it was something along those lines, anyway. But I thought I should be able to do it, so I've done it a couple of times.

Henry took the more engrossing and reflective way to converse that he learnt at the centre home to his wife. His conversations with her, which he did not consider so rewarding before, had changed.

I am more talkative, I want to talk more, and bring things up that I hear and see and read in the papers: so the dialogue between me and my wife is decidedly more developed, we talk more with one another.

To feel uplifted in everyday life

Mary was a 76-year-old woman who had been living alone since her husband died 2 years ago. She had worked as a cashier at the post office. She lived in a flat on the first floor of an old housing estate and was in daily contact with her children and grandchildren who lived in the same city. They helped her with the cleaning, the laundry, and anything else she needed help with. The rest of the household chores she tried to manage on her own, but she did not have as much strength as she used to. She got tired sooner and had to take breaks. Her mobility deteriorated because of her Parkinson's disease, her legs would not quite carry her. For that reason she used a wheeled walker both indoors and outdoors and travelled by bus or government subsidised taxi service longer distances. Besides the household chores, Mary spent a lot of her time reading or watching TV. Several times a week she also participated in activities organised by the pensioners' club that she was a member of. However, she was less active in the club than before. She had relinquished some of her duties because she did not have the strength to deal with the responsibility of having them. Her reduced mobility had forced her to give up the more physically demanding activities on offer at the club. She had a few female friends that she met every now and then and who she sometimes joined on short excursions. Despite her social circle, Mary felt that her life was boring, mostly because of the severe loneliness she had felt ever since she became a widow. Not being able to do everything she wished to also affected her mood and she often started crying. She was taking medication to help with her mood swings.

The physiotherapist she was in contact with at her local health centre got Mary a place at the day care rehabilitation centre, 2 days a week for 8 weeks. At the day care rehabilitation centre she got to participate in various physical exercises. Mary participated in physiotherapy to help counteract muscle stiffness and she also practiced walking up and down stairs. Walks were another reoccurring element of Mary's physical exercising. Weather permitting, she and other patients would go for outdoor walks around the neighbourhood, and if not, they would stay in and walk up and down the corridors of the day care rehabilitation centre. Mary thought that her mobility improved a tiny bit during her time at the rehabilitation centre but that it was not a lasting improvement. Having finished at the centre she needed more help around the house, especially with the more demanding household chores. When she had errands to run, she often used the government subsidised taxi service instead of catching the regular bus like she would have done before. “It [everyday life] has become more difficult, it's more difficult for me to walk”.

Besides the physical activities at the DCR centre, Mary also took part in more hobby-like activities. She sewed and made printed fabrics that she would then give her relatives for Christmas. She appreciated being able to do something with her hands. “So it's really encouraging, that thing about doing something, I think that's good”.

She also found the company of the others rewarding, particularly being able to talk to others with similar problems to herself. She could compare her own ailments with that of others and found that she was fortunate not to be in pain. Despite the lack of significant physical improvements, she found the contents of the day care rehabilitation programme stimulating for both the body and the soul.

During her time at the centre, Mary felt that it enriched her everyday life and filled the days when she went there with meaningful content. Even those days when she did not go, it helped her to know that she had something to look forward to.…and you've got expectations—I get to go there today.

Mary thought that the DCR centre contributed to her mental stability and to her feeling a little happier than before she began attending.

I mean, I've been really, like I just wanted to cry before, but I think I'm better anyway. Of course, I guess it cheers you up that day nursery.

When her time at the day care rehabilitation centre was over, Mary missed it and wanted to go back. She especially missed the company. She was also hopeful she might gain some physical flexibility through participation in the physical activities. She was promised a second period, but didn't know when she would be allowed to start again. On one occasion when she decided to pay them a visit, she brought a freshly baked sponge cake that she jokingly called a “bribe cake.”

Uplifted by the stimulation that the DCR centre meant for Mary and not least the knowledge that she would be allowed to come back made it easier for her to deal with her loneliness and her sorrow about not being able to do everything she would have wished to.

It's hard to say what's improved, but I think it's better anyway now, thanks to the day care rehabilitation centre. I have that to think about as well, that I'll get to go back.

Discussion

The findings in the form of four case-stories described changes in the participants' everyday life such as changes in occupational performance and well-being. The case stories also described possible explanations for these changes, which will be discussed.

The participants' occupational performance had changed in different ways during the rehabilitation period. They described that they had resumed activities they had prioritised previously and that they performed activities easier and in a safer way than before. The participants had also changed their attitude toward their performance of daily activities and had understood the importance of keeping active. One possible explanations for these changes in occupational performance was the physical training at the DCR centres. The participants described that the physical training had contributed to their physical improvement, for example on balance and walking that, in turn, had affected their performance. Evidence shows that late-life exercise has important benefits, both for people with and without functional limitations, on physiological parameters (e.g., muscle strength and aerobic capacity), as well as on basic physical functions (e.g., walking and balance) (Chin A Paw, van Uffelen, Riphagen, & van Mechelen, 2008; Keysor & Jette, 2001). However, the evidence of the beneficial effects of late-life exercise on performance of daily activities is less clear. In a systematic review (Keysor & Jette, 2001), the authors concluded that improvement in activities of daily living may not follow directly from favourable changes in basic physical functions. Keysor and Jette (2001), Rejeski and Focht (2002), and von Bonsdorff et al. (2008) argue that physical exercise alone may be insufficient in improving elderly persons perceptions of their level of function.

There were other explanations that appeared to have had an impact on the changes in the participants' occupational performance. The personnel's deliberate policy not to provide more help than necessary gave the participants opportunities to train physical functions such as getting up from a chair as well as the ability to perform activities in daily living such as dressing and undressing. The participants' belief in their ability to perform a certain task was enhanced when the training was successful. This may be explained as enhanced self-efficacy (Gage & Polatajko, 1994), which in turn was experienced as a factor that positively influenced their occupational performance at the DCR centre as well as at home. According to Bandura (1981), self-efficacy determines the amount of effort people expend before terminating the activity and how long they will persevere in the face of adversity. In the physical exercise group-training sessions the participants were inspired to do their best, which also allowed their perceived self-efficacy to be strengthened. They compared themselves with their fellow patients and saw that they could keep up with the group. Another event that could serve as an explanation could be the perception that the DCR centres provided a safe environment where the participants could experiment with their altered level of performance. The possibility of being able to experiment in a safe environment is essential for the individual's development of a new understanding of perceived efficacy according to Gage and Polatajko (1994). They also underscore the importance of personal performance accomplishments as well as observing successful performance of peers (i.e., vicarious learning), as two important strategies that occupational therapists can use in order to strengthen perceived self-efficacy. According to Gage and Polatajko (1994), it is essential for the practice of occupational therapy to recognised that perceived self-efficacy can influence the likelihood of an activity being performed outside of a protected environment.

The discussion group was another event, which may have contributed to the participants' resumption of and change of attitude to daily activities. The group was led by an occupational therapist with the aim to help participants resume an active and healthy lifestyle. Group counselling with similar objectives was recommended by Rejeski and Focht (2002). Such groups can, according to the authors, encourage individuals to be active and independent as well as encourage integration of physical activities into everyday life. The use of different types of groups in occupational therapy has been described as an important tool, especially in psychosocial occupational therapy (Cole, 2008; Eklund, 1997; Mosey, 1986) but also in occupational therapy for elderly people (Clark et al., 1997; Nilsson & Nygård, 2003). A positive experience of an occupational therapy group programme was described by participants in an activity group (Nilsson & Nygård, 2003). The group offered the individual an opportunity to compare his or her own situation with how others viewed and handled matters. An adaptation process was started and the participants contemplated and reflected on their own life situation in relation to the themes brought up during the group sessions. This is congruent with reasons listed by Cole (2008) describing why occupational therapists form client groups. The reasons include capturing the energy generated by interaction in order to support client's effort in coping with adversities and to motivate change.

Participants also described that they experienced a change in well-being. They felt happier and more mentally stable and feelings of being abandoned had given way to more hope for the future. In addition to previously mentioned events, socialising with other patients and taking part in craftwork were perceived as explanatory events. Being given the opportunity to socialise at the DCR centres meant that the participants could share experiences with others who had similar problems. According to Yalom (1995), the opportunity to compare oneself with others and come to a realisation that one is not unique in ones misery is a source of relief and an important therapeutic factor in group psychotherapy. It has also been reported to be of importance in occupational therapy groups (Nilsson & Nygård, 2003; Webster & Schwartzberg, 1992). Similarly, in a study of day care settings for older adults, Tse and Howie (2005) found that the social component (i.e., companionship) was valued by all participants. In a literature review by Dahan-Oliel, Gélinas, and Mazer (2008), the authors found that social participation and different types of leisure activities were related to elderly persons' well-being.

To take part in craftworks like sewing was described by the participants as rewarding and encouraging. Creative activities such as craftwork have been used within occupational therapy throughout the history of the profession (Kielhofner, 2009). Several studies examining engagement in craftwork and other creative activities in relation to elderly persons with disability have shown a positive influence on well-being. The findings were that the absorbing engagement in the activities gave pleasure and enjoyment, temporary relief from problems (Andersson Svidén & Borell 1998; la Cour, Josephsson, & Luborsky, 2005), pride in the achievements (Nilsson & Nygård, 2003), and relaxation (Andersson Svidén & Borell 1998; Nilsson & Nygård, 2003).

Regularity represented another event that may have affected well-being. During the 8-week long rehabilitation period, the participants attended the centre regularly 2 or 3 times a week. While at home, the knowledge that they were going back within a few days gave them something to look forward to. This was also true for participants who were waiting for a second rehabilitation period. Tse and Howie (2005) also found that having something to look forward to on a regular basis was connected to well-being.

Methodological considerations

By using a narrative approach (Polkinghorne, 1995), it was possible to capture individual changes in the participants' everyday life as outcomes of day care rehabilitation programmes. The narrative approach was also appropriate in order to understand what it was in the programmes that made a difference for the individual. In this way, this study contributes to a deeper knowledge of the benefits of day care rehabilitation that would not have been possible to capture using quantitative methods.

Several aspects of trustworthiness have been addressed (Lincoln & Guba, 1985). To create thick descriptions in the case stories, the selection of interviews was based on an ambition to obtain the widest possible range of information. Although each of the four case stories contained different descriptions of changes, they were nevertheless representative of the other participants' experiences since elements of the same outcomes could be identified in the remaining seven interviews. The interviews were conducted about 3 weeks after the discharge from DCR. This time interval was chosen in order to make it easier for the participants to remember what their rehabilitation period had entailed. The time between admission to the centre and the interview was about 12 weeks. By asking questions related to the participants' earlier descriptions of everyday life (Tollén et al., 2008), the interviewer could facilitate their reflection of experienced changes. Each of the stages in the analysis process was discussed with the other authors in order to generate stories from the data that were plausible and understandable (Polkinghorne, 1995). In the same way, they took part in comparisons between the transcriptions and the plots as well as the case stories in order to ensure that the plots and the case stories were well founded in the empirical data. Although the authors were well acquainted with the DCR centres, none of them were involved in the work.

A possible limitation in our study was our choice of outcomes: changes in everyday life. Although we did not restrict ourselves to positive outcomes only, the main results were of changes for the better. Only one person (Mary) described that she needed more help around the house after the rehabilitation period, which could be attributed to her Parkinson disease. The day care centres included in our study had as their primary goal not only to improve but also to maintain physical ability. However, due to our approach we were not able to capture the latter aspect and the four interviews that did not include any descriptions of change were excluded from further analysis. An important question is if the findings were influenced by the participants' willingness to please. It is worth noting that four interviews did not include any descriptions of change and, hence, cannot be regarded as positive findings. In addition, some participants expressed critical views regarding the DCR centres, showing that they were not uncomfortable voicing negative issues. However, views on the DCR centres were not part of the aim of the study and have consequently not been included in the findings.

Conclusion

An important finding in this study is that the changes in everyday life concerning occupational performance showed that the participants had developed skills that they used outside the DCR. The findings indicate that it was no single event that alone had led to these changes. Rather it appears to be a combination of several events, which together contributed to these changes. Examples on such events were physical training, the discussion group, and socialisation with the other patients in formal as well as in informal sessions. Even for patients who do not improve in their occupational performance, the findings illustrate that DCR could contribute to changes in their everyday life due to enhanced well-being, which in turn would make it possible for them to better manage difficulties in everyday life.

Conflict of interest and funding

The authors have not received any funding or benefits from industry to conduct this study.