The concept of meaning in life is philosophical in nature and refers to purpose, significance, and self-value (Urry et al., 2004). Meaning in life centers on an individual’s interpretation of what it means to live life and make sense of existence, while having goals and purpose (Westerhof, Bohlmeijer, & Valenkamp, 2004). Although meaning in life is a universal human motive (Frankl, 1978), the importance of this phenomenon specifically in the later stage of life has been recognized (Erickson, 1985; Tornstam, 1996; Wong, 1989). According to Wong (1989), meaning in life becomes increasingly important in later life when thoughts of death inspire people to take advantage of potential opportunities for living and motivate experiences of meaning in life. Erikson (1985) described the final stage of life as being characterized by the balance between ego integrity and despair. Developing and maintaining personal integrity is the primary task of late adulthood, and achievement of that task leads to a sense of meaning in life. Tornstam (1996) labeled the final stage in life “gerotranscendence,” in which older adults develop a new perspective of their lives associated with wisdom and spirituality and a deeper knowledge of life and meaning by integrating life’s experiences.
Although the importance of meaning in life to older adults is clear, it may be increasingly difficult to find meaning in life in late adulthood as a result of losses and transitions that are common in old age (Westerhof et al., 2004). Ability to find meaning in life is connected to relationships, social roles, and psychophysical functioning, which typically diminish with advancing age (Westerhof et al., 2004). A conceptual framework that can help us understand how the transitions and losses of old age affect meaning in life is van Manen’s (1997) framework of life worlds. According to van Manen, four fundamental life worlds are part of everyday life and provide the context within which meaning in life is experienced: lived space (immediate space around us within our world), lived body (physical or bodily presence in the world), lived time (subjective time), and lived relation (relationships with others). The transitions of older adulthood such as changes in roles, relationships, and functioning are experienced in these four life worlds, and meaning in life is recreated during aging as the life worlds shift in response to changes.
In a review of the literature, no studies were found that examined meaning in life from the perspectives of long-term care (LTC) residents. However, there is research related to aging and meaning in life, which may be relevant for understanding its significance in LTC residents. For example, studies have revealed that relationships are integral to the experience of meaning in life for older adults (DePaola & Ebersole, 1995; Dwyer, Nodenfelt, & Ternestedlt, 2008). A sense of self is often identified through relationships with friends and families, and these relationships are often the main sources of meaning (Moore, Metcalf, & Schow, 2006; Takkinen & Ruoppila, 2001). Research has shown that sense of self, relationships, positivity, and spirituality add purpose and meaning to the lives of older adults (DePaola & Ebersole, 1995; Moore et al., 2006; Takkinen & Ruoppila, 2001). In addition, research has demonstrated that the ability to find meaning in life positively affects psychological health and disease course and can be physiologically protective (Debats, Drost, & Hansen, 1995; Fjelland, Barron, & Foxall, 2007; Frankl, 1978; Moomal, 1999; Reker, Peacock, & Wong, 1987; Ryff & Singer, 1998), and older adults who have difficulty finding meaning in life tend to experience more negative health outcomes than those who do not (Fjelland et al., 2007).
The ability to find meaning in life has been shown to have a significant effect on health and well-being (Fjelland et al., 2007; Moore et al., 2006). It is important that health care providers working with older adults understand the implications of finding meaning. In particular, health care providers can assist older adults living in LTC to find meaning in their lives, as they have the potential to influence many aspects of life of LTC residents, such as whom they see and what they do (Kane, 2001). This may be especially important, given the predicted increase in numbers of older adults, including older adults residing in LTC facilities (Government of Newfoundland and Labrador, 2007; Statistics Canada, 2006). Given the link between ability to find meaning in life and overall health and the predicted growth in older adults residing in LTC, the exploration of meaning in life from the perspectives of LTC residents is timely and relevant. In this article, we describe a study that was conducted to explore meaning in life for LTC residents.
Hermeneutic phenomenology, as described by van Manen (1997), was determined to be the most appropriate approach to explore meaning in life for LTC residents, as it studies individuals’ personal interpretations of their lives and makes meaning of their experiences. Hermeneutic phenomenology informed how data in this study were collected, compiled, analyzed, and interpreted. The research team consisted of the first author (as principal investigator [PI]) and two research supervisors. The PI collected the data, while all members of the research team were involved in data analysis and interpretation. Using this collaborative analysis approach, as described by van Manen, four themes emerged.
Participants and Setting
A purposeful sample from the LTC resident population was chosen, as they had lived the experience and could discuss and provide insight into the meaning in life phenomenon for this segment of the population. The LTC building, from where the participants were selected, is an old facility within a rural area in Atlantic Canada. The building has three units: one is specifically for clients of Veterans Affairs Canada (VAC), and the remaining two units house men and women, some with dementia and others who are cognitively intact, in semi-private and three- and four-ward rooms.
Eleven residents, 7 men and 4 women ranging in age from 64 to 92, participated in this study. Four residents were married, 1 was single and never married, and the other 6 were widowed. The participants’ average length of stay in LTC was 2 years. Three of the participants lived on the VAC unit in single rooms and the others resided on another unit in shared rooms. All participants met the inclusion criteria: Mini-Mental State Examination (MMSE, Folstein, Folstein, & McHugh, 1975) scores of 20 or greater and deemed cognitively able to participate; able to and interested in describing their experiences of meaning in life; and able to provide informed consent. MMSE scores of 20 to 24 may be indicative of mild dementia, but there is some overlap with the normal scale of 22 to 30 (Molloy, Alemayehu, & Roberts, 1991). To ensure that residents were able to participate on the day of the interview, the PI consulted with the staff nurses, and their expert recommendations regarding cognition and ability to give informed consent were heeded.
In-depth, audiorecorded, semi-structured interviews were conducted to obtain experiential descriptions. Table 1 identifies the questions that were used as a general guide for the interviews.
Table 1: Semi-Structured Interview Questions
The nurse manager, in collaboration with the nursing staff, identified residents who met the inclusion criteria. The nursing staff discussed the study and its purpose with residents, and a list of interested residents was given to the PI. Each interview involved a brief introduction and a discussion of the study, and those agreeing to participate signed the informed consent form. Throughout the interviews, the PI deliberately put aside or bracketed her personal thoughts, experiences, values, feelings, and beliefs in an attempt to fully comprehend meaning in life from the residents’ perspectives (Trochim & Donnelly, 2006).
Prior to, during, and after the interviews, the PI’s observations were collected and recorded in field notes. Throughout the data collection, both a reflective journal and methodological journal were also maintained. The methodological journal described how the data analysis evolved. Reflexive journaling allowed the PI to acknowledge how her subjectivity could influence the analysis, data thematizing, and interpretation, thereby enhancing study rigor. Also, through data source triangulation—including the literature, interviews, reflective journal, field notes, and methodological journal—and investigator triangulation, confidence in the data was increased (Lincoln & Guba, 2000). Study rigor was also maintained throughout the research process by negative case analysis, reflective writing, and collaborative conversations among the research team.
The in-depth participant interviews were transcribed, and analysis of the transcripts occurred throughout the data collection process. The PI immersed herself in the data by listening repeatedly to the audiorecordings of the interviews and reading/rereading the interview transcripts, reflective journal, field notes, and methodological journal, which provided a deeper insight into meaning in life. Immersion in the study data resulted in the identification of significant statements or quotes. The PI continuously reflected on the four life worlds as described by van Manen (1997): lived space, lived body, lived time, and lived relation. Statements were coded and classified, and themes that provided an understanding of meaning in life emerged.
Through language and writing, a hermeneutic interpretation of the data and insights about meaning in life from the perspectives of LTC residents were revealed and summarized (van Manen, 1997). The interpretive summaries were revised within the context of the four life worlds and further refined in collaboration with the research team. Voice tone, inflection of the words, choice of words, and gestures and emotions of the residents further allowed the PI to obtain true personal experiences of meaning in life from their perspectives.
To gain a comprehensive understanding of the residents’ existence and an appreciation of the meaning in life phenomenon, the PI attempted to put herself in the worlds of the residents, recognizing that the participants’ experiences of meaning in life were personal and unique and generalizations should not be sought.
The study was conducted in accordance with the Tri-Council Policy Statement (Canadian Institutes of Health Research, 2010). The study was granted ethics approval through the relevant university and health authority.
The participants in this study and the dynamic interplay between the hermeneutic conversations and writing and rewriting revealed four themes in meaning in life for LTC residents: Connectedness, Survival Despite Declining Functional Capacity, Engaging in “Normal” Activities, and Seeking a Place of Refuge. These four themes and the life worlds (van Manen, 1997) with which the themes are associated are presented in Table 2.
Table 2: Study Themes and Life Worlds Related to Meaning in Life
Relationships help establish identity or a sense of self that is developed over time and throughout life, and this unique experience defines who we are. Family, friends, and caregivers typically are central to the life world, lived relation, and the experience of connectedness, and are integral to finding meaning (Wiggs, Young, Mastel-Smith, & Mancuso, 2011). When admitted into LTC, sense of connectedness may fade. Participants attempted to maintain connectedness by integrating their past relationships and redefining their concept of relationships to fit into their existence in LTC. A sense of connectedness was derived through relationships with family, others, and a spiritual being.
Connectedness and Family Relationships. In our study, residents adapted relationships to their current environment through the brief, albeit significant, interactions and connections with family and friends. Reminiscing about the past through photographs and stories was an adaptive technique used by residents in an effort to bring their past connections and relationships into their current existence. One participant talked about pictures that his mother had and reminisced about the experiences associated with these pictures. His facial expressions, eyes, and tone of voice as he talked about the pictures were full of pride and love:
I tell you that when I was growing up, I never have much time because I worked with my father all of the time, you know, there was [sic] 19 of us in the family. He used to fish and he used to go in the woods. He had a farm there with 25 head of cattle on you know. We lived in the ’30s, so we lived good. He had a farm…my uncle had a mill and he was sawing logs and fishing and farming and doing everything.
Reminiscing about his family history provided continuity of his identity, thereby creating a sense of connectedness and meaning in life.
It was through family that some achieved purpose and meaning to go on each day. One resident poignantly reflected her purpose and will for living:
I told my daughter that last year I wish I would go. It is time for me to go. They say you got your children you got your grandchildren and they don’t want you to go. If they [children and grandchildren] didn’t want me it would be a different story.
Connection with family clearly instilled meaning for many LTC residents in the later stage of life.
Reminiscing about relationships and the corresponding sense of connection through relationships and within community was clearly illustrated in one resident’s discussion: “Everything I did, like when I worked, it was meaningful definitely. I enjoyed working. I had a lot of friends. I knew everybody in ‘[town]’ one time.” Discussing past relationships and connections within her community contributed to her sense of identity and enhanced meaning for this participant.
Connectedness and Other Relationships. The change in lived space necessitated that the residents adapt and expand their connections to include people in their immediate environment. Relationships with staff became highly valued, particularly for those residents with few or no visitors. Discussions indicated that relationships with facility staff played an integral role in maintaining personal interactions and sense of connectedness, thereby creating meaning in the residents’ everyday lives. One resident discussed her personal interactions with staff and was overjoyed by their affection toward her:
I went in the hospital when I had this “surgery” in January and I was there until the end of July. They were going to adopt me, they said. Because I was in there for so long, and I loved it. You know they were so nice.
This craving for human compassion, love, and connection was extended to the PI throughout the interview and was demonstrated by the resident’s hugs, kisses, and physical contact. The basic human need for affection and sharing was apparent throughout all interviews; tears were shed, laughter was shared, and the desire for affection was obvious.
Connectedness and Spirituality. The need for connections extends beyond friends, families, caregivers, and those in the immediate environment to include spirituality. Connections with a spiritual being are important for many individuals throughout all stages of life (Breitbart, Gibson, Poppito, & Berg, 2004; Wallace & O’Shea, 2007). Recognition that there is a higher purpose and potential to have greater meaning in life is sometimes discovered through spiritual relationships (Patterson-Sterling, n.d.) and inspires some people to behave more compassionately, which creates a greater sense of meaning in life.
One resident openly discussed his spirituality and its impact on meaning and purpose in his life. He shared his personal experience of meaning in the context of his spirituality and how he coped with his physical decline. Despite his physical condition, he seemed reassured, comforted, secure, and at peace as a result of his spiritual beliefs:
So I comes in, I takes [sic] my prayer book out a couple of times a day. I will read the chapter in the Bible. I am a firm believer of that stuff…. I think there is something after death, and I think even though if you have something wrong with you there is always something greater…I think something comes over you for a purpose…. All I do is sit here and look out the window at the lights and how beautiful it is. And that God has given me another day.
For this resident, meaning in life was achieved through a sense of greater purpose discovered through his spirituality.
Survival Despite Declining Functional Capacity
As people age, declining health may affect the ability to carry out everyday tasks. Self-worth and sense of self can be compromised when activities of daily living cannot be performed and can sometimes contribute to feelings of helplessness, loss of autonomy and independence (Heidrich, 1993), and negatively affect meaning. Reflection on the lived body life world resulted in an acceptance of the present body and limited functional capacity and fostered a sense of survival. Although some residents in our study discussed declining health and connected this with death, some found meaning in the small pleasures derived within the context of their present lived space and body. A sense of survival, despite declining health, was fundamental in deriving meaning for the residents in this study.
The integration of the lived body from past into the present within the residents’ lived time and space was evident. Health decline seemed to positively influence need for survival and foster futuristic thinking. This was poignantly reflected in one resident’s comment:
When I had one leg for that whole time, I could do anything. When I went home, I baked and I don’t know. I did everything. I made my bed, washed my hair. I did everything…then when I lost my other leg, I couldn’t do that…I get up and I know I got to do it, and I try to.
The reflection on past abilities and continued attempt to live each day, despite her functional limitations, created meaning in life. Residents recognized their declining health and corresponding limited functional ability and adapted their goals and dreams accordingly. Goal setting and dreaming were powerful processes in futuristic direction, sense of accomplishment, and inspiration, thereby enhancing need for survival and creating meaning. The future was often viewed in the short term and sense of achievement induced through simple acts of everyday living. Some of the residents’ goals were as fundamental as getting up in the morning and/or attempting to stay up. When one resident was asked about meaning in life, he commented, “The most to me now is getting up and trying to stay up. I am going to try to get up and stay up.” Positivism and eagerness for everyday living were demonstrated by many of the residents despite and in spite of their declining health.
Other goals were substantial, such as one resident’s desire to get his driver’s license back. He stated:
I needs [sic] to get back my license. See, I might get them back if when [my] hands get better. There is nothing wrong with my feet, they are not that bad…. I wish I could jump aboard and just drive. That is my goal for the summer. Try to get my license back again.
This goal inspired him to increase his physical fitness and provided meaning for living and surviving. Although this resident found inspiration and motivation through his declining health and functional capacity, other residents were frustrated and emotional, evidenced through tears in the everyday challenge to find meaning.
Engaging in “Normal” Activities
In understanding a person and his or her meaning, it is necessary to explore the person’s world, which involves profession, activities, skills, and related components. Activities unveil much about past and current existence and represent a significant component of an individual’s world and have the potential to reveal how meaning is experienced. The transition from home to LTC induces feelings of loss for this past existence. Residents adapted to changes in their lived space and time by continuing in activities that were considered a normal part of life prior to relocating to LTC and seemed to represent a sense of living and fostered meaning. Feelings of self-worth, sense of self, and pride were also derived from these activities.
Self-worth is an “overall measure of how much we value ourselves” (Stevens, 2009, What Is Self-Worth? section) and refers to self-esteem and respect. Purposeful activities and ongoing contribution to life tend to enhance self-worth. As people age, participation in activities that induce a sense of self-worth tends to become less frequent, possibly due to physical and/or cognitive decline. Therefore, it is critical to find self-worth through everyday activities in an attempt to experience meaning.
In this study, feelings of normalcy, self-worth, and sense of self were induced in the residents through a number of activities, including cooking and baking. Engaging in valued activities is integral to a person’s existence and helps define individuality. One resident stated that “they [staff] bakes muffins and, you know, cakes and I helps [sic] them out.” Not only did this activity help the resident pass the time, his use of the word “help” indicated feelings of contribution. Another resident talked about her hobby: “I buy wool always. I wouldn’t take nothing from nobody. I give them [dishcloths] away if somebody wants them. And to the church. You know because they need them in the kitchen.” Her smiles, laughter, and excitement were evidence of the pride and sense of contribution through knitting. Her ability to contribute enhanced her sense of independence and self-worth, creating meaning in life.
While some activities instilled feelings of worth, sense of self, and pride, other activities seemed to pose as only ways to pass time. Activities such as bowling and bingo did not provide meaning; they simply occupied the residents’ time. Although many of the residents commented on these activities, their words did not indicate that these activities were meaningful. One resident commented, “No. I don’t enjoy that bingo and card games. I would rather knit you know and do my puzzles.” These activities did not make the residents feel valued or enhance their sense of contribution. For many residents, these activities were not a normal part of their lives prior to LTC admission, and they were not interested in engaging in these activities now. Purposeful activities created meaning while other activities simply served to pass time and held little value.
Seeking a Place of Refuge
Lived space has the potential to produce a sense of security and comfort, as it is a place of refuge where autonomy can be achieved and privacy can be sought. This place of refuge can be lost in the transition from home to LTC, and this relocation typically involves the loss of home ownership and means sharing a space with unfamiliar people. For many residents, the LTC environment negatively affects autonomy and privacy thereby reducing security, comfort, self, and overall meaning in life. Despite these challenges, residents continued to strive for autonomy and privacy through integration of the past lived space into the present and potential future environment.
The value of autonomy and privacy cannot be overstated, as they provide significant meaning, particularly for LTC residents for whom these facets of life are sometimes restricted. One resident in the study commented about the lack of privacy in his room, which he shared with two other individuals:
The nurses comes [sic] and pulls the curtain between me and him across and he told her to haul the curtain back. She looks in and I was stood back on. I was washing myself…he [roommate] would come in with his wheelchair and come up on both sides of my bed.
Autonomy and privacy are often realized through an individual’s environment or lived space, resulting in feelings of independence, choice, control, and self, which are sometimes lacking in the LTC environment.
The desire and search for a place of refuge continued, despite the residents’ current environment. One resident continued to feel a sense of autonomy through home ownership. This ownership served as an augmentation of this resident reinforcing his sense of independence, autonomy, and individuality. The integration of his experience of being a homeowner into his current environment made him feel the autonomy and privacy that was lacking in the LTC facility. In the same way that this resident felt a sense of autonomy through home ownership, other residents experienced a loss of autonomy and privacy by selling their homes. Loss of autonomy, control, and independence was clearly demonstrated through one resident’s comment about being a “patient” as opposed to a “resident” in the LTC facility. He had become a passive actor in his life: dependent, helpless, and felt that he had little control or influence over his care or activities.
Many of the units in this LTC facility were institutional, with little decoration or personality. Residents were encouraged to bring personal items from home; however, limited space restricted what they could actually bring with them. Personality and character were nonexistent despite attempts to individualize these spaces. As a result of environment, desire for longevity was negatively affected as evidenced by one resident’s comments:
There is nothing to look forward to. Nothing. Some people talks [sic] about what a wonderful place it is. You seen the size of it, you know what they got done. It is not big enough for one person hardly. I don’t know what will happen if I live to see another year.
Frustration, hopelessness, and helplessness prevailed as a result of the physical existence for some of the residents; however, feelings of hope were fostered by the anticipation of future relocation into a newly built LTC facility. All of the residents discussed with excitement the prospect of having their own rooms, and many stated, “It’s too good to be true.” The new building, with private rooms, would enhance their ability to have autonomy and privacy, thereby creating meaning in life.
The themes that emerged reveal what is significant and valued for the LTC residents in this study and can be linked to the limited literature on meaning and older adults.
The theme connectedness captured the importance of the life world of lived relation and the significance of family, friends, staff, and community and corresponding connectedness for the residents in finding meaning within the LTC environment. Although the residents in this study did not articulate that reminiscing about the past enhanced meaning in their lives, through the hermeneutic phenomenological process, the research team was better able to develop insight into meaning based on the interviews. The residents reflected on past experiences, relationships, and connections and integrated them into the present and also looked forward to future interactions.
It has been demonstrated that reminiscence programs stimulate personal meaning evolving around the self and social relations, decrease depressive symptoms, and enhance positive thinking in older adults (Westerhof et al., 2004). Reminiscing about relationships and the corresponding sense of connection through relationships and within community was common throughout the interviews and seemed to contribute to a sense of identity and enhanced meaning. This research supports the need for LTC residents to learn adaptive strategies such as reminiscing and integrating past experiences into their present existence, to adjust to life’s losses and transitions and create meaning.
In addition to reminiscing, the residents in this study continued to feel a sense of connectedness by extending relationships to staff and those in the immediate environment, including the PI, for whom listening to the residents’ stories was a sad reminder of the loneliness sometimes experienced by those in LTC. The extension of connections was of particular importance for those LTC residents whose relationships were limited for a variety of reasons.
Participants in this study also achieved a sense of connectedness through spirituality. Spirituality may offer purpose and meaning toward the end of life. Research suggests that spirituality is critical in the final stage of life (Fry, 2000; Kirby, Coleman, & Daley, 2004; Wallace & O’Shea, 2007) and may help older adults cope better psychologically and physically (Fry, 2000).
Survival Despite Declining Functional Capacity
This theme evolved from the life world lived body and reflected the need for survival even when confronted with physical and medical decline that affected functional capacity. Most of the participants were challenged with diseases and illnesses that limited their ability to engage in everyday activities. Despite these limitations, the residents continued to seek meaning and purpose each day, and these conditions created desire for survival.
Wong (1989) suggested that adaptation is necessary to age successfully, and strategies such as positivity, commitment, optimism, and future planning can enhance meaning even in the face of adversity. Research has indicated that people find meaning despite adversity through survival, determination, and inner strength (Frankl, 1978; Moore et al., 2006; Reker, 1997; Wong, 1989), and this was evident throughout the interviews with the residents in this study.
Wong (1989) also suggested that when there are dreams to be fulfilled, tasks to be accomplished, and new joys to be experienced, meaning and purpose tends to be reinstated. Some residents in this study planned short-term goals such as simply getting up in the morning, while one resident made plans to get his driver’s license back. Residents were motivated by these goals, coped with adverse conditions, and achieved meaning in their everyday activities.
Engaging in “Normal” Activities
This theme denoted the need to continue participating in activities that were a part of the residents’ life world of lived space prior to admission into LTC. Engaging in normal activities emphasized the importance of feeling a sense of contribution and being valued, which resulted in feelings of self and identity, thereby creating meaning in life. Many of the discussions evolved around the everyday activities that denoted their regular or normal lives. The need for engaging activities, as opposed to time passers, was necessary for the residents to feel like active, contributing members of the community.
Choi, Ransom, and Wyllie (2008) found one of the causes of depression in older adults was stale programming and lack of meaningful in-house activities. Although the participants in the current study did not suggest being bored with the current programming options, they did not indicate any interest in many of those activities available to them. Although research demonstrated the importance of quality activities in promoting meaning in life for older adults (Brooker, 2008; Choi et al., 2008; Walsh & Waldmann, 2008), the literature does not describe the significance of engaging in normal activities, and this requires further exploration.
Seeking a Place of Refuge
The theme Seeking a Place of Refuge evolves from the life world lived space, which refers to a person’s environment. Upon relocation to LTC, many of the residents in this study experienced losses, particularly in their personal space. It is recognized that this personal space provides privacy and autonomy and has the potential to enhance meaning (Kane, 2001; Thomas, 1998; Wang & Kuo, 2006). Thomas (1998) advocated for the Eden Alternative® environment in LTC that emphasizes a nurturing environment where residents feel loved, needed, and at home while facilitating privacy, autonomy, and companionship. Kane (2001) suggested that it is not surprising that older people prefer to avoid nursing homes and that families experience guilt when their loved ones have to go to LTC. Kane recognized the importance of nursing home residents feeling a sense of privacy in that they can be alone when desired, be alone with others when they wanted, and be in control of information about themselves in terms of confidentiality. Westin (as cited in Kane, 2001) suggested that privacy helps people exercise autonomy and maintain individuality, achieve emotional release needed for self-reflection, and attain limited and protected communication. While privacy is essential in LTC, it is necessary to balance the sense of privacy with promotion of meaningful activity, enjoyment, and relationships.