Meaning in life is an important but elusive construct that has traditionally been thought to be the domain of philosophy or theology. References, however, to meaning and its importance in people's lives are found in sociological, psychological, anthropological, gerontological, and nursing literature.
Several nursing authors have stressed the importance of meaning in life to patients. Fitzpatrick, in her life perspective rhythm model, emphasized the meaning attached to life as a central concern of nursing. She stated: 'Those who have no meaning do not continue to live" (Fitzpatrick, 1983) and further added that meaning in life is mtimately linked to health. Others who have emphasized the importance of meaning in life include Ebersole and Hess (1985), Fox (1979), Pender (1987), and Peterson (1985). Ebersole and Hess (1985) state "the gerontic nurse's task is to use every avenue to help the older person find meaning in the last phase of life." Although the aforementioned authors stressed the importance of meaning in life, their statements have not been tested. There is a paucity of exploratory research on the topic, especially as it relates to older persons. The purpose of this study, then, was to explore meaning in life among older people by identifying factors they perceived as meaningful and the extent to which they experienced fulfillment of meaning in their lives.
Summary of Studies Showing Percentages of Subjects Listing Each Category oi Meaning
To date, the two major approaches to studying the concept of meaning have emerged from psychology: studies based on Frankl's work (1962; 1967; 1969) using the Purpose in Life (PIL) scale (Crumbaugh, 1964), and Devogler and Ebersole's (1980) analyses of essays on meaning in life. The PIL scale measured the degree of fulfillment of purpose in life (meaning fulfillment) whereas the Devogler and Ebersole approach yielded categories of what was meaningful in one's life (meaning framework).
Relationships consistently ranked as the most important category in the studies reviewed on meaning framework. Religion (belief), service. growth, work, and health were also listed as important areas of meaning. Although most studies reported the percentage of subjects listing each category as meaningful, Klinger (1977) and McCarthy (1983) reported their findings in rank order. Table 1 summarizes the results of these studies.
According to Frankl (1962), a person's search for meaning in life is the primary source of motivation. An existential vacuum results when a lack of meaning or purpose in one's life is experienced. This condition is estimated to afflict 20% of the general population (Frankl, 1962; Klinger, 1977; Lukas, 1972). Frankl's (1962) estimate was based on his clinical assessment that approximately 20% of his patients who sought psychiatric help had problems related to meaninglessness. Klinger (1977) surveyed 182 college students and reported that 20% claimed to find no meaning in any pursuit. Lukas (1972) interviewed 1,000 Viennese on the street corner, asking them if there was something so valuable to them that it gave their lives meaning. Responses to her question also indicated that 20% suffered from a lack of meaning. In addition, Lukas (1972) found that fewer people over the age of 60 than between the ages of 30 and 60 could state something that contributed meaning to their lives.
As people age, their life situation changes. There may be a variety of losses, such as death of significant others, changes of residence, retirement, and a declining health status. It has been suggested that loss of meaning is a serious threat to older people because of the many changes and multiple losses that many encounter in the later years of life (Klinger, 1977; Lukas, 1972; Peterson, 1985). Reker and Wong (1988), drawing from Frankl's and Maddi's (1970) conceptualizations, have begun to move toward developing a theory of personal meaning, and state as one of their postulates that "the personal meaning system of an individual will become increasingly more integrated as a function of age."
Several authors related meaning in life to health status. Fisk (1978) measured purpose in life among 41 elderly persons on moving into a retirement home and again 3 months later and found a significant loss of meaning in life. In addition, loss of meaning was associated with declines in both mental and physical health status. Baum (1981) and Findlay (1981) also found a significant correlation between purpose in life and physical health status among older persons. A loss of meaning in life was found to be positively related to depression as well (Crumbaugh, 1981).
These authors have all used a psychological perspective, viewing meaning as a mental construct and a primary motivational force in the lives of individuals. This approach minimizes the role of social forces and has limited potential for explaining how meaning develops, changes, and is sustained throughout life.
CONCEPTUAL AND THEORETICAL PERSPECTIVE
The theoretical framework that guided this study was symbolic interaction. Symbolic interaction is a broad perspective within the social psychology that is useful for understanding people and their behavior in their social worlds. Meaning is viewed as the central idea in symbolic interaction (Manis, 1972) and refers most frequently to the meaning of symbols and situations that connote either small, time-limited events or broader situations, such as one's life situation and oneself (Thomas, 1972; Weinstein, 1969). People do not simply respond directly to events and situations, but give meaning to them. Actions are then based on the meanings the situations have for each person rather than a direct response to the event or situation.
For meaning to develop and for an individual to be able to say "yes, my life has meaning and this is what gives it meaning," a certain sense of self must be present. In contrast, psychologists view self-concept as a precursor and necessary condition for development of meaning in life (Battista, 1973); symbolic interactionists contend that an individual's definition of self is dynamic and emergent. The self must be defined as a point of sentience, "an axis of meaning for the relating of the individual to the objects in his (or her) world" (Brittan, 1973).
A simplified model to illustrate this perspective can be found in Figure 1. Interactions are viewed as the starting point for the development of meaning. Through interaction, the meaning of symbols, one's definition of self, and the meaning of situations evolves. Meanings are dynamic rather than static and, through interaction, change and continue to develop. A person's actions, then, are based on the meanings given to the situation. This, in turn, is interpreted and evaluated through further interaction.
Using the symbolic interactionist perspective, meaning for the purpose of this study was defined as follows:
* Meaning in life: the definition of oneself in relation to the world, consisting of meaning framework and meaning fulfillment.
* Meaning framework: a person's beliefs regarding what is valued and has significance in life.
* Meaning fulfillment: the degree to which the framework is being satisfied or fulfilled in an individual's current life situation.
The purpose of this study was to explore meaning in life among older people by identifying the factors perceived as meaningful (meaning framework) and the degree of fulfillment (meaning hilfillment) experienced by older persons.
The sample consisted of 81 respondents aged 62 years or over affiliated with a senior center, either through the activities program (n = 32), regular attendance in the meal program (n = 30), or for services to the homebound (n = 19). Respondents from the activities group and the meal group were randomly selected from larger groups. Those respondents comprising the homebound group represented all of the homebound clients meeting the selection criteria and consenting to participate. Selection criteria included the ability to speak, read, and write in English, and mental competence. The sample was selected from these three groups to maximize variability in the meaning framework and meaning fulfillment variables.
In general, this sample consisted of white women in their mid-70s with low to middle socioeconomic status. For the total sample, respondents' ages ranged from 63 to 88 years with a mean age of 76.5; 75% were women, 44% were married, 47% were widowed, and 9% were divorced or separated. The two major religious groups were Roman Catholic (62%) and Protestant (33%). Education ranged from 6 years to 20 years with a mean of 1 1 .1 years. Fiftytwo percent of the subjects had 12 years or more of education. Fortyfive percent of those who responded to a question on income received between $5,000 and $9,000, whereas 33% received between $10,000 and $19,000.
Initial contact for scheduling a home visit was made by telephone for those in the homebound group and in person at the center for those in the activities and meal groups. Because of the extent of the health problems of most of the homebound clients, 17 of the 19 subjects required assistance in completing the questionnaire. For these respondents, questions were read as stated in the questionnaire and answers were recorded exactly as given. Any additional dialogue was reserved until the questionnaire was completed. Before the questionnaire was administered, orientation was assessed by having the subjects write their name, address, and date on an index card. Informed consent was also obtained. Respondents in the activities and meal groups who agreed to participate completed their questionnaires at home and later returned them in a sealed envelope to a box at the senior center.
A single question was used to elicit responses regarding meaning framework: "Is there something or things so important to you in your life that they give your life meaning?" This question was based on a similar question asked by Lukas (1972) in her research. Subjects were then asked to list things that were meaningful to them in their lives according to degree of importance. Space for a list of up to 10 items was provided because Devogler-Ebersole and Ebersole's (1985) research indicated that people reported an average number of 6.29 areas of meaning (Figure 2).
Fulfillment of Meaning Scale*
Several scales measure aspects of meaning fulfillment or related constructs. Most research done on the topic of meaning in life has been based on Frankl's ideas and operationalized in the Purpose in Life scale (Crumbaugh, 1964). The PIL scale consists of 20 items scaled with a Likerttype technique except that each extreme of the scale is defined using descriptors specific for each question. In addition to questions related to meaning, it also contains questions related to control and fear of death. Critiques of the PIL scale include a cultural bias (Garfield, 1973) and the inclusion of items that reflect value orientations (Battista, 1973).
Because of these problems, as well as inconsistency with the symbolic interactionist perspective, a new instrument was developed by the investigator based on the theoretical definition of fulfillment of meaning (Figure 2). In this investigator's past clinical experiences with older persons, discussion of the topic of meaning in life suggested some important components of meaning, such as interest and satisfaction in daily activities and a general sense of purpose in life. Based on this experience and the literature, individual items that reflected the theoretical definition were selected and revised into Likert format from the PIL scale (five items) as well as other scales by Wheeler (1980) (two items), Reker and Peacock (1981) (one item), and Battista and Almond (1973) (four items). Questions that reflected value orientations or locus of control were not included.
The resulting scale, the Fulfillment of Meaning (FOM) scale, used in this study consisted of 12 questions with Likert scaled responses. Possible scores ranged from 0 to 48, with high scores indicating a high degree of fulfillment of meaning in life. The questions constituting the FOM scale were determined to have content validity with respect to the theoretical definition of meaning fulfillment by three independent expert judges. In a small pilot study, criterion validity of the FOM scale (using the PIL scale as criterion) was .87 with a Cronbach's alpha of .89. Because this instrument is in the early stages of development, further validity, reliability, and normative data are not yet available.
Seventy-three respondents (89%) reported having something so important in their lives that it gave their lives meaning. Of these 73 responding, 60 listed items that gave their lives meaning. Thirteen respondents did not list any items.
From responses to the meaning framework question, categories were determined based on subjects' responses and findings in past research studies. Placement into categories was done independently by two researchers to prevent bias.
Relationships were the most important category for the majority of respondents (57%). Service, another socially-related category, was important to 12% and included volunteer work, care of family, and helping others. Religion-related items were most important for 13%, whereas 10% reported activities as most important. The remaining 8% were divided among the categories of living/ growth, home, health, and learning. Figure 3 shows the percentage of respondents listing each item as most important and meaningful in thenlives.
Number (and Percent) of Subjects Listing Categories as Most Meaningful According to Degree of fulfillment of Meaning
The range for total number of items listed by respondents was 0 to 10 with a mean of 2.67 and a standard deviation of 2.83. Although space was provided for subjects to list as many as 10 meaningful items, very few subjects actually identified 10 items. Analysis of variance showed significant differences between groups (F = 4.67, ? = .01 3) for number of items listed as meaningful. Subjects in the homebound group reported significantly fewer meaningful items than did the other two groups. The meal group reported fewer items than the activities group.
The specific relationship that most subjects listed as most meaningful was that of spouse. A total of 17 subjects (28%) listed their spouse as a source of meaning, 1 1 subjects ranking this first. Throughout all the ranks, children were listed by 45%, grandchildren by 28%, and friends by 25%.
Fulfillment of meaning scores ranged from 6 to 46 with a mean of 31 and standard deviation of 8.2, indicating that most of the respondents generally reported a high degree of meaning fulfillment. However, eight people stated their lives were meaningless. Of these, four were from the homebound group, three from the meal group, and one from the activities group. Four of the above six subjects who stated their lives were without meaning included absence of or difficulty with relationships in their life situations. Other prominent themes in these brief statements were poor physical health (for two subjects) and lack of meaningful activities (related to poor health for two subjects).
When the relationship between what was meaningful to respondents (meaning framework) and the degree of fulfillment of meaning was examined, chi square analysis revealed no statistically significant difference in degree of fulfillment based on type of meaning listed as most important. Table 2 shows numbers and percentages of subjects listing each category of meaning as most important according to low, medium, and high FOM scores. Only 57 respondents are represented in this table because all subjects without meaning and all subjects with missing data on either the meaning framework question or the FOM scale were omitted. Because no real trends were noticeable indicating that any one type of meaning seems to foster greater fulfillment, it may be that having something to contribute meaning to life is more important than what it is that is meaningful.
In regard to meaning framework, the majority of subjects listed relationships as most important to them in each of the first five ranks. Four of the six subjects who described their lives as meaningless identified problems with or loss of relationships in their lives. This emphasis on the importance of relationships was consistent with findings in the other studies summarized in Table 1. All of the studies cited in Table 1 showed relationships to be of primary importance, with the percentages of subjects listing this category ranging from 30% to 46%. Of those studies using college students as subjects, the percentages of subjects listing relationships as being of primary importance ranged from 30% to 37% (Devogler, 1980; Devogler-Ebersole, 1985). The study that dealt with adults of all ages found 46% of subjects listed relationships as most important (Devogler, 1981). This may be an indication that as people age and some social roles (such as work) fall away, relationships may gain importance as a source of meaning.
Relationships are of key importance within the symbolic interactionist perspective. Through interaction with others, situations are defined and meaning emerges from these definitions of situations. Because meaning is basic for people to understand situations and function successfully in the world (Manis, 1972), relationships and interaction are critical to the establishment and maintenance of meaning. This may explain why the majority of people rank relationships as most important in giving life meaning. Through interaction in relationships with others, the person defines situations and discovers meaning in all aspects of life situations.
For the categories of religion (most important for 13%) and service (most important for 12%), findings in this study paralleled results from most of the earlier research (Table 1). For all of the studies summarized in Table 1, religion (belief) ranked second or third in importance, ranging between 12% and 18% of subjects listing this category as meaningful. A spiritual or higher purpose in life may be an example of a relationship with God or may be reflective of the social nature of organized religion. Related to service, it is possible that the moral value placed on helping others supports one's definition of self as useful and thus lends purpose and meaning to life in that manner.
Activity within this study was defined to include specific activities such as bingo, fishing, hobbies, and crafts as well as travel, activities in general, and work. This category involved social participation in many of the activities, although items such as watching television were probably solitary activities. No single category in other studies reflected these same items; however, the categories of expression and of work incorporated some of the elements found in the activity category. The importance of activities may be a reflection of this sample being selected from a very active senior citizens center where many activities are encouraged and available. Additionally, the majority of activities listed involve social settings and, as such, may provide the structure for interaction to take place and for relationships to develop.
The remaining four categories, each listed by 2% as most important, included satisfaction in living and personal growth, health, home, and learning. The percentages of subjects listing each category in this study were similar to previous findings except for the living/growth category, which was chosen by fewer subjects, and home, which was not identified as a source of meaning in previous studies. Older people may perceive growth differently than younger respondents, and one's home may be a source of meaning because it represents autonomy and stability.
The majority of subjects in this study reported a moderate to high degree of fulfillment of meaning in life based on results from the general meaning question and the FOM scale. Only 10% of subjects reported no meaning in life, that life was meaningless and without purpose. This is higher than the 3% to 5% reported in three studies, only one of which used adults in their sample (Devogler, 1980, 1981; Ebersole, 1981). Three other authors estimated, however, that this condition of meaninglessness affected approximately 20% of the population (Frankl, 1969; !Ginger, 1977; Lukas, 1972). Although definite conclusions cannot be made, the 10% of older persons surveyed in this study who experienced a sense of meaninglessness fell midway between these two reported statistics. Again, this may have been a reflection of the sample being drawn from an active senior center.
Half of the subjects reporting meaninglessness were from the homebound group, which had the most functional limitations and poorest health status. Thirty-eight percent of the meal group reported no meaning, whereas only 13% from the activities group reported no meaning. These data support Crumbaugh's (1972) suggestion that as losses occur in later Ufe and health declines, the loss of meaning in life becomes a more powerful threat. However, whether meaning in life declines as a result of losses or deteriorating health status, or has been consistently low throughout the person's life remains to be explored in a prospective study.
The relatively even distribution of types of meaning listed by subjects according to FOM scores may indicate that what is of prime importance is that people can identify something that is meaningful to them. This is similar to Frankl's (1967) view that one's search for meaning is an individual process of discovery rather than a powerful source of meaning "prescribed" by a therapist.
CONCLUSION AND NURSING IMPUCATIONS
The findings suggest areas important to nurses working with older persons. What gives meaning to life and the degree of meaning fulfillment needs to be assessed. Even though the majority of subjects indicated that relationships were most important to them, assessment should be done of individual clients regarding what is most meaningful to them. Clients without meaning in life or with low levels of meaning need to be identified and interventions explored that will help increase fulfillment of meaning. The question used in this study ("Is there something or things so important to you in your life that they give your life meaning?") was successful and can also be used clinically to assess meaning. By asking this question, nurses can get a general idea of the degree of meaning fulfillment the client is experiencing. Then, by asking clients to describe things that give their lives meaning, the nurse is able to gain insight into clients' needs and behaviors based on what is meaningful to them.
As nurses become more aware of what is meaningful to older people, they can plan and carry out interventions based on interaction to support or improve areas meaningful to the older person. This may include supporting existing relationships or referring individuals who have lost significant relationships to a Friendly Visitor program or senior center where new relationships may be established. Perhaps nurses need to be more concerned with assessment and intervention to help patients meet their spiritual needs.
For persons for whom learning is of prime importance, nurses could encourage awareness of and participation in informal or formal learning opportunities available in their communities. A symbolic interactionist perspective suggests that through interaction, nurses can assist clients to redefine situations and rediscover meaning. If we as nurses can gain further understanding of meaning in life for older people, perhaps interventions can be developed and tested that will foster maintenance and growth of personal meaning fulfillment throughout life.
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Summary of Studies Showing Percentages of Subjects Listing Each Category oi Meaning
Fulfillment of Meaning Scale*
Number (and Percent) of Subjects Listing Categories as Most Meaningful According to Degree of fulfillment of Meaning