Nurse-patient interaction and self-transcendence: assets for a meaningful life in nursing home residents?

For running SEM-analyses, large samples of N ≥ 200 are recommended [68‐71]. Thus, the present sample consisted of 188 (92.0%) out of 204 long-term NH residents, residing in 27 NHs, located in two small and one large urban municipality in Mid-Norway (N = 88, living in Joy-of-Life Nursing Homes (JoLNH); these are NHs which have undergone a certification process of 1–2 year working on meeting the residents social, cultural and spiritual needs [72], along with a large urban municipality in Western Norway (N = 100, ordinary NHs which are not certified as a JoLNH). Long-term NH care was termed as 24-h care. Exclusion criteria were short-term care, rehabilitation stay, and diagnosed with dementia. Inclusion criteria were as follows: (1) municipality authority’s decision of long-term NH care, (2) residential stay of 3 months or more (the reason for this was two-fold; 1) moving to an NH represents stress and is found to be demanding; therefore, we did not want to interrupt asking many questions about wellbeing, joy-of-life, meaning-in-life, etc. during this vulnerable phase, and 2) before replying to the questionnaire the residents need some experience of the inhouse life in an NH. Thus, we wanted the resident to have stayed for 3 months or more), (3) informed consent competency recognized by responsible doctor and nurse, and (4) capable of taking part adequately in an interview situation.

Cross-sectional data were collected during 2017 and 2018. The Regional Committee for Medical and Health Research Ethics in Norway (ref.nr 2014/2000/REK Central) as well as the Management Units at the 27 NHs approved the study. The participants provided voluntarily written informed consent. A nurse who the NH residents knew well presented them with oral and written information about their rights as participants and their rights to withdraw at any time. Each participant provided informed consent. This population may have difficulties completing a questionnaire on their own. Therefore, six trained researchers (three in each part of Norway) conducted one-on-one interviews in private. Researchers with an identical professional background (RN, MSc, trained and experienced in communication with the elderly, as well as teaching gerontology at an advanced level) were trained to conduct the interviews in the same manner. To avoid misunderstandings, interviewers read each question loudly, and held a large-print copy of questions and possible responses in front of the participants. This study is part of the project Health promotion factors in Joy-of-Life Nursing Homes funded by the Norwegian Research Council. This project aimed to explore health promotion factors in Norwegian NHs, including certified JoLNHs and ordinary NHs. Accordingly, the three scales used in this study were part of the larger questionnaire comprising 9 scales representing 120 items as well as sociodemographic data (age, gender, marital status, residential time in the NH); thus, small breaks at specific points during the interview process were adopted to avoid tiring the participants. The nine scales were assessed in the following order; 1. Health-related QoL assessing symptom burden, 2. Joy-of-life, 3. a single item assessing loneliness, 4. Sense of coherence, 5. Self-transcendence, 6. Meaning-in-life, 7. Nurse-patient interaction, 8. Depression and anxiety, and 9. OPQOL-brief quality-of-life questionnaire. The OPQOL-brief data were recently published in a study testing the psychometric properties of the Norwegian version of OPQOL-brief [73]. Similarly, the Joy-of-Life scale was psychometrically tested, and used in a study assessing the associations between Nurse-Patient Interaction and joy-of-life [74] in the sample which is used for the present study.

The Nurse-Patient-Interaction Scale (NPIS) was developed in Norway to assess the vital characteristics of NH residents’ experiences of the nurse-patient interaction [51]. The NPIS 14 items assess NH resident’s ability to obtain a sense of wellbeing from essential relational and caring qualities embedded in the nurse-patient interaction. The term ‘nurse-patient interaction’ covers NH residents’ perceived interaction with their professional caregivers in the NH; these professionals are nurses (RNs), Licensed Nurse Assistants (LNAs) and caregivers without any formal education in health care. The NPIS is a 10-point scale from 1 (not at all) to 10 (very much); higher numbers indicate that residents perceive better nurse-patient-interaction. Examples of NPIS-items include the experience of being taken seriously, and being understood, respected, and recognized as a person, as well as being listened to and feeling good resulting from the nurse-patient-interaction. The items were developed to measure NH residents’ ability to derive a sense of wellbeing through the nurse-patient-interaction. The NPIS has shown good psychometric properties with good construct validity and reliability among NH residents [51].

Self-transcendence was assessed by the Self-Transcendence Scale (STS), developed in the U.S. to identify experiences of later life and reflecting expanded boundaries of the self [39, 75]. The STS comprises 15 items rated on a 4-point Likert-type scale from 1 (not at all) to 4 (very much); higher scores indicate higher self-transcendence. The STS was translated into Norwegian and validated among NH residents, showing a two-factor construct of self-transcendence [50], which is used for the present study. The items ‘Having hobbies or interests I can enjoy’, ‘Involving in others’ and ‘Sharing my wisdom’, were indicators for interpersonal self-transcendence (ST1). Test items for intrapersonal self-transcendence (ST2) were ‘Accepting myself as I grow older’, ‘Adjusting well to my present life situation’ and ‘Adjusting to changes in my physical abilities’. In former studies, Cronbach’s α for the total scale ranges between 0.80–0.88 [76‐78].

The Purpose-in-Life-Test (PIL) was designed to assess meaning-in-life and is commonly used for this purpose [79‐81]. The PIL contains 20 items which are based on Frankl’s logotherapy [82‐84]. Test items include questions such as ‘My life is: empty, filled only with despair – running over with exciting things’ and ‘In thinking of my life, I: often wonder why I exist – always see reasons for being here.’ Each of the 20 statements is scored from 1 to 7 where 4 represents a neutral value; whereas the numbers from 1 to 7 stretch along a continuum from one extreme feeling to the opposite kind of feeling. The range of possible scores is 20–140; numerically higher scores indicate greater meaningfulness [82]. The PIL was translated into Norwegian by Bondevik [85] and has previously been used and validated with older adults showing good psychometric properties [52, 86‐88].

The data were analyzed by descriptive statistics using IBM SPSS version 25. The hypothesized relations between the latent constructs of NPIS, ST1, ST2 and PIL were tested through a structural equation model (SEM) using Stata 15.1 [89]. Using SEM accounts for random measurement error and the psychometric properties of the scales involved are more accurately derived. Missing data was low in frequency and were handled employing the listwise procedure. Research has indicated that Cronbach’s α cannot be generally relied on as an estimator of reliability [90]. Thus, composite reliability was estimated using the formula by Hair and colleagues [70], as shown in Table 2; a coefficient of ≥0.7 is good whereas 0.6 is considered fair for both reliability coefficients [77, 79, 82, 83]. For the correlation analyses, the p-value was set to 1%, whereas the estimates based in SEM-analyses commonly include both 5 and 1% p-values. Factor loadings below 0.32 are considered poor, ≥0.45 fair, ≥0.55 good, ≥0.63 very good, and above 0.71 are excellent [91].

The 188 participants’ ages ranged between 63 and 104 years, with a mean age of 87.4 years (SD = 8.57). With 8 missing, the effective sample was N = 180, consisting of 132 women (73.3%) and 48 men (26.7%). The mean age for women was 88.3 years (SD = 1.80) and 86 years (SD = 1.16) for the men. In total, 23 were married, 22 cohabitating, 1 was single, 106 were widows/widowers, and 36 were divorced. Table 1 displays the means (M), standard deviations (SD), Cronbach’s α, and Pearson’s correlation matrix for the latent study variables. The correlations between the measures were in the expected direction. Moderate correlations were found between the latent constructs (Table 1). The α-levels for the various measures indicate an acceptable level of inter-item consistency with Cronbach’s alpha coefficients ranging between 0.63–0.88 [97]; however, ST1 and ST2 comprised only three items each and consequently displayed a lower α coefficient of .63 (Table 1).

More specifically, a significant impact of nurse-patient-interaction on interpersonal (ST1), intrapersonal self-transcendence (ST2) and meaning-in-life was found, as well as a significant indirect relation to meaning-in-life, mediated by self-transcendence (ST1, ST2).

Our results showed that NPIS seems to have an outstanding position as a resource for ST1, ST2 and meaning-in-life in this vulnerable population. However, the influence on PIL was mediated by ST1 and ST2, indicating that to facilitate NH residents’ meaning-in-life, health professionals should support ST1 and ST2. Previous research underlines that NH residents’ perceived nurse-patient interaction is critical to their sense of dignity, self-respect, feelings of self-worth, meaning-in-life, and wellbeing [33, 36, 59, 98‐100]. NPIS covers aspects such as being taken seriously, being understood, respected and recognised as a unique person; all of which relate closely to a sense of dignity, as well as a sense of self-worth and self-respect. Resulting from their frailty, vulnerability and dependency, NH residents stress their need for connectedness or belongingness with the nurses [31‐33, 101, 102] highlighting the relationships to their caregivers as essential for wellbeing [103, 104]. Moreover, dignity significantly predicts older adults’ satisfaction with NH staff [38] and has been related to the nurse-patient relationship [33]. NPIS emerged as vital for self-transcendence in the present results as well as in the literature [57, 105‐108], and is found to boost global wellbeing [29, 48]. Consequently, nurse-patient interaction might influence on NH residents’ wellbeing; physically, emotionally, socially, functionally and spiritually.

Former studies have shown that NH residents emphasize the nurses’ attitudes, appearance and behaviours [108, 109], to act as a confirmation of their worthiness or worthlessness [31, 110, 111]. Connectedness in a trusting nurse-patient relationship reduce anxiety and depressive symptoms [112], and facilitate feelings of being valuable, safe and cared for. Such experiences provide meaning-in-life while facing the end of it. Along with competent pain and symptom management, the nature of the nurse-patient interaction in long-term NH care is crucial. Frustration, suffering, hopelessness, meaninglessness and depression result from not being attended to or treated with indifference, and thereby violating individuals’ sense of worthiness [113, 114] which negatively impact residents’ mental and physical symptoms or ailments [29, 112].

Possibly, older adults’ self-acceptance and thereby their sense of self-worth and value can be strengthened by active listening, recognizing and empowering the uniqueness of this person whose subjective experiences are taken seriously and respected, all of which supporting global wellbeing. If older adults’ in NHs feel understood, acknowledged, confirmed, and valued by their nurses, self-transcendence, and meaning will increase; consequently, gratefulness and wellbeing redoubles. However, the accomplishment of such a health-promoting nurse-patient interaction requires caregivers who are willing to and competent in engaging with their residents in different ways, such as learning about the person through life histories [115‐118], listening to their life experiences, wisdom, dreams and frightens. Professional nursing care is determined by the way nurses use their knowledge, attitudes, behaviour, and communication skills to appreciate the uniqueness of the person being cared for [118‐120].

The second research question aimed at investigating the inter-relationships between the constructs of inter- and intra-personal self-transcendence and meaning-in-life. The latter is often seen to be an explicit goal of NH care in Norway [29, 31, 121]. If looking at the total and indirect effects, interpersonal self-transcendence (ST1) showed a great influence on meaning-in-life; ST1 includes being involved with others and the society, having hobbies or interests and sharing one’s wisdom with others [50]. This finding is in line with a longitudinal study by Norberg and her colleagues (2015) of 190 oldest-old individuals in Sweden; self-transcendence was significantly related to wellbeing overall. Moreover, studies among NH residents in Taiwan and Norway have disclosed a negative association with depressive symptoms [122, 123] and a positive association with wellbeing [48]. Also, Hoshi [124] found a mediated effect of self-transcendence on the relationship between vulnerability and wellbeing in 105 Japanese hospitalized elders. Accordingly, facilitating these aspects among NH residents will increase meaning-in-life, and consequently wellbeing. Furthermore, intrapersonal self-transcendence (ST2) involving self-acceptance, adapting well to this specific life situation and one’s functionality, displayed a significant impact on meaning. Research reveals that self-transcendence reduces stress, enhances wellbeing, hope and meaning among several patient groups facing the vulnerability of serious, progressive disease including multiple sclerosis and systemic lupus erythematosus [125], older women living with rheumatoid arthritis [126] as well as among individuals with spinal muscular atrophy [127] and amyotrophic lateral sclerosis [128]. Also, self-transcendence has been used to design programs effective in promoting successful aging among older adults in the community [129, 130]. This indicates that supporting self-acceptance and adaption to one’s life situation will support meaning among older adults in NHs. The various aspects of self-transcendence seemed to be forceful vitalities, revealing significant influences on meaning-in-life, which represents an essential goal for NH care.