Older rehabilitees' life-course agency in Finnish gerontological rehabilitation.

Abstract Aims: This study investigates gerontological rehabilitation sessions of Finnish rehabilitees in the framework of life-course agency from the perspectives of temporal orientation and agency. Methods: The research data were obtained by non-participatory observation in 11 individual goal-setting sessions between 11 rehabilitees and their personal counsellors. The data were analysed in accordance with data-driven, qualitative content and narrative analysis, with an emphasis on the life-course agency approach. Results: Four temporal orientations of older rehabilitees were identified in the rehabilitation sessions: (i) timeless, (ii) past, (iii) present, and (iv) life course. For each temporal orientation, the rehabilitees displayed different kinds of agency. Fractured agency was intertwined with the timeless orientation, frozen agency was related to the past orientation, practical agency to the present orientation, and transitional agency emerged in relation to the life-course orientation. Conclusions: The article contributes to the discussion of how older adults’ rehabilitation should be reformed within the Finnish context. The study suggests that a person-centred gerontological rehabilitation process should be conceptualized in terms of an agency-based approach with a personally constructed and temporally embedded life-course perspective. This kind of conceptualizing could promote empowered cooperation and innovative interventions with flexible schedules in the rehabilitation processes of older adults.


Introduction
This study examines older rehabilitees' individual goal-setting sessions from the perspective of life course agency. To date, the perspective of older rehabilitees has not been the focus of research on gerontological rehabilitation (1,2). In particular, there is a lack of research from the viewpoint of older rehabilitees' life course. Instead of traditional medical or occupational therapy approaches, this study assumes a perspective of life course agency. Life course agency is understood as the individual ways subjects use to construct their life course through choices and actions, framed as interplay between the past experiences, engagement with the present and orientation towards the future (3,4). We address life course agency from two perspectives: temporal orientation and agency. The temporal orientation in rehabilitation sessions of the study is analysed not only from the perspective of the future goals for rehabilitation, but also from the present and the past orientations. Agency is analysed as the actions and choices engaged in by older rehabilitees in order to influence the goal-setting of the rehabilitation process and their whole life course. This study contributes to the discussion on developing person-centred rehabilitation services for older adults.
In the fields of occupational therapy and gerontology, rehabilitation is traditionally described as a client-centred and goal-directed process in which the main focus is, as much as is possible, an independent and autonomous life for rehabilitees (1,2,5,6,7). However, the concept of independence has been criticized for lacking the crucial principle that all people are interdependent without being able to autonomously control their life courses within unrestricted contextual demands and constraints (8,9,10). In multiprofessional rehabilitation, individually meaningful goals for the coming process are crucial (7,11,12). We lack deeper understanding of how the older rehabilitees' previous life course with different occupational histories is taken into account in these goal-setting sessions. This study examines older rehabilitees' temporal orientations in goal-setting sessions and how these orientations are part of the individual life course agency. The study is conducted by utilizing observation data from eleven clinical rehabilitation goal-setting sessions between eleven older rehabilitees and their counsellors.
Based on the findings, we suggest new ideas for understanding and organizing gerontological rehabilitation as a person-centred practice, and suggest how a life course agency approach could contribute to the development of person-centred rehabilitation practices. This development is especially important in Finland nowadays due to the current social welfare and health care service reform. The reform requires changes in rehabilitation services at structural as well as at practical levels, and demands the development of health promotion and rehabilitation services for the rapidly increasing number of inhabitants over the age of 65. At the same time, cost-effective, high-impact services and evidence-based rehabilitation with person-centred approaches should be researched and developed (13).
In the next section, we address the main theoretical concepts of agency and life course agency. We also discuss goal-setting as the first and crucial phase of the person-centred rehabilitation process.

Agency at the intersection of the individual and social dimensions
Agency is a complex phenomenon. It has been defined from various perspectives in a range of professional practices (14,15,16), disciplines (3,17,18,19,20) and cultures (21,22). The concept of agency is generally divided into two dimensions: personal and structural (or contextual). In the first dimension, the emphasis is on the identity, autonomy, free choice and competence of a person (see 18,22). The second dimension stresses the socially structured demands of a person's environmental structures for agency (14,19). Alongside these approaches, some authors have suggested a conceptualization of agency in which the focus is on the dynamic interplay of these two dimensions as they vary within structural contexts of action (23, cf. 3, 24).
In theories of occupational therapy, agency is closely related to the concept of occupation as a meaningful and purposeful activity of an individual. In this activity, agency can be seen as a means for, as well as a result of, participation in an occupation (20). In the same way, human occupation, occupational identity, occupational behaviour and occupational competence are related to the concept of agency, and these also influence the success of occupational adaptation (see 25, 26, also 11). Nyman et al. (20) have introduced a transactional perspective into occupational therapy practice where agency is negotiated and created in everyday occupations situated in different socialcultural contexts. Bergström et al. (27) have suggested the concept of enacting agency to express the negotiations of stroke patients when dealing with different characteristics over a span of time and a range of difficulties in everyday life as well as in different situations and environments.
According to Wray (22), agency should be understood as a creative, generative and relational process through which older adults handle issues from their everyday lives, meaning that agency with empowerment is directly related to successful aging (focus on the personal dimension of agency). From the perspective of environmental gerontology, Oswald and Wahl (28) emphasize that, at the behavioural level, agency is about reactive and proactive aspects of using, compensating, adapting, retrofitting, creating and sustaining places (focus on contextual or environmental dimension of agency, see also 14). Personal (P) and environmental (E) dimensions are both basic concepts in theories of occupational therapy, but with the extra dimension of occupation (O) and they are mainly theorized and utilized only in the individual level of therapy processes (26,29).
Overall, theoretical discussions in the field of occupational therapy have emphasized a person's genuine interdependence with social, cultural and natural environments (29). From the standpoint of the authors, in these approaches the life course and temporal perspectives are not emphasized accurately. These theoretical concepts are discussed in next section.

The perspective of life course agency
The concept of agency has also been researched and formulated from a life course perspective.
According to Emirbayer and Mische (23), agency is a temporally embedded process of social engagement, informed by the past (in its habitual aspect), and oriented towards the future (as a capacity to imagine alternative possibilities) and the present (as a capacity to contextualize past habits and future projects within the contingencies of the moment). This means that in order to understand the dynamics of agency, it must be analytically situated within the flow of time. From the temporal life course perspective, human agency is an individual-level construct and fundamental for social action situated in a context. Life course is structured by the historical, political and cultural period of a society. In the context of these, each cohort and individual formulates their own life courses (4,30,31).
Formulating a life course refers to life course agency, which is understood as exerting influence to shape the trajectory of one's life. According to Hitlin and Elder (4), life course agency contains two aspects: a situated form of agency (the exercising of action with long-term implications) and the self-reflective belief about one's capacity to achieve life course goals. They have also differentiated three other kinds of agency: (i) existential agency, (ii) pragmatic agency and (iii) identity agency.
These four kinds of agency exist and are activated for different situational contexts and demands of environmental factors during the life coursebut always in an individual way. This life course approach to gerontological rehabilitation could offer older adults a unique, comprehensive possibility to evaluate their present situation, but also to identify and interpret their previous and future life course. In these cases, they can negotiate who they are, what has happened to them, and what other alternatives there will be in the future (7, see also 32,33).
This study explores life course agency from the perspectives of temporal orientation and agency in the goal-setting sessions of gerontological rehabilitation. The temporal orientation of older rehabilitees is analysed from the perspective of the rehabilitation goals, but also from the present and the past orientations of the rehabilitees. Agency is analysed as the actions and choices older rehabilitees make to influence the goal-setting for the rehabilitation process and their whole life course. To date, this kind of life course agency perspective has not been accurately included theoretically or practically in goal-directed rehabilitation. In the next section, the current practices and basis of goal-directed gerontological rehabilitation are presented.

Goal-directed gerontological rehabilitation
The traditional approach of physical medicine and rehabilitation is causal, linear, sequential and grounded in a non-changeable past: from this moment to the future towards concrete rehabilitation goals (see 7). In the mechanistic rehabilitation approach to time, the future is open. It is an empty space in which interventions are based on the principle that the future is approaching mechanistically, defined by the previous rules, events and official protocols. This mechanistic approach is the main principle in geriatric medicine as well, in which aging means a reductive process with new diseases, severe functional declines and social losses. In this temporal orientation of effective services, gerontological rehabilitation encounters extraordinary challenges in building a theoretical basis and practices for older rehabilitees, whose status and value are constructed mainly through the view of post-adulthood (7). In addition to geriatric rehabilitation (i.e. the medical rehabilitation approach for older people), the concept of gerontological rehabilitation has also emerged, which is based on multidisciplinary knowledge and multiprofessional practices in rehabilitation services. However, there is not a common convention of how to conceptualize this new practice (7).
In traditional physical medicine and rehabilitation in Finland, the primary aging processes are not properly part of geriatric medicine. Primary aging processes are not clearly or multidimensionally recognized by professionals, and only diagnosed diseases with functional declines as a level of secondary aging are accepted as a basis for medical rehabilitation. However, recent multiprofessional rehabilitation is described as a client-centred and goal-directed process in which the main focus is on achieving, as much as is possible, an independent and autonomous life for the rehabilitee, without defining what these concepts as practical outcomes really mean. In addition, current gerontological rehabilitation can be labelled as activity-or participation-focused services through which older individuals can continue their lives at home for as long as possible. However, in rehabilitation practice to date, the concepts of activity and participation have been strictly conceptualized and implemented narrowly (7).
Goal consensus and collaboration between a client and counsellor, called the working alliance (34 cf. 5, 6, 12, 35), is significant for effective rehabilitation outcomes. However, many clients do not have clear goals for their lives, much less for their rehabilitation (36). Life goals may influence participation in rehabilitation programmes, but it is not clear whether rehabilitation programmes focusing on life goals will improve rehabilitation outcomes (37). However, Bright et al. (38) have described how the actual, dominant model of care was assessment-based and deficit-driven, in which professionals set suitable goals that fit the services better than they do the people involved. Life course agency with this kind of comprehensive temporal orientation could be used to build a broader approach to rehabilitation goals (see 36).

Aim and research questions
This study focuses on Finnish gerontological rehabilitation sessions in which the goals for the rehabilitation process were negotiated between a rehabilitee and a counsellor. From the perspective of older rehabilitees, the study aims to examine their life course agency. The following research questions are addressed: 1. What kinds of temporal orientations of older rehabilitees can be identified in the rehabilitation sessions? 2. How are these different temporal orientations interrelated with the older rehabilitees' agency?

Material and methods
Ethnographic observation data (40)  The data of this study were collected as a part of the IKKU project during its first pilot courses before any educational and developmental interventions of the project had been implemented. Most of the older people lived at home without any permanent home-services. They mainly had musculoskeletal symptoms in their lower limbs and body that created risks for their everyday activities and independence. The total observed data consisted of 147 individual or group sessions with 48 rehabilitees (with a mean age of 81) over 33 rehabilitation days.Ethical approval for the project was obtained from the Ethical Committee of the University Hospital. Following the ethical guidelines of scientific research, the older rehabilitees and the counsellors were carefully informed about the project before agreeing to participate in the research.

Data collection and participants
Eleven individual rehabilitation sessions of eleven older rehabilitees with their personal counsellors from six different rehabilitation centres were observed during the first pilot rehabilitation courses.
For the purpose of this study, all eleven individual goal-setting sessions from the total data were included. The sessions took place in the first part of the one-year rehabilitation process and were labelled as individual goal-setting discussions within the rehabilitation programme. The observed sessions lasted approximately 40 minutes (with a range of 30-60 minutes). The counsellors were instructed to use the GAS method (Goal Attainment Scaling) for documenting older rehabilitees' goals for the rehabilitation process (41). Counsellors did not have any special training in using the GAS method, a new method that was formally introduced in the rehabilitation guidelines made by Kela. The guidelines included only an official form and headings about, for example, setting shortand long-term goals but it lacked questions and advice on how to ask about these goals.
The eleven participants of the study are described in Appendix 1. Ten were women. Two were married and living with their spouse at the time of the study. The other nine had been widowed.
Seven of them were living alone and two of them occasionally lived with another family member.
The counsellors working with the rehabilitees were physiotherapists, occupational therapists or registered public health nurses. In two of the observed settings the discussions were carried out by a pair of counsellors.
The data collection was conducted by the first author, an experienced observer with a background in occupational therapy and multidisciplinary expertise in working with elderly people in various health care and rehabilitation contexts. As a responsible project researcher of the IKKU project, she was familiar with the rehabilitation programme, its contents, the professionals and the rehabilitees themselves, so gaining access to the rehabilitation sessions was relatively easy. As a non-participant observer, she located herself behind the rehabilitees so as to not disturb the interaction. She did not interfere with the goal-setting discussions except for in the situations when she was directly invited to do so. Observations focused especially on the descriptions given by the rehabilitees themselves concerning, for example, health conditions, daily life activities, meaningful life course situations, rehabilitation needs and expectations for rehabilitation.
The handwritten field notes included descriptions of time, duration, the physical environment, participants, tools, contents and structure of the discussions. The rehabilitation was documented in rough sentences that followed the course of the sessions from start to finish, including issues raised, discussions, decisions and outcomes. In addition, comments on the atmosphere expressed by the rehabilitees or the counsellor were written down. The field notes of these eleven individual goal-setting sessions were revised after each observation day as a part of overall observation notes. This resulted in 44 pages of transcribed observation data offering a rich description of gerontological rehabilitation sessions concerning goal-settings discussions. So even though the rehabilitation sessions were not audio-recorded (because of the desire for minimum interference), the data were representative, rich and multifaceted.
For the purpose of this study, the data were organized and summarized by the first author.
On the basis of the transcribed data, thick descriptions of the goal-setting sessions were created.
These descriptions included rehabilitees' accounts of their present situations, everyday activities in different environments and social relationships, their previous life course activities with different tasks and roles, and discussions about rehabilitation goals as a dialogue with a counsellor. In this phase, each observed session was organized and summarized in the same way.

Data analysis
Both qualitative content analysis (42) and narrative analysis (43) were utilized in accordance with research questions through three dynamic phases. First, to respond to research question 1, the summarized thick descriptions were analysed by content analysis from the perspective of temporality in order to determine the different temporal orientations of older rehabilitees. As a result, four temporal orientations were identified illustrating the comprehensive temporality aspect of older rehabilitees. These were then discussed by the first author in conjunction with the other authors. Second, a narrative approach was utilized to identify six narratives that illustrated different temporal orientations of older rehabilitees' expressions and discussions. The narratives were created by combining the equal traits and features of these expressions and discussions. The narratives were thus not authentic in the sense of being identifiable with any of the eleven older rehabilitees in particular. Pseudonyms for the narratives are used, meaning that we gave a name (e.g. Anna) to each constructed narrative. Each constructed narrative is based on at least two individual rehabilitees. This means that, for example, Anna's narrative is constructed based on two original cases (Elsa and Tove, see Appendix 1). Third, the narratives were analysed from the perspective of older rehabilitees' agency utilizing qualitative content analysis by all the authors. Agency was investigated as personal actions and choices of rehabilitees in the observed goal-setting sessions and as a part of their life courses. As an answer to the second research question, each of the temporal orientations was found to be intertwined with one specific kind of agency. In next findings section, we present the constructed and named narratives (not authentic cases) to illustrate the answers to research questions.

Findings: Temporal orientations and the agency of older rehabilitees
All of the rehabilitees expressed the specific and emphasized temporal orientations in the observed rehabilitation sessions in which the goals for the rehabilitation process were negotiated between a rehabilitee and a counsellor. Altogether, four temporal orientations were identified: (i) timeless, (ii) past, (iii) present, and (iv) life course. Furthermore, a specific kind of agency was found to be related to each temporal orientation. Fractured agency was intertwined with the timeless orientation, frozen agency with the past orientation, practical agency with the present orientation, and transitional agency emerged in relation to the life course orientation. Next, the four temporal orientations and illustrative narratives are presented in more detail together with interrelated agency (Table 1). In each case, the findings are further briefly discussed theoretically from the life course agency perspective and practically from the person-centred perspective in gerontological rehabilitation.

Timeless orientation with fractured agency
The timeless orientation was identified in three observed goal-setting sessions (Edith, Lisa and Margaret, Table 1). In such cases, the rehabilitees' talk jumped confusedly between the past and present with a minimized perspective on the future. Related to the timeless orientation, rehabilitees' capacity to solve practical demands or challenges was weak, and they were able only occasionally to express some interest in the rehabilitation process without connecting these interests to the present or future. During the sessions, the rehabilitees acted according to their own will timelessly and did not respond to the supposed tasks of the session. This behaviour indicated that these rehabilitees were not doing what was expected in goal-setting sessions. The rehabilitees seemed to lack the physical, mental or cognitive capacity to interpret their own role as a rehabilitee or their opportunity or duty to work on their personal rehabilitation goals for the programme. All this demonstrates that the rehabilitees' agency was fractured. The following two constructed narratives (Maria and Gerda) illustrate how the timeless orientation and fractured agency were present because of either the physical, mental or cognitive condition of the older rehabilitee.
In the rehabilitation session, Maria, who was dealing with severe physical challenges and mild mental issues, expressed, when she was asked to set her rehabilitation goals, that "all of life is guessing". She was tired and depressed because of the many medical symptoms, functional limitations and social changes she had experienced during the last few years. She expressed that she was tired of dealing with so many sudden health problems, which repeatedly complicated her everyday life. For her, the rehabilitation session with this goal-setting demand was another problem to solve. With her fractured agency, Maria seemed to exhaust herself due to the lack of energy, power and belief in her own efficacy in the rehabilitation context. Gerda's narrative offers a different illustration of the timeless orientation and fractured agency. Despite her mild cognitive problems, Gerda was happy, lively, and talkative in her rehabilitation session. In her storytelling, the past events of her life and the present time were mixed and disordered. During the session, the counsellor's questions failed to disturb her drifting story.
Instead, she just continued her fractured narrative to the end of the session. Occasionally, Gerda would pay attention to some minor issue concerning the rehabilitation, but these moments passed quickly and she did not express any clear goals of her own for rehabilitation. She moved cheerfully from the session to another appointment.
The fractured agency of older rehabilitees can be compared to a state in which the essential basis of agency (4) is broken, meaning that they display no capacity to identify or analyse their own life situations, nor the demands of the forthcoming rehabilitation session. From the viewpoint of person-centred rehabilitation, these individuals need extra, peaceful time to orientate to their life situations as a whole, and also the possibility to cancel or postpone their rehabilitation.

Past orientation with frozen agency
The past orientation was identified in the observed rehabilitation sessions of Erik and of Ulla (table   1). In these sessions the behaviour of the rehabilitees was stable with a rigid orientation to the past, while no clear interest or actual capacity to focus their orientation to the future or even to the present. At the same time, it was not appropriate for these rehabilitees to set their own rehabilitation goals. Their frozen agency represented a rigid life course produced by a past-influenced approach to their own lives. Their typical way of acting was to express continuous resistance in rehabilitation sessions, in which pressure is applied to personal habits and routines and in which the person seems not to have any other way to act (see 4,30).
The sessions of both these rehabilitees were deeply focused on previous life stages such as working life, where they had had notable roles, or on societal hobbies and volunteer work that featured demanding tasks. The most motivating target for participation in the rehabilitation process was to return to a certain physical condition, social status or positive feeling of self. Failing to achieve these, rehabilitation was considered by these rehabilitees to be of no benefit. The next constructed narrative (Folke) illustrates frozen agency with a past orientation. Folke was confused, and even slightly aggressive, in the rehabilitation session because his present situation as an older man with health and functional limitations was the focus of discussion. He stated, for example, that "the other people wanted me to come here". He was surprised about rehabilitation and wondered why he was in gerontological rehabilitation with the so-called old rehabilitees with frozen agency require support and time to process their previous life with their current, differing roles and statuses, and also to deal with their present situation as well. It is through these processes that they could orientate themselves to the future, especially as older individuals, not only as rehabilitees. They could also benefit from opportunities to pilot a range of rehabilitation interventions and find their own way to continue rehabilitation without any outside pressures or ready-made programmes with routines and timetables that could be obstacles to their agency and typical way of acting.

Present orientation with practical agency
Two of the rehabilitees (Elsa and Tove) displayed a present orientation and practical agency (Table   1). During the observed sessions, they behaved kindly and also normatively in the expected way, so they could be defined as standard, assumed or easy rehabilitees from the perspective of professional practices and institutional routines. They expressed their problems, opinions and wishes clearly and easily put them into practice. These rehabilitees had identity performance that displayed a capacity to act within socially prescribed role expectations in a rehabilitation context (see 4,30). They also showed proactive adaptation with a capacity to defy social dictates with polite free will, meaning that after rehabilitation they continue their previous lifestyle and habits. For these rehabilitees with this practical agency, rehabilitation was based on medical problems, mainly physical ones, and limited their roles in the rehabilitation sessions from this perspective, as the constructed narrative of Anna illustrates.
Anna, with her present orientation, lived in the current moment in which chronic diseases with different symptoms and necessary healthcare services occasionally disturbed her subjectively independent and satisfactory life at home. In a rehabilitation context, her chronic sickness and functional limitations came into focus and it seemed that she did not like this kind of attention, which she showed by expressing silent resistance through ironic comments. Anna discussed her everyday life with hobbies and activities, but she seemed to limit them to her private territory in the home context, and refused to bring these issues to the institutional structure of rehabilitation. She had a clear and autonomous perspective on her own life and some critical opinions of medical and rehabilitation services she had received during her life course. She discussed her rehabilitation needs like a consumer. She did not demand any opinions from professionals, but instead asked for and selected the services for herself.
In terms of practical agency, for these self-directed, self-initiated and independent rehabilitees, it was easy to co-operate and to act in a rehabilitation context. From the person-centred perspective, these rehabilitees have autonomous rights and the self-determination to limit their personal information as they have done in a rehabilitation context (see 8,9,10). They might benefit from receiving as much information as possible about multiprofessional versatile rehabilitation services, so that they can make decisions based on the best knowledge (see 4,33) and according to schedules which fit their personal situation.

Discussion
In this study of the gerontological rehabilitation goal-setting sessions of older Finnish rehabilitees, we identified four temporal orientations (timeless, past, present, and life course) with specific forms of agency (fractured, frozen, practical, and transitional). We examined life course agency from two perspectives: temporal orientation and agency. First, the temporal orientation in rehabilitation sessions of the study was not only analysed from the perspective of goals for the rehabilitation, but also from the past, and the present orientations. Second, agency was analysed as the actions and choices older rehabilitees made in order to influence the goal-setting of the rehabilitation process and whole life course. When designing and carrying out person-centred services, it is important to recognize all kinds of temporal orientations and agencies of older rehabilitees in different contexts of gerontological rehabilitation.
In the observed sessions, the rehabilitees usually expressed a narrowed perspective on the future and showed caution in order to not be too brave or demanding when describing their longterm plans. They often seemed not to express their inner hopes, needs or dreams, which were called for, however, by counsellors in order to construct genuine person-centred goals. Usually their expressions were on a common, general level. In contrast, some of the older female rehabilitees On the basis of our findings, implications for the development of person-centred gerontological rehabilitation can be formulated. The findings showed that most of the rehabilitees were not capable of setting goals for the rehabilitation process in their first sessions. Therefore, we emphasize that older adults need sensitive, tentative and preliminary time to construct their rehabilitation readiness (44,45) before setting goals for their forthcoming rehabilitation. There also needs to be an informative discussion between the rehabilitee and a counsellor so that the process can begin with genuine co-operation. During this time, older rehabilitees can identify their capacity as agents of their own life course, analyse their life situations with personal life goals, personal interests and, step by step, set their own meaningful rehabilitation goals for a certain temporal orientation in the future.
Generally, in rehabilitation the perspective of professionals is automatically causal and prospective, from the present to the future. This study revealed that older rehabilitees can hold a contrary perspective. They mainly describe their lives in a retrospective or teleological way: from the present to the past, and how they have come to this moment. This conflict of perspectives could be the main obstacle in providing effective, person-centred services, because it interferes with cooperation and makes motivating older rehabilitees more challenging.
Based on the findings, we propose that an agency-based approach for gerontological rehabilitation is needed so that it can be seen as a person-centred practice. This approach means that older rehabilitees are able to take an active and meaningful role during the whole rehabilitation process, for which their temporal orientation and life course agency are taken into account and supported when designing content, methods, durations and timetables. For occupational therapy, a life course agency perspective could provide new possibilities to more clearly establish the profession in gerontological and community-based services, where genuine individual agency is constructed in cultural, social, physical and natural temporal structures. This life course agency approach, influenced by sociology, psychology and social psychology, is broader than the current perspectives of occupational therapy, in which theories are mainly applied in individual processes and based on health sciences. In occupational therapy, temporality is mainly seen as an environmental factor (46), not as a unique dimension of agency or life course (cf. 47).
Rehabilitation services for the current and future elderly cohorts should be constructed by a life course agency approach with a temporal orientation. Particular features of agency such as autonomy, control of one's own life, and fulfilment of values and beliefs in different individual settings and cultural groupings, must be taken account as part of the rehabilitation process (22).
These aspects seem to be especially important when promoting good health and functional capacity as essential factors in the process, and also when supporting meaningful roles, especially for older women, and encouraging contact with family members and friends. However, it seems that older women of the past and present, as well as of future cohorts, use different strategies to pursue an active life and remain in control. These features of agency and empowerment require extra attention and special study in cohorts as well as in gender-sensitive gerontological rehabilitation (see 30,48).
Even though the amount of the observed sessions of the study was small, the observation data were based on authentic rehabilitation sessions collected by the first author who was qualified professional in the area of gerontological rehabilitation. The collected observation data were rich and multifaceted, providing unique possibilities to describe the older rehabilitees' temporal orientations and agency in the context of gerontological rehabilitation. On the other hand, the limitations of the study are also connected to this same issue: observation data were based on one person's observations who made her own theoretical choices to observe the rehabilitation sessions with handwritten notes and without audiotaping the sessions. However, this qualitative study gave a fresh perspective on describing older rehabilitees' expressions and behaviours in a unique rehabilitation context. Based on the findings of the study, both theoretical and practical suggestions to develop person-centred rehabilitation of older adults were identified. More studies are needed to confirm the findings and to understand how the professional backgrounds of the counsellor affect the collaborations with older rehabilitees. In individual rehabilitation sessions, there are always two persons collaborating and this reciprocal relationship between client and counsellors formulates the overall situation and course of discussions (see 35). In this study, the focus was on older rehabilitees. Specifically, it was on how they create and promote their concrete temporal orientation and life course from the perspective of agency. The focus was not to analyse how counsellors with specific professional backgrounds react or respond to these. However, this collective agency, (35) should be the focus in forthcoming studies.
In the future, longitudinal research also needs to address older rehabilitees' life course agency and the possible continuities and transformations in it during the rehabilitation process.