This study aimed to fill a gap in the literature regarding the moderating role of the elderly-to-social worker ratio in the associations between institutional caregiver interactions, family caregiver interactions, perceived control, and perceptions of the meaning in life among elderly care residents. The findings demonstrate that the relationships that elderly residents have with institutional caregivers and their perceived control promote a sense of meaning in life. Moreover, the moderating effect of the elderly-to-social worker ratio at the organizational level affect the relationships between institutional caregiver interactions, family caregiver interactions, and meaning in life. As discussed below, the study findings partially support research hypotheses.
Caring relationships and meaning in life
The present study found evidence that institutional caregiver interactions have a positive impact on meaning in life among the elderly, supporting H1. In the ethics of care theory, the key elements that determine the quality of professional caring interactions include respect, acceptance, and understanding attitudes during the service process [
48]. Research indicates that daily interactions between care staff and elderly residents not only directly affect resident’s physiological health but also their mental health status, providing evidence for the importance of establishing professional caring relationships in institutional care. Such a professional connection does not only make the elderly residents more dependent; instead, it makes them feel supported and cared for during interactions, thus promoting the overall wellbeing of care recipients [
49].
Conversely, the present study found that family caregiver interactions do not directly predict perceptions of meaning in life among elderly residents, contrary to the prediction made in H2 and inconsistent with existing literature on Asian community-dwelling elderly populations. The unexpected finding can be attributed to the development of meaning in life under the life course perspective. According to this theory, family is no longer an important life goal to be completed for an elderly person after moving into a nursing home, but rather one that has already been achieved, which provides satisfaction and achievement [
50]. Moreover, evidence shows that family has no significant influence on perceptions of the existence of meaning in life among elderly nursing home residents in western Europe, both individuals with normal cognition and those with Alzheimer’s disease [
51].
Although Chinese culture emphasize interdependent self and familial connectedness, older adults often feel lonely due to the lack of family involvement after having been admitted to the care home [
52]. On the one hand, the elderly who can receive support from a harmonious family are less likely to live in institutional care [
53]; on the other hand, the accessibility of elderly homes such as location, traffic or physical environment might act as barriers to family caregiver interaction with the elderly. Elderly residents tend to believe that their responsibility for family has been completed before moving into the elderly home, and no longer feel the need to rely on their family members. Therefore, the family caregiver interaction has no significant effect on the meaning in life of the elderly.
Regarding perceived control, the present study found evidence that it has a positive impact on meaning in life among the elderly, supporting H3. For elderly people with long-term care needs, a sense of control in life is a key dimension that the ethics of care theory addresses [
54]. In the later stages of life, the elderly with a higher perception of control are at a lower risk of mortality [
55]. Elderly with stronger perceptions of control are more positive when facing physiological changes. They are also more likely to maintain their preferred living habits after moving into residential care, which may improve their life satisfaction. When elderly people have a greater sense of perceived control, they are more capable of using relevant resources to overcome obstacles in a challenging environment through their own efforts, which positively affects their sense of meaning in life [
56].
Finally, the present study found evidence that the elderly-to-social worker ratio moderates the associations of institutional and family caregiver interactions with meaning in life, supporting H4 and H5, respectively. While several researchers have found a positive correlation between the number of nursing staff and service outcomes in care institutions [
57,
58], few studies have paid attention to the ratio of social work staff at these institutions. The service team who directly provide care to the elderly are often composed of multi-professionals. And the quality for multi-professional’s cooperation requires as well to consider the number of social workers, as they facilitate communication, autonomy for professionals, safe team culture, and suitable care planning [
59]. Insufficient elderly-to-social worker ratio will lead to heavy workload, which was one of the most common barriers for developing a closer connection of staff to residents [
31]. Because residents and families are struggling with difficulty to find meaning in life in care facilities, they need adequate social workers to build the supporting system for their daily lives. Thus, the suitable elderly-to-social worker ratio not only affects the financial management, but also improves the service efficiency.
The moderating analysis results indicate that the elderly-to-social worker ratio does not have a significant moderating effect on perceived control and meaning in life. This finding may highlight the shortcomings of social workers in fostering a humanistic service atmosphere in long-term care facilities. Social workers might prioritize perceived control during service delivery at the interpersonal level, inadvertently overlooking the deprivation of elderly individuals’ sense of control within institutional regulations at the structural level. Due to the necessity of complying with institutional regulations in the service delivery process, there is very limited space for staff to offer the elderly a sense of autonomy. To foster humanistic care, social workers need to prioritize the rights of the elderly both on an interpersonal and structural level.
In China, only very few institutions employ full-time social workers, which reveals that the government do not attach sufficient importance to people’s mental health in long-term care. However, the social worker could improve the mental health status of elderly residents, respond to families’ concerns, and contribute to the outcome of cross-disciplinary cooperation [
60,
61]. Although social workers in institutional care have an important role in supporting the care residents, they are often underused and overlooked over the course of facilitating care delivery from family and staff. An adequate elderly-to-social worker ratio not only increases the effectiveness of interventions on the psychological needs of elderly residents, but also promotes the positive impact of family caregiver interactions on their mental health statuses. Since social workers play a critical role in promoting the relationship between caregiver interactions and meaning in life, the elderly-to-social worker ratio is an important factor promoting the living status of elderly residents.
Implications for policy and practice
The concept of meaning of life provides a direction for addressing elderly resident’s mental health in institutional care. Since the landscape in institutional care has shifted dramatically, resident needs will continue to grow in complexity due to changes in life expectancy and more widespread recognition of mental illness [
62]. Governments have the responsibility to guide healthcare institutions, as well as allocating more resources for mental health and social services. Governments should also encourage these institutions to employ an adequate number of professionally certified social workers through establishing a reasonable staff ratio standard in welfare policy, in addition to attracting more qualified social workers to work in institutional care by improving the payment for social workers, which can improve the efficiency of institutional care services.
Operational guidelines for long-term care services should not just be limited to standards for service procedures or task completion, but also pay attention to staff attitudes and skills during their interactions with elderly residents in care facilities. When establishing service standards and management regulations, institution managers should keep an open mind toward the actual needs of elderly residents, as well as encourage positive cooperation between social work services and other care services. The findings of this research encourage care facilities to fully leverage the strengths of social workers in coordinating social activities, facilitating caring relationships, and creating a humanistic environment. Social workers should also take the initiative to establish a support system between elderly residents and institutional andfamily caregivers to improve their sense of meaning in life.
Limitations
Although this research has made some theoretical and practical contributions, it also has the following limitations that must be addressed. First, the sample for this study was selected from the population of elderly care institutions with social work services in urban areas; concerns about generalizability arise when the research conclusions are applied to institutions without social workers or institutions in rural areas. Moreover, the cross-sectional data collected through the measurement instruments can only verify correlations between variables, and cannot identify causal relationships between independent and dependent variables. Finally, since the development of institutional care service mechanisms for spiritual wellbeing services is an ongoing process, further research may consider incorporating qualitative analysis to enhance understandings of meaning in life.