Older Adults Experiences of Reflective STRENGTH-Giving Dialogues©: An Interview Study

Background: A major health problem that frequently accompanies old age is long-term pain, but pain must be acknowledged by older adults and health care providers. Interventions are needed to alleviate pain and suffering’ while holistically providing health care that promotes wellbeing. The intervention project, Reflective STRENGTHGiving Dialogues© (STRENGTH) was implemented to increase health and wellbeing among community dwelling older adults living with long-term musculoskeletal pain at home. Aim: The aim of this study was to describe the older adults’ experiences of the intervention Reflective STRENGTH-Giving Dialogue. Method: A life world hermeneutic approach was used in collection and analysis of data. Twenty community dwelling older adults participated were interviewed in their homes after the intervention. Findings: The findings consisted of five themes and showed that the older adults experienced the Reflective STRENGTH-Giving Dialogues as a continuous and trusting relationship that alleviates the pain and breaks the loneliness. They expressed it as a new way to talk about life with pain. The dialogues supported reflection and memory and resulted in a transition in orientation in life. Conclusion: The Reflective STRENGTH-Giving Dialogues helped the older adults to increase their intellectual, emotional, and physical engagement in daily living. The dialogues facilitated a transition in orientation from past to present, to the future, and from obstacles to opportunities. The dialogues were oriented towards enjoyments, meaning, courage and strength in life as a whole which promoted the older adults’ sense of well-being and vitality. The dialogues also facilitated carrying out small and large life projects. The Reflective STRENGTH-Giving Dialogues created a deepened caring relationship that contributed to an increased sense of security, strength and courage, all of which enhanced the potential for better health and wellbeing.


Introduction
A predominant health problem that frequently accompanies old age is long-term pain [1][2][3][4][5], and especially musculoskeletal pain [1,6]. Even though debated, [7] there is a common belief that this type of pain is an inevitable consequence of aging [7][8][9]. It is known that pain influences the older adults' quality of life in an extensive way. Pain causes a range of disabilities related to physical, psychological, social and existential aspects, [3,5,6,[10][11][12][13] all of which need to be addressed in the provision of health care [14]. In spite of disabilities, there is foremost a desire among older adults to remain in their homes as long as possible, which also coincides with current health care policies [15][16][17][18]. The home has often become essential in life as being intimately tied to the older adults' identity, integrity and way of living [16][17][18]. However, fears often surface of losing one's home [16,18].
Unfortunately, long-term musculoskeletal pain is a health problem with potential to restrict the older adults' ability to remain at home and to lose one's home [16].
Community dwelling older adults' experiences of living with longterm musculoskeletal pain at home has been described by Gillsjö et al. [9,16,19]. It became obvious that the older adults acted as their own coaches and felt forced into learning to endure and live with pain with a minimum of guidance. Their main focus was not the pain itself, but to live daily life despite pain with a focus on joy and meaning in life. There was a need for holistic and individually tailored health care focused on preserving and promoting health and well-being in life for these older adults. The method Reflective STRENGTH-Giving Dialogue (STRENGTH) was developed to address the older adults' lack of support and guidance when living with health problems such as pain [20].

The Method Reflective STRENGTH-Giving Dialogue ©
The method Reflective STRENGTH-Giving Dialogue © (STRENGTH) was developed based on knowledge drawn from the dissertations of Gillsjö [16] and Berglund [21]. The method was developed with the aim of guiding and supporting older adults in learning to endure and live their lives with long-term pain at home. A focus was on promoting and preserving health, well-being, joy, meaning and strength in life. The method STRENGTH was derived from Berglund's [21][22][23] didactic model: "The challenge-to take control of one's life with long-term illness". This didactic model deals with the challenges involved in taking charge of one's life and learning to live with long-term illness. It is grounded in a life-world perspective, [24][25][26][27] in which human beings are seen as a whole and the human experience is the basis for learning. The human being's experiences can be explored and conceptualized through reflection and analysis of these experiences. Similar to Gillsjö [16], Berglund [21] argued the need for guidance in learning to live with long-term illness. The process of learning in the situation is complex and involves both conscious reflection and coping in the situation within life as a whole. It is therefore difficult to delineate the process of learning from life itself.
The method Reflective STRENGTH-Giving Dialogue © [20] is illustrated in (Figure 1). The focus in the dialogues is to holistically and individually guide and support the older adults in their situations in a way that enhances their sense of meaning, strength, courage, health and well-being in their situations. Central to this method is that the health care professionals learn to ask open questions and apply a tactful and challenging approach with sensitiveness to the older adult's current life situation, problems and issues. The key dimensions are used as corners stones in dialogues and are used to help health care professionals to frame the dialogues. For example, the key dimension (S) is used by health care professionals to ask the older adults to state and describe their current situation. This question relates to facts that cannot be changed such as age, health problems and other circumstances in life.
The key dimension reflection (R) is central in the dialogues and is used to help the older adults to consider possibilities and choices in life. It supports the older adult in distinguishing between possible options in the situation from those that are impossible. Questions are used in the dialogues to encourage reflection and to help the older adults to verbalize their situation. The intent is to deepen the older adults' understanding in the situation in a way that supports active standpoints that contribute to meaning and joy in life.

Settings and Aim
The method Reflective STRENGTH-Giving Dialogue© (STRENGTH) was used in an intervention study conducted in 2014. The intervention STRENGTH consisted of an initial educational program followed by set times with continuous supervision to equip and support the health care professionals (n=10) during the period of four months. Each health care professional carried out dialogues once a week with one to two community dwelling older adults (n=20) who received community based care services at home. Tools to support reflection in form of pictures and booklets were offered to be used in the dialogues from the midst of the project. The total time for the study was six months. Face to face interviews were conducted with older adults and the health care professionals the month before and the month after the intervention. Data were also collected through questionnaires at the time of the interviews. The questionnaires were Brief Pain Inventory-Short Form, Geriatric Depression Scale-20, KASAM-13 and the Moral Sensitivity Questionnaire. These questionnaires have been tested for reliability and validity and considered as being appropriate in this context [20]. This study comprises the interviews after the intervention with the aim of describing the older adults' experiences of Reflective STRENGTH-Giving Dialogues.

Method
A life world hermeneutic approach, [28,29], grounded in life world theory [25,26,30,31] was used in this study. The overall aim in this approach is to increase individuals' knowledge and understanding of one's existence and experiences in light of descriptions and clarification of lived experiences. Dahlberg et al. [31] points out openness and orientation towards the phenomenon as key components in the RLR approach for collecting data.
The hermeneutic approach, influenced by Gadamer [28] and Ricoeur [29], was used in analysis of data. The subject matter in the analysis was interpretation of data in which understandings and explanations coincide and interact [29]. The analysis started with an open and naive reading and was followed by a critical reading.
This was important in the effort to find explanations contributing to further development of the phenomenon. Gadamer [28] argues that all people have an existential pre-understanding of life, know the significance of recognizing, reflecting upon and questioning one's preunderstanding and how it influences the interpretation of the phenomenon.
Dahlberg et al. [31,32] points out the significance of "bridling" one's pre-understandings and current understandings to obtain openness in understanding and interpretation of the phenomenon. Bridling is described as a conscious approach used to maintain a scientific, reflective and sensitive attitude to gain increasing understanding of the phenomenon.

Participants
The inclusion criteria for the community dwelling older adults was as follows: age 65 or above; have lived with long-term (persistent or regularly recurring) musculoskeletal pain at home for at least six months; and receiving community based health care.
They also needed to be willing to participate and be able to understand and respond to questions. See Table 1 for a full description of study participants before and after the intervention.
The health care professionals who participated in the intervention identified older adults that met the inclusion criteria, gave them a letter with information and asked if they were willing to participate. The older adults that consented to participate were contacted through phone by the researchers for further information and to set a time for interviews.
There was a loss of two participants during the time for the project. One man died and one woman became cognitively impaired to an extent that restricted participation in the study. Two older adults, one man and one woman, were admitted to the hospital for a period of one to two months.
The dialogues were planned to be carried out every week which in some cases was not possible due to the older adults' situations involving illnesses and other activities. Occasionally, the loss of dialogues was related to health care professionals' holidays and illness.
The number of dialogues that were planned was 320. The actual number that was carried out in the study, given the above circumstances, was 181.

Data Collection
Qualitative face to face interviews were conducted with each participant before and after the intervention. The interviews were carried out as dialogues in which the participants could reflect upon their own experiences with openness and flexibility as suggested by Dahlberg et al. [31]. The interviews encouraged the participant's reflection and deepening of understanding the phenomenon. Each participant was initially asked the question: "Would you please describe your experiences of Reflective STRENGTH-Giving Dialogues?" This open approach initialized a reflective process which in turn led to new thoughts, emotions and questions based on the participant's description of their experience. The subsequent questions were also oriented towards the phenomenon of study and used to enhance and deepen the understanding of the phenomenon. The researchers remained open through a conscious and deliberate "bridling" of their own pre-understanding of the phenomenon as suggested by Dahlberg et al. [31,32]. The interviews were audiorecorded and transcribed verbatim.

Data Analysis
The analysis of data with a hermeneutic analysis can be described as a continuous dialogue with the text, vacillating from parts to whole, with the aim of discovering patterns and qualitative meanings to enhance and deepen the understanding of the phenomenon [31]. Critical and demanding questions were asked in the dialogue with the text throughout the analysis to consciously "bridle" the researchers' pre-understanding and understanding [31,32]. Initially, the text was read as a whole for familiarization with the text. This first reading was followed by a reading with focus on the phenomenon and oriented towards identifying meaning units in the data (i.e. one word, a sentence or a longer excerpt of the text). The identified meaning units were compared and contrasted and similar meaning units were clustered and condensed into preliminary themes. In this process additional questions were asked in order to identify patterns and linkages in the data. Examples of questions were: What stands out? What are the differences and similarities? How are the different themes related to each other? The analysis and interpretation of data followed the hermeneutical circle in which the analysis moved between parts and whole in a continuous ongoing iterative process [28]. Preliminary themes, as parts, were critically compared and contrasted in relation to the text as a whole until final themes emerged. Quotations from the interviews were used to illuminate the findings of the participants' lived experiences of the Reflective STRENGTH-Giving Dialogues. As a final step, a comprehensive understanding [28,29] was written based on the researchers' critical reflection, interpretation and preunderstandings of the older adults' experiences of the phenomenon.

Ethical Considerations
This study followed the principles outlined in the Declaration of Helsinki [33], and was approved by the Regional Ethical Review Board in Gothenburg (814-813). The heads of social welfare and home health care in three communities consented to participate. The participants achieved both verbal and written information and gave their informed consent. They were informed about that they could interrupt participating in the study without explanation or consequences. Each participant's identity was protected and treated confidentially.

Findings
Four themes emerged in the analysis of data aimed to describe and gain an understanding of older adults' experiences of Reflective STRENGTH-Giving Dialogues © . The themes that emerged were: The themes are presented below and illustrated by quotes from the text.

Continuous and trusting relationship
The older adults appreciated the continuous STRENGTH-Giving Dialogues with a specific health care professional. The dialogues carried out on a set time were described as an opportunity to develop a relationship, which contributed to a sense of security in daily life with pain: "It gives a sense of security when one learns to know and can rely on a person". The continuity in the dialogues and the sense of being able to rely on the health care professional facilitated development of dialogues that were carried out in mutual trust. The trusting relationship was described to be nurtured by the health care professionals' way of carrying out the dialogues and ability to focus on the older adults' needs in the moment. The relationships were described as being on the same level: "one feels like one is on the same wavelength". The dialogues were described in words as being pleasant and encouraging and it was experienced as being important to "be allowed to talk of the record between four eyes, so to speak". One description of the dialogues was: "It's good to be taken seriously. It's nice to have someone that returns, is professional and gain one's confidence. It is good that one can talk with someone that one can trust". The older adults experienced that the healthcare professionals were open and trustful. They listened and asked questions without demands: "There have not been any oddities in any way.one can raise it with her since there haven't been any demands in advance about what to talk about". It was described as valuable that a professional health care provider carried out the dialogues. One older adult said: "since she is a nurse, she knows what it is all about, that's good".
The level of trust in the relationship and increased sense of security in life could be understood and viewed in light of the older adults' descriptions of their experience. They found an opportunity in the dialogues to talk about issues that they otherwise found impossible to bring up and discuss with significant others. Examples of such issues were older adults being explicit about what they did not want to talk with others about in regard to their pain or how poorly they actually felt in life. One woman said: "I can't talk to my siblings, I can't talk to my daughter, I can't. Whom can I talk to? I just don't want to. Yes, those innermost feelings and so on, but it feels good to talk to X". The significance of the dialogues for this woman's sense of well-being could be further understood in light of the following description: "Yes, it gives me strength and energy. Do you understand what I mean? It gives me. It's like I take the energy from her". Another older adult described the dialogues as giving strength "both to mood and way of being". The strength achieved through the reoccurring dialogues and trustful relationship addressed physical, emotional and social aspects in life which promoted and preserved the sense of well-being. Examples of this were when thresholds were removed to prevent falls or appliances placed in the bathroom to strengthen the older adults' ability to increase independence in relation to personnel hygiene.
The continuous dialogues and the trusting relationship that evolved were described and understood to contribute to not only increased well-being, security and strength but also to increased engagement, confidence, courage and freedom in daily living. This is illustrated in light of the one man's initiative to decrease the antidepressant medication during the time for the intervention. "I took three tablets and now I'm only taking one half ". It was noted that the man not only talked faster, more freely and with more energy but also seemed to move easier in the apartment despite the remaining dizziness. It could be understood that the continuous and trusting relationship that evolved in the dialogues had a holistic impact in the older adults' health and well-being.

Alleviates the pain for a moment and breaks the loneliness
The older adults experienced that the STRENGTH-Giving Dialogue alleviated their pain for a moment. One older adult said: "First of all, one forgets about one's difficulties so to speak. One forgets about the pain and forgets about all the difficulties". It could be understood that this distraction from pain was a positive experience that helped the older adult to relax. An older adult said: "one forgets about it when one has someone to talk to.it has been relaxing". The older adults experienced the dialogues as pleasant moments. "I've felt very good, I have. I don't think about that I'm in pain, I relax and it improves. It was so pleasant, didn't feel any pain". The experienced relief of pain and sense of increased well-being was also objectively noted through the older adult's self-rating of pain and well-being before and after each dialogue. One woman said: She asked me before how I rated the pain in the body and how I rated it after the dialogues, and I said that the pain almost disappeared during the time I talked, because it is so much that is interesting.
The dialogues were described to convey a positive feeling that could be felt in the whole body and the older adults wanted this feeling to remain as long as possible. One woman said: "Yes, I think one becomes happier oneself, it rubs off. It remains and one wants to keep it as long as possible". The positive effects of STRENGTH-giving dialogues could be further understood in the older adults' descriptions of the dialogues. They not only ascribed the dialogues a relief of pain and increased ability to relax, they also felt that the dialogues broke their sense of loneliness. This contrasted their lives in general that were described to consist of several hours alone in silence: "One is lying down in silence for many hours". It was understood that the dialogues were important and that it was worth waiting. "It is a break in the middle of the week and when one has something, someone to talk to one forgets about everything else". The experienced comfort and diminished loneliness that the older adults designated in the dialogues were understood to lead to thoughts that involved reaching out to others to fulfil goals in life. One woman said that the dialogues had given her energy and strength to the extent that she considered working as a volunteer in a second-hand shop for some hours every week to socialize: "Yes, I thought why not? Then I will get out and meet with people and talk a little".
The continuous dialogues were described to break the older adults' loneliness and alleviate the pain for a moment. The older adults could relax and the dialogues conveyed a pleasant feeling, a feeling that the older adults wanted to hold onto as long as possible. In light of these descriptions, it could be understood that the dialogues contributed to comfort that helped to ease the older adults' burden and increase wellbeing in daily life. that a health care professional came to specifically talk with them about their situation. One older adult said that "it never happened to me before". They described the dialogues as unique: "I'll tell you that this has been very positive since I've never talked about pain in this way before; I think this has been very nice". The older adults described that they felt free to talk about their lives with pain with all its difficulties and disappointments, but also meanings and enjoyments. This new way of talking about life with pain with someone that listened was described as contributing to an emotional relief that helped to ease the older adults' burden.
I guess there is a little psychological part in this also when one gets the opportunity to tell someone that one has an ache, that one has pain. I think it's a little like an outlet, that one is allowed to let out that one is in pain, it's very difficult to explain it accurately.
The older adults appreciated the dialogues and described the difficulty to achieve the same sincere attention from friends and relatives "one gets the opportunity to talk about oneself; it's not everyone that wants to sit and listen to that, it's gratifying". The individual face to face dialogues were experienced meaningful and valuable in the effort to convey one's innermost thoughts and emotions related to living with pain.
It feels very, very good to get the opportunity to talk; it lies in here and rankles. I think it's very pleasant to talk about it because then I can cry even though I don't do that all the time any longer, I feel I can talk normally for the most.
The older adults' reflection upon their thoughts and emotions was supported by the health care professional in the dialogues. One woman noted that: "She is very good at asking questions and talk". She continued saying: "She is very good at reciting what one says". The dialogues were appreciated as a new way of talking about pain even though it was not always easy for the older adults to record the content in the dialogue or specifically point out the positive aspects in particular. One older adult described that the dialogues had been good and wished that they would continue in the future even though it was difficult to phrase specifically what had been good. "I don't know what to say other than everything that we talked about has been very meaningful to me. I hope that things like this will continue in the future since it has an influence on us older adults".
The older adults said that the dialogues with the health care professional led to shared discoveries about how the pain influenced the older adults' daily lives and how they dealt with the pain. In light of the older adults' descriptions it could be understood that the dialogues led to mutual learning resulting in new insights. Examples of this were a two-fold understanding of ways to deal with pain in life. One alternative was "to not strain oneself too hard and allow the body to decide what is feasible to a greater extent". Another way was more of an offensive approach. The older adults took the decision to challenge themselves and carry out activities despite pain, knowing that it would cost and cause even more pain in the near future.
The opportunity to talk with an outsider on one's own terms was described as new and good experience. The older adult's own understanding in the situation was challenged when someone was curious, listened and asked questions. It was experienced as a new way of talking about life with pain, an approach that holistically influenced the older adults' sense of well-being.

Supports reflection and memory
The older adults described the dialogues as positive and something that they looked forward to even though they sometimes forgot the content in them. In spite of this, it could be understood that the dialogues contributed to a lasting sense of well-being. The majority of the older adults felt that the tools that were used to support memory and reflection in shape of pictures were useful. The pictures helped to focus on building blocks in the STRENGTH-Giving Dialogues. "It's like one thinks in a different way and these pictures; they were great fun". Both the health care professionals and the older adults wrote in the booklet. The older adults' life stories were viewed and analyzed in light of the section in the booklet that dealt with the perspectives past, present and future. The booklet also contained a page with the image of a weigh bowl which was used to evaluate and clarify positive and negative aspects in life. "Yes, I view it more positively in a way, see possibilities in another way. There is a chance that I can feel better physically". The booklet was also used by the health care professional and older adult to summarize the dialogues.
One of the older adults found it difficult to concentrate and had not written in her booklet. One man who was a skilled craftsman and sportsman described with pride his identified strengths and what he found positive in life. In the weigh bowl he had identified loneliness, regrets, sorrow and lack of wellbeing as negatives but hope of recovery and going back to Norway on the positive side.
It could be understood that the tools that were used in the dialogues supported the older adults in telling their life stories, recall and convey memories and feelings, and reflect upon their current situation and future to come. One example of this was a man showing the picture he had chosen to reflect upon in one of the dialogues. The picture imaged a dancing couple. The man wrote the following on the back side: "The picture gives me a warm feeling of tenderness and forethought, but also optimism about a brightening future". The man described the feeling that the picture evoked: "I think that one sees intimacy, everyone embraces each other which gives a bit of a warm feeling; it looks hopeful". He kept the picture visible on a shelf. The man experienced that the picture conveyed a feeling that lasted over time since it often reoccurred in daily life in times of fading. This feeling could be understood to symbolize good memories in life, memories that he wanted to hold onto. He felt that the picture gave him strength to live the life that now was filled with loneliness. Another example related to pictures was a woman who chose a picture that illustrated a long dock reaching endlessly out into the water. She said: "Well, I got in into my head that I should go beyond the dock and see what it could be like further away. That is how I felt. I want to try to do that. I don't want to be sitting here and become depressed. It doesn't work, I can't do that". The woman experienced that this picture was of significance for her in the dialogue with the health care professional in relation to the present time and her future.
There were variations in use of the pictures in the dialogues. It also varied regarding to what extent and how the pictures evoked the older adults' thoughts, emotions and memories. Some informants described difficulties in relating to the pictures and found the use of them as a strange activity in the dialogues. Overall, it seemed that the pictures were experienced as meaningful and to the older adults in recalling the content in the dialogues and deepening their feelings and reflections in the dialogues. The older adults sometimes had difficulties in describing the content in the dialogues, but they had less difficulty describing the feelings that the dialogues evoked. It seemed that the use of pictures

Transition in orientation in life
Their orientations in the dialogues shifted from a focus on pain to increased focus on wellbeing and life as a whole: "We have talked about my whole life". The dialogues were focused on joy and meaning in life. They were also oriented towards what the older adults could do and desired to do in the present and in the future with less focus on difficulties and things that were impossible. The older adults described how the STRENGTH-Giving Dialogues contributed to increased selfconfidence, strength and courage to deal with daily living and carrying out small or large life projects. It could be understood that the dialogues about the older adults' strengths and possibilities had significance for this transition in orientation. One older adult said: "I did not have quite that self-confidence then that I've spoken of today. I've become more and more positive after each dialogue". The older adults also described how their sense of strength increased as a result of their orientation in the dialogues on what they could do and what gave them strength and energy in life. This was described by a woman who felt that she became stronger and stronger during the time for the dialogues and was able to fulfill several of her life projects. "I never thought it would reach so far that I would become stronger and stronger. I've been down to the village, walked down to the gardener all by myself and bought flowers". It could be understood that the dialogues helped to strengthen the older adults' orientation on enjoyments and meaning in life, even for those who already had a positive attitude towards life.
The desired life projects were significant elements that were discussed in the dialogues. Sometimes the desired life project could be set as a goal, sometimes it became modified and at other times stayed as a desire that could not become reality. Some of the older adults described certain steps that had been taken to investigate possibilities to reach and fulfill their goals. Desired life projects and goals were not as explicitly surfacing in the early phase of the dialogues but became more explicit and deeper over time and were clearly described towards the end of the study. Examples of life projects were to go for a walk, drive a car or "The only thing I want to do is to start working". The joy in fulfilling goals could be viewed in light of a woman who fulfilled several of her goals. "I've reached these goals which make me happy to. I got a patio in there, I had that as one goal, I made those you know". Also noted was a desire to connect with relatives that one had not met for many years. "I just want to see the girl, this is my hope". Another profound example was a woman who visibly looked happier in the end of the study and had discharged herself from intermittent care at the nursing home. "I did not find it fun any longer". The small and large life projects that were highlighted and reflected upon had more of a clear existential dimension as the desire "to take part in life as long as possible, and to remain at home". It could be understood that the reflection and discussion in relation to life projects, even those that could not be fulfilled, contributed to a transfer in orientation towards present and future time and were of significance for the older adult's experience of well-being.
The older adults experienced the focused content areas in the dialogues as important in life which contributed to a transition of orientation in life to an increased open mind. This was expressed in words such as "ok, if I have got this insight it might lead to other insights". It could be understood that the dialogues influenced the older adults' priorities in daily living. The change in priorities had significance for the ability to participate in activities with others. One older adult described that he earlier avoided burdening others and abstained from help even though that would have helped him to participate in activities. The dialogues gave this man insight, courage to prioritize his needs despite the feeling of being a burden to others, and acceptance of care that facilitated his ability to participate in activities.
The dialogues actually helped me to deal with this since it can end up like this: they call from unions that I'm a member of and say `can't you come? We can come and get you. ' But then one thinks that no, I don't want to be a burden and should I sit there then, no, no, I don't care about doing that today one says then. But I think they helped me very well with this.
The older adults were happy to talk about their life stories. There was a strong engagement in telling one's story and they were proud of the life they had lived. "The dialogues have been good, feels good to talk with someone that listens about old times". The older adults experienced that they were challenged to talk about present and future time in the dialogues. It was described as difficult since many older adults considered themselves to have no future: "I've my future behind me". At the same time there was an uncertainty about the future. "Well, one has to take one day at a time. It tends to always resolve itself; it always does in the end". It could be understood that it was of significance to explore the older adults' life with pain, thoughts about the future and their abilities to influence the future. The new insights seemed to have an effect on their willingness to change their ways of dealing with life to promote well-being.
Well, one does not know anything about the future. But I think that I will not keep doing the same thing so intensively as I've done so far; I'll change so that I might not get so much pain. Because one has the pain even if one is still but not as much if one does a little something extra.
The awareness of the limitation of time in life became very obvious in situations in which the older adults expressed the desire to die. They described that they had lived their lives and their children had done well, which gave a sense of being successful in life. "I wish that I could die. I don't see any reason why not, I've children and they are good and steady". It could be understood that the STRENGTH-Giving Dialogues contributed to create a space in which the older adults could talk about their goals and expectations in life, which was an opportunity that seldom existed in their everyday life.
It could be understood that the STRENGTH-Giving Dialogues increased the older adults' understanding, engagement in life, courage and strength to be sensitive and true to oneself and others in a way that created possibilities to rethink and gain insights about how to live life and future goals. The transition in orientation involved focusing on possibilities and desires in life and on things that led to joy and meaning in life.

Comprehensive Understanding and Discussion
The Reflective STRENGTH-Giving Dialogue © was a meaningful intervention that influenced older adults in their lives with pain in a way that promoted their sense of well-being. The continuous and trusting relationship that was developed in the dialogues created a sense of security in life. The developed trust and sense of security enabled increased strength, engagement, confidence and courage in daily living with long-term pain at home. The dialogues alleviated the pain for a moment through distraction of thoughts and broken sense of loneliness. They also contributed to a transition in orientation from past to present and the future. The feeling that followed the dialogue seemed to last longer than the older adult's memory of its content. Recall of the content was supported by pictures and a booklet that teased out feelings, thoughts and supported memory and reflection. The focus on joy, meaning, courage and strength in life in the STRENGTH-Giving Dialogues promoted the older adults' sense of well-being and vitality which facilitated the ability to carry out small and large life projects.
The findings can be primarily illuminated and understood in light of the theory of existential well-being by Todres, Galvin and Dahlberg [34]. In this theory the term "Dwelling-mobility" is used to characterize the deepest possibility of well-being. From a phenomenological perspective well-being is both a way of being in the world as well as the feelings related to this experience. The experience of "Dwelling-mobility" contains the motion between the possibilities and adventures related to being in the world and the sense of being at home in the given situation. In this theory, the deepest potential for well-being entails the feeling of rootedness, flow, peace and possibility. A life with long-term pain can contribute to a sense of rootlessness and homelessness, a sense of not being at home in one's own body or context [16,28]. The inability to move due to pain forced the older adult to be still, rest and abandon activities [35]. This disturbed the balance between movements and restricted the older adults' possibilities to participate in activities. The social isolation influenced thoughts, movements and actions. To not be able to carry out small or large life project changed the older adults' conception about oneself in a way that tended to increase their isolation. The results showed that Reflective STRENGTH-Giving Dialogues helped the older adults to express their thoughts, feelings and experiences. The reflection and transition in orientation of their thoughts and actions from what they felt impossible towards focusing on possibilities and an increased sense of well-being. It emerged in the results that Reflective STRENGTH-Giving Dialogues are a new way of talking about life as a whole and not only pain itself. The focus in the dialogues on joy, meaning, strengths and possibilities seemed to be especially important in the older adult's experience. The holistic orientation in STRENGTH-Giving Dialogue contrasts other methods used in a health care setting since these methods primarily focus on management of the health problem itself and not the person as a whole in the context of daily living [36][37][38][39][40][41]. Interviews with health care professionals before the intervention STRENGTH show the need of a holistic orientation in the provision of health care to older adults with long-term musculoskeletal pain. They felt powerlessness in the situation and the need of methods to guide and support them in the provision of health care became obvious [42]. It is shown in a study by Ciccone et al. [43] that the use of an intervention with focus on self-management increased the patients level of knowledge, skills related to self-management and willingness to change behaviors associated with health. In light of these findings one can assume that STRENGTH has the potential to diminish the health care professionals' sense of powerlessness [42].
The existential dimensions of being a human in relation to temporality, spatiality, embodiment, intersubjectivity and mood emerged in the results. It can be understood that these dimensions were further developed and strengthened by the STRENGTH-Giving Dialogues, which led to increased well-being. It might, in fact, be the underlying reason for the older adults' descriptions of increased strength, courage, energy, joy and meaning in life as a whole.
The STRENGTH-Giving Dialogue has its starting point in the older adult's life-world, a perspective in which the narrative is central. The older adult often referred to the past, the life they had lived. However, the use of the pictures and booklet in the dialogues supported the transition in orientation to present and future time. This transition also seemed to be crucial for the older adults' ability to take initiatives and gain strength to carry out small or large life projects such as going outside in the garden or for a walk, participating in activities, starting volunteer work and creating a patio. A prerequisite for this movement intellectually, emotionally and physically seemed to be the safe and caring relationship that was developed in the dialogues. The results described how this relationship enabled in-depth dialogues and unburdened the older adults in their situation while giving courage, increased engagement and activity in life. From a life world perspective, the dialogues can be understood to set the body in motion. Thoughts, feelings and emotions are coherent in the lived body which clearly can be viewed in light of living with long-term musculoskeletal pain. It was understood that the older adults had a sedentary lifestyle with restricted intellectual, emotional and physical motion before the dialogues started. However, it seemed that the dialogues set the body in motion physically when thoughts and emotions were set in motion between temporalities (past, present, future) and between obstacles and possibilities in life.
The method STRENGTH with the key dimensions was fruitful and had positive influence in older adults' lives with pain. The pictures seemed to support the recall of memories which helped to deepen the reflection. Emotions were set in motion which facilitated vocal expressions and descriptions of experiences when linked to a picture. The feeling that was evoked in the dialogues often reoccurred in the older adults' daily life. The positive influence of using pictures in the dialogues and its lasting effect in the older adults' daily living support an extension and development of this tool in the future. The summaries written in the booklet supported the older adults' reflection and transition. The dialogues contributed to a sense of being set in motion which promoted the older adults' wellbeing in life as a whole.

Methodological Considerations
There was no effort to statistically control gender or living status in the study. Women living alone with pain were the predominant gender and living status among the older adults in this study. One third of the older adults were men. It is known that the prevalence of this type of pain is higher among women than men with a degree of difference ranging across studies from 10%-100% [2,[44][45][46][47]. Additionally, the demographic statistics show that women live longer than men which in part explains the living status for older women in society at large [48]. There was a range in age between 72-97 years and the older adults had lived with pain for at least 6 months. The variation in age, gender, marital and living status contributed to a result that reflects older adults' experiences of Reflective STRENGTH-Giving Dialogues when living with long-term musculoskeletal pain in the context of home.
The health care professionals carried out 181 of 320 possible dialogues, which is a limitation in the study. Many of the older adults in this study had multiple health problems, which in part can explain the restricted number of dialogues. Examples of this were that health problems required admittance to hospitals for shorter or longer periods, led to increased cognitive impairment or death. Other factors influencing the number of dialogues refer to the health care professionals' situation such as absence from work related to sickness and vacations.
The interviews after the intervention were carried out by the same researchers as the interviews before the intervention. This facilitated a focus on the experience of the method in the interviews since the life story was already known. The face to face interviews facilitated the opportunity for the interviewers to reflect upon and continuously confirm the participants' verbal and non-verbal expressions. Thorough descriptions of the participants' experiences were achieved which enhanced the trustworthiness [49][50][51][52]. Furthermore, the researchers were able to observe the older adults regarding verbal and non-verbal expressions and motion. It was obvious that many of the older adults seemed more vital after the intervention than before. They expressed verbal and non-verbal increase of joy and satisfaction in life. This was shown through happier and more relaxed face expressions, talking freely and with more engagement. Additionally increased motion, as shown by a more upright posture and relaxed gait, was observed. These observations were incorporated into the results which in part explain the choice of method for analysis of data. Some of these changes might in part be related to the fact that the older adult and interviewer had met earlier. However, as an interviewer one could observe that there was something more profound in the change than effects of a reunion.
The sample size in this study is limited in regard to quantitative measures and it can therefore be viewed as a pilot study. The quantitative results will not be dealt with in this manuscript. The positive qualitative findings in this study raise the need to conduct studies that include a higher number of participants with increased range in age, variation in health problems and context. This is a way to evaluate the transferability and generalizability of the method in other contexts [31,53]. The observations and information collected during supervision of the health care professionals call for the need to extend the collection of quantitative data as number of acute alarms, phone calls, visits and admittance to other health care settings as well as changes in medication.
Two of the researchers (CG, MB) have mainly been responsible for the analysis of data and presentation of the findings. The researchers (KN, LH) have read and critically reflected upon the researchers' bridling of pre-understandings and interpretation of data to secure the trustworthiness of the findings [52]. This strengthened the trustworthiness since both co-authors acted as co-judges examining the themes separately [50]. The potential for these findings to be transferred into other contexts is determined by how the readers can relate the results into earlier experiences, knowledge and context [53]. The method and results in this study can be used in planning and conducting individualized holistic care to guide and support older adults living at home with musculoskeletal long-term pain. It can also be used in education and as reference points in future research.

Conclusions and Clinical Implications
The Reflective STRENGTH-Giving Dialogues© increase engagement and motion intellectually, emotionally and physically in their daily lives. to The dialogues were oriented towards enjoyment, meaning, courage and strength in life as a whole which promoted the older adults' sense of well-being and vitality and facilitated the potential to carry out small and large life projects. contributed to an increased sense of security, strength, courage and confidence, which implies that t Reflective STRENGTH-Giving Dialogues