The results of the analysis consist of five main categories that each contain three or four subcategories (Table 1). Results are presented using examples and quotes to illustrate variety in the material and to increase trustworthiness for readers. Reference to residents’ quotes are abbreviated single letters, e.g. (F).
(Please insert Table 1 here).
Perceived hopes and expectations
The analyses showed that the older persons thought that the combined intervention included aspects that brought hope of improvement in their everyday life, e.g. “I thought to myself: Ten STS, how hard could it be?” (A). The hopes were related to their life at the NH compared to their prior life, with individual aspirations such as ”[…] returning to the vigor I had before” (A); and “to be energized and stop my armchair sitting” (B). Goals related to mobility were prominent, although reasons varied from “…being able to get up and move about independently” (C) to “ walk with a cane, so I can visit my family in Spain” (D).
It appeared that initial low expectations were re-evaluated as the intervention proceeded: “I am surprised that my legs gained so much strength just by adding some extra stand-ups during ADL. Being older, I thought there was not much to build on. But apparently…” (E). Also, the expectations of the ONS, which were initially low, were exceeded over time. Descriptions ranged from “unproblematic” to “something of a treat” (D), although some flavors were more popular than others.
Some remained more neutral in their judgements, such as this 97-year old: “I chose to see the changes for what they are. No miracles, but a sense of improvement. I’m not getting any younger“ (C).
Health-related driving forces
One of the major internal driving forces expressed was curiosity as to whether they could regain some strength, but also around the concept: “I became curious as it was a new idea and a novel concept that I had never heard of before” (F).
Some used their inner voice as a driving force in the training: “I challenge myself by posing questions while I train: Can I do five more?” (G). Others used their competitive thinking: “I want to perform well and I love to compete... also with myself” (D) or by finding some desire: “I always did more, but only scored the compulsory ten as I wanted to do the rest just out of joy” (A).
The analysis also underscored external driving forces such as the importance of helping each other. For example, supporting another project participant: ”I felt sorry for my ill friend, not being able to fully take part. Still, we have each other” (C). The older persons were grateful for the support received during the intervention. One person received valuable support from her son, who adjusted the activities he did with his mother to her mobility at the time. Initially they re-planted flowers indoors, then did some outdoor gardening, and later took walks outside.
Although most had chosen to perform the health concept individually and within the space of his or her own NH apartment, some reflected on the potential of group interventions at the unit: “It would have to be led by someone enthusiastic. Not all staff are suited for it” (A). A few described how they had taken on a leader role to encourage their companions to move: ”I had the opportunity to guide others - a really nice experience!” (A).
Lastly, some needed more support from others: ”Reminders and encouragements are what I need. I am even unsure of the extent to which I adhered to the intervention” (H). Lack of sufficient support was also experienced: ”They were supposed to serve me drinks twice daily. But I had to remind them. Frustrating!” (F).
Another driving force related to the importance of being acknowledged for their adherence and ambitious efforts. One participant proudly reported that she had “[…] independently performed the STS and taken the ONS perfectly. With an immaculately filled flowchart, staff could confirm” (B).
Others pointed out the gains perceived by working closer with the staff. Several commented on their nice collaboration during the intervention, although they knew the staff were obliged to support them in performing the daily STS and taking the ONS. In several instances, they reminded one another about doing the STS during daily life activities, to refill the fridge or document progress. Some older persons were disappointed that the staff collected their flowcharts, as they wanted to show family and friends their progress (C+F).
Staff seemed to acknowledge the older persons’ individual needs, negotiating personalized set-ups for the combined intervention. At one unit, the STS was provided for one person prior to the intake of the ONS as a “reward he had deserved”. Someone else drank the ONS before performing the STS to gain energy, while she had her second ONS as an “avec” with her evening coffee.
One of the driving forces in the intervention was the feeling of becoming energized. “I joined the project with few expectations, but of course I had to continue. The drinks… wow, they were perfect! Good size, pleasant taste and nice texture mm” (C). “I feel SO much more energetic compared to my earlier limitations” (A). This sense of energy was a continuous driving force that the older persons used to try to remind themselves to keep going while counting the STS. One participant added a nice view: ”I do them by my window to gaze out at nature. To find something to focus on” (A).
Appreciated daily activity
The analyses showed that the combined intervention was a welcome change to the daily routines. Initially, it seemed somewhat challenging to integrate into the day: ”[…] it depended on the abilities of the staff to distribute the ONS regularly, it was messy at first” (I). However, after the intervention, some even chose to implement the health regimen as an addition to their daily routines e.g. during morning wake-up: “[…] just to do a few STS to get myself going” (F). Similarly, two persons described taking their ONS before getting out of bed (J + K). One argued: “[…] to fill up my energy quota” (K). Also, the ONS was more appreciated when served chilled, which meant that several made the effort to walk to their fridge to fetch the flavor they wanted: ”I have changed my routines and now get up and walk, also to the TV to change the channels” (C).
Findings also showed that older persons acknowledged the benefits of gaining strength. A sentence that was often heard was: “I feel benefits from being strong in my new everyday life ” (L). Some described how their increased strength allowed new routines: ”I now make my bed daily and… well, I have set the rule for myself to go outdoors daily” (G).
Several of the older persons wanted to continue their new, more active life. Descriptions of attempts to maintain the STS/ONS concept after the study had finished concerned individualizing care to find a good balance: ”I want to find balance in my daily routines; being active without getting sore muscles, which I dislike” (L). Some also expressed concern about not getting the ONS any more. Someone asked the researcher: ”Is there a possibility to get them at times in life when energy might run low?” (C).
A concept easy to perform and integrate into daily life
The findings also illustrated that the intervention was hardly noticeable, easily integrated into daily activities. Several older persons indicated that they liked the simplicity of the routine: “It was so easy to integrate. I noticed that I still have some learning potential in me” (C). Several described how they had integrated the STS exercise into other daily activities: “I stand up and pull my trousers up without any support now” (M). “I don’t see the harm in it, the sacrifice of doing the STS is a small one” (C). Similarly, the intake of the ONS was described as being easy to add to the activities of the day: “… really uncomplicated and easy to deal with” (F), “…the staff delivered the ONS to us” (M). One person described their drill: ”I just grab hold of it and let it pour down my throat in one serving. No big deal!” (A). Others reflected on the whole concept: “I didn’t regard any of it as a strain. In fact, it was almost too easy. I once said: This is easy to the point of being silly” (N).
Another aspect of the health concept being easy concerned the high level of applicability due to low safety and spatial demands, i.e. it could be easily and safely performed. In both the field notes and interviews, the persons’ eagerness to show their environmental adaptations to the STS were evident. Most chose their favorite chair, others chose a chair because of its armrests, its sturdiness or even that it was odd: “I chose this chair because it stands out, and seeing it reminds me to do the STS” (A). Some cited safety reasons: “I either use a chair at my dinner table, or get up from my armchair with my roller locked securely in front of me” (C) or: “I have found the perfect way for me to perform them (pointing to the footboard on her bed that she used as a support to stand up)” (O). Similarly, a few described using the railings in the corridors of the NH for STS support.
The data analysis also described the concept as flexible on many levels. Some described the ONS as small enough for one serving, while others used a straw or a glass with measurements on it: “I used the glass to monitor my intake. I drank it in about one hour” (P). Others emphasized the flexibility of the STS: “It is flexible, so I increased my effort over time, to give all my muscles their share. When I started I had my arms straight out like a lever when I pushed up. Now I have my arms folded over my chest or even raised above my head” (A). Another participant had her own approach to the STS exercise: “For me it works best to get them done all at the same time, so I do all 40 STS once a day (F). A few described needing the concept to be flexible: ”I can occasionally, but not all the time. That would be too tiresome” (Q).
A beneficial healthy concept for all
Descriptions of the easily grasped health components of the combined intervention were very common: “I think we added STS exercises in all the everyday activities. Going to the bathroom, washing at the sink, dressing… so the legs got their share of training. And it still feels fine” (F). The same man described his increased mobility: “I have started taking walks in all the corridors. I stroll around and sit on different seats along the way” (F).
Most people reflected on the benefits of the health concept. A few persons initially described being unsure if any changes had occurred although eventually stated: “Well, I’m sure it does some good as I feel more alert. But it’s hard to tell since the dosage was quite limited” (C). Likewise, some mentioned now having “a good feeling”, or “a more positive outlook on life”, and others being more limber: ”Now, I can even get up from extremely low heights without support. So improvements have been noticed, definitely” (D). “I was at my son’s the other day and I could easily get up from that low toilet of his. I was beyond pleased” (G).
One person even described impressive improvements: “I could walk to the moon and back. Go out on my own again – without my cane! I am happier and more energized. You see? Just start whenever. It is never too late” (A). This participant had noticed that the ONS was high in protein and shared her thoughts: ”I think a bit differently now, e.g. about this bread I eat. I have started buying rye bread that contains more protein. I have it here, you see? Because the bread that I am served here only consists of empty air, as I see it” (A).
The last subcategory in the findings touched upon the older persons’ recommendations for future health interventions. They re-iterated the view that the concept should be for everyone and early on. One lady illustrated what several concluded: “As I see it, it would be most practical to include all of us at the unit. No problem” (M). Several commented that they would have benefited from this on admission to the NH: “I sincerely think that this is a good concept to offer anyone already on arrival to the NH” (A). Some arguments were: “Especially if you consider the fact that you become steadier and improve balance” (C).
Interestingly, about half of the older persons spontaneously told the interviewer that they would definitely participate again, given the opportunity. One emphasized the influence the concept had on her mood: “I loved that it was… a mixture. That I got energy from the ONS too. I was a little bit down at the time. Not depressed, but I couldn’t walk outside independently. After having done the intervention, I was much more able” (A).
Final words from some of the older persons concerned their own choice to continue: “I have continued training. I believe it is good to hang in there and keep it up” (M), and the insightful comment from a participant: “I have continued, for the sake of my own health” (C).
The last step of the analysis included the identification of an overall theme. In this study, the older persons’ experiences of the combined intervention is viewed as A health concept with a social potential, as participants feel acknowledged and strong enough to help others.