Meaning in life of older persons: An integrative literature review

Abstract

Background:

Meaning in life of older persons is related to well-being, health, quality of life, and “good life.” However, the topic is scarcely covered in nursing literature.

Objective:

The aim of this integrative review for nurses is to synthesize knowledge from scholarly literature to provide insight into how older persons find meaning in life, what are influencing circumstances, and what are their sources of meaning. The review serves as a starting point for including meaning in life of older persons as a major concern for nurses in their role as health promoters.

Method:

An integrative review was performed including empirical research literature and texts on theoretical perspectives.

Ethical consideration:

Researches agree with ethical codes for research of universities in the Netherlands. For literature reviews no additional procedures are necessary according to Dutch law.

Findings:

A total of 44 heterogeneous texts were included in this review. Finding meaning in life is challenging for older persons. Older persons find meaning through a developmental process, by creating and discovering. Meaning in life is found in connection with self and others. Health, living together, high socio-economic status, social relations, activities, and religion are associated with experiencing meaning in later life. The main source of meaning in life of older persons is human relationships. Other sources of meaning in life vary by age and culture.

Discussion:

The review provides insight into meaning in life of older persons. There are several gaps in knowledge: literature is culturally biased, research on discovery of meaning and daily meaning is limited, and research from a nursing perspective is lacking. In practice, nurses have many opportunities to attune to meaning in life of patients. Further development of competence and training are needed.

Conclusion:

Keywords

Care of the older person literature review meaning in life nursing well-being

Introduction

Meaning in life of patients: a major concern for nurses

The recent World Health Organization (WHO) Report on Aging and Health defines healthy aging as “the process of developing and maintaining the functional ability that enables well-being.” Functional abilities are the attributes that enable persons to be, and do, what people have reason to value,¹ in other words, the abilities that provide well-being and meaning in life. Health, well-being, and meaning in life are related concepts^2

–6 that differ more or less according to their definitions. Huber et al.⁷ defined a conceptual framework for health, consisting of six dimensions: bodily functions, mental functions and perception, daily functioning, quality of life, social and societal participation, and the spiritual dimension, including meaning in life. Thus, meaning in life is a contributing component of health or well-being. Yet, meaning in life is also regarded as an important topic in ethical debates about what constitutes a good life.^8

–11 There are reasons to think that the main difference between well-known conceptualizations of subjective well-being¹² or psychological well-being¹³ on the one hand and meaning in life on the other is exactly the moral component in meaning in life.^8,14

Nurses have a broad view on health, as patients have. Both groups value all of Huber et al.’s⁷ dimensions of health equally, different from, for example, doctors and policymakers who generally emphasize bodily and mental functions. Meaning-in-life problems are considered core problems for nursing care,¹⁵ but the subject is mainly covered in psychology, anthropology, theology, and philosophy literature, leaving a gap of knowledge in the scientific nursing literature. Nurses have a major role to play in prevention and in maintaining health and well-being of patients.^15,16 Therefore, meaning in life of older persons is an important concern for nurses with regard to this role.^17,18 Supporting patients in maintaining, or attaining, meaning in life promotes well-being, health, quality of life, and the “good life” of patients. However, many nurses seem to stick to the physical aspect of care. They lack the attitude, skills, and knowledge to provide care related to meaning in life of patients.^19

–23 This integrative review provides nurses with a necessary knowledge base of meaning in life of older persons, as a starting point for including this major concern for nurses in their role as health promoters.

The concept of meaning in life

“What is the meaning of life in general?” “What does my life mean in the end?” “What is meaningful in my life at this moment?” These are the three questions every human being may ask now and then during his or her life. All three questions are about meaning, but they are referring to different, although interrelated, concepts. The first question is about cosmic meaning or meaning of life.²⁴ There are many different views on meaning of life,²⁵ for example, from a religious, existentialistic, or a humanistic point of view. The second and third questions at the start of this paragraph are on meaning in life, or personal meaning (in life). This is the concept we focus on in this review. Meaning in life is a comprehensive construct that is conceptualized in several ways. Brandstätter et al.²⁶ synthesized definitions of meaning in life from more than 50 authors:

Meaning in life is a highly individual perception, understanding or belief about one’s own life and activities and the value and importance ascribed to them. Meaning and purpose are related to terms like order, fairness, coherence, values, faith and belonging. Some authors differentiate between meaning and purpose, the latter being more goal or action-oriented, whereas others use meaning and purpose interchangeably. Meaning in life comprises the engagement in or commitment to goals or a life framework and the subsequent sense of fulfilment and satisfaction or lack thereof.

Meaning in life is thus a multidimensional construct. Derkx²⁷ distinguishes seven dimensions of meaning in life:⁸

Purpose. What are the goals and aims I strive for?

Moral values and justification. What are underlying values? When and why do I believe a goal is (morally) worthwhile?

Efficacy. Do I feel competent ? Do I experience that I can influence something, my own life?

Self-worth. Do I know myself valued for who I am and what I do? Self-worth is also influenced by being held in high esteem by others.

Comprehensibility. Do I sense coherence in life? Can I understand how events make sense in the larger story of my life?

Connectedness. Do I feel connected to others? Am I part of something valuable?

Excitement or wonder. What makes me curious? Do I feel engaged in something or someone? Is something important at stake for me?

As the questions in this paragraph illustrate, meaning in life encompasses a moral judgement, based on (personal and societal) values.^8,10,28,29 In personal meaning, we can distinguish two levels: global and situational meaning.^30,31 Global, ultimate, or existential meaning involves the “big questions in life” about the ultimate meaning of one’s individual life, such as “Who am I? What should I do (or have I done) with my life to make it worthwhile? Where do I belong ?”³² Situational meaning in life, meaning of the moment, or daily meaning refers to the attempt to understand the value and purpose of experiences on a day-to-day basis.^30,31 We will use the term “daily meaning.”

Some other constructs are overlapping with meaning in life. Psychological well-being as defined by Ryff and colleagues^6,13,33 is partly overlapping with the dimensions of Derkx of meaning in life. But, subjective well-being as defined by Diener is more related to satisfaction with life than with meaning in life.^12,34,35 The concepts of meaning in life and spirituality are partly overlapping as well. Although meaning in life is important in spirituality, spirituality is also connected to a transcendent experience: “a higher power,” “the sacred,” or “deepest reality,”^4,36

–39 which may not be necessary to experience meaning in life.

Meaning in life of older persons

Meaning in life during the later years is important, as in all stages in life.⁴⁰ It is associated with well-being,^4,41

–44 quality of life,^45,46 and living in place instead of in institutions.⁴⁷ Furthermore, meaning in life, especially the dimension purpose in life, reduces the risk of Alzheimer’s disease or mild cognitive impairment in aging persons⁴⁸ and even the mortality risk.^47,49
–51 Although later life may come with functional decline and personal losses, some authors argue that in this period, people are well capable of preserving meaning in life^52,53 or that old age is a period of spiritual growth^40,54,55 and even transcendence.⁵⁶ Indeed, some empirical research reveals that older adults still report a good level of meaning in life.^57,58 However, empirical findings are mixed. Other research indicates a decline in meaning in life in later years, especially in the domains purpose in life and personal growth.^{6,13,33,59

–62} In face of end of life, older persons may reflect on existential questions.⁵² Older persons can experience the search for meaning in this life stage as a source of distress which limits well-being.⁴¹ In the oldest old (85+ years), adverse events may lead to a decline in sense of coherence, one of the dimensions of meaning in life.⁶³ Clearly, different angles and measures show other perspectives: preserving meaning in life may be challenging in old age.

Aim of the review and research questions

We focus on the following three questions:

How do older persons find meaning in life?

What circumstances are associated with meaning in life in older persons?

What are sources of meaning in life for older persons?

Methods

We performed an integrative review of different types of scholarly literature. An integrative review is the only review method which allows the combination of different methodologies (quantitative and qualitative) and theoretical literature. This method is suitable for complex concepts, theories, or healthcare problems.⁶⁴ The review consisted of the five stages of Whittemore and Knafl:⁶⁴ problem identification, literature search, data evaluation, data analysis, and presentation. The problem identification is described in the introduction of this article.

Literature search and data evaluation

The search and evaluation of literature is summarized in Figure 1. Databases Scopus, CINAHL Complete, MEDLINE Complete, Nursing Allied Health Collection, Invert, and PiCarta were searched for relevant articles and book sections. The following search terms were used: (“meaning in life” OR “meaning of life” OR “searching for meaning”) AND (ag* OR old* OR eld* OR “later life”). The search was limited to English and Dutch literature and to relevant disciplines (psychology, nursing, social science, and humanities). There was no time limit applied. Catalogs of two university librariesⁱ were searched. Furthermore, we read literature suggested by experts. References of relevant articles and books were scrutinized for more literature (snowballing). The search resulted in 574 texts which were subsequently evaluated. Texts were included if they were about meaning in life of old persons, responding to one of the research questions and were written to academic standards: academic (peer reviewed) articles and book sections from scholarly literature. Exclusion criteria were as follows: articles about a specific medical condition, articles about meaning in life of younger persons only, articles that were about other constructs (resilience, spirituality, and well-being) without relation to meaning in life in the problem statement or abstract, articles about validation of instruments or about therapeutic interventions, and texts without scientific background. The included texts were very heterogeneous in type and discipline, varying from qualitative, quantitative research articles to academic textbooks and (philosophical) essays. Because of the heterogeneity of the texts, we did not apply an instrument to further assess the quality of the documents besides the inclusion and exclusion criteria. The aim of this review is not to provide evidence, but to give an overview of the scholarly literature.

Figure 1.

Flowchart of literature search and evaluation.

Analysis and synthesis

Eligible articles and book sections were read several times and summarized. Themes in and through the texts were analyzed using both the themes that were already in the included texts and themes that emerged from the data inductively. Subsequently, we combined themes to categories. Finally, we synthesized the findings in Figures 2 and 3 which give a more imaginative overview of the results of this review.

Figure 2.

River of finding meaning in later years (and legenda).

Figure 3.

Relations and sources of meaning in later life.

Results

In the review, 44 texts were included (Table 1). A total of 3 theoretical articles and 23 research articles were included. The 23 selected research articles incorporated qualitative methods (7), quantitative methods (13), and mixed methods (3). We also included 18 book (section)s. These offered mainly theoretical perspectives, although most were as well based on empirical research.

Table 1.

Included texts in the review.

Sources (44)	Author, year, reference number
Book (section) (18)	Baars, 2011;⁶⁵ Baars and Phillipson, 2014;⁶⁶ Bateson, 2010;⁵⁴ Bohlmeijer, 2007;⁶⁷ De Lange, 2008;⁶⁸ Derkx, 2011;⁸ Erikson and Erikson, 1998;⁴⁰ Greenstein and Holland, 2015;⁵⁵ Tromp, 2011;⁶⁹ Huizing and Tromp, 2015;⁷⁰ Marcoen, 2006;⁵² McAdams, 2012;⁷¹ Kaufman, 1986;⁷² Reker and Wong, 1988;⁷³ Reker and Wong, 2012;³¹ Tornstam, 2005;⁵⁶ Westerhof, 2010;⁷⁴ Westerhof et al., 2003⁷⁵
Research article (23)	Qualitative (7) Ebersole and De Paola, 1987;⁷⁶ De Paola and Ebersole, 1995;⁷⁷ Thomas et al., 1990;⁷⁸ Dwyer et al., 2008;¹⁸ Moremen, 2005;⁷⁹ Dittmann-Kohli, 1990;⁸⁰ Moore et al., 2006¹⁷ Quantitative (13) Alea and Bluck, 2013;⁸¹ Prager, 1996;⁸² Reker and Woo, 2011;⁵⁷ Fegg et al., 2007;⁸³ Bar-Tur et al., 2001;⁸⁴ Van Ranst and Marcoen, 1996;⁸⁵ Pinquart, 2002;⁵⁹ Phillips and Ferguson, 2013;⁸⁶ Krause, 2004;⁸⁷ Krause and Hayward, 2012;⁸⁸ Braam et al., 2006;⁸⁹ Clarke et al., 2000;⁶⁰ Haugan, 2013⁴⁶ Mixed methods (3): Takkinen and Ruoppila, 2001;⁹⁰ Westerhof and Dittmann-Kohli, 1997;⁹¹ Grouden and Jose, 2014⁹²
Theoretical article (3)	Carstensen, 2006;⁹³ Randall and Kenyon, 2004;⁹⁴ Scheibe and Carstensen, 2010⁹⁵

With regard to the first research question “How do old persons find meaning,” we identified the following categories and themes and in the texts:

Developmental process. Continuity, discontinuity, and old age as life stage;

Creation of meaning. Understand through reminiscence, engagement, learn through experience, and adaptation to negative events (coping styles and coping strategies);

Discovery of meaning. Silence and contemplation;

Daily meaning;

Connection. Self, others, something greater than oneself and society.

With regard to the second question “What circumstances are associated with meaning in life in older persons?” we identified one common theme in selected texts: associations with meaning in life.

With regard to the third question “What are sources of meaning for old persons?” we identified the following categories and themes:

Most important sources;

Differences in sources. Age differences and cultural differences.

We describe our findings regarding the three research questions in the next three paragraphs with the help of two figures.

How do older persons find meaning?

Finding meaning in later years is described in different ways. Based on the literature, we compare it with a winding river, finding its way through the scenery (Figure 2): changing and developing during quiet and turbulent times in connection with the environment. Several streams contribute to the flow of the river, as several processes may contribute to finding meaning in life. In this section, we elucidate the different processes which we found in the literature review. Many authors describe meaning in life as a developmental process, related to the continuity and discontinuity of life,^54,55,72,96 or related to a specific task which is set for a life stage.^40,56 Finding meaning in life is by most authors described as an active process of conscious choices: creation of meaning. In the comparison with a river, we imagine a flow or stream in the river, or even sometimes whirling water and accelerations. Yet, a river can also be smooth, almost unruffled, with suddenly bubbling something up to the surface. In comparison: finding meaning can as well emerge passively, as a discovery in contemplation.^31,94 Finding meaning during later years is thus a dynamic process. Meaning-finding comprises two levels: to the ultimate (global and existential) meaning in their whole life, as well a day-to-day level: daily meaning. Connection with self, others, or something greater than oneself and society is pivotal for finding meaning.

Developmental process

Meaning: continuity and discontinuity

Meaning is created both in continuity and discontinuity of life. Older persons generally perceive themselves as the same self as they have always been.⁷² During life, they relate to initial cultural pathways: societal norms and expectations how a life should be. These cultural pathways provide continuity in life and meaning.⁷² However, life is not always a gently flowing river. In every life, there are moments in which a person chooses, or is persuaded by circumstances, to continue a chosen path, or change direction: attaining or missing turning points like birth or death, marriage, or career. Bateson^54,96 articulates these discontinuities as moments in which people “compose” their life and meaning. In these discontinuities, people create a pattern of multiple activities and experiences, which expresses who they are and what they believe in. According to Bateson and Kaufman, meaning creation is a non-linear creative process. Bateson compares this process to a work of art or the preparation of a meal. Greenstein and Holland⁵⁵ stress that for leading meaningful lives, both continuity and development through crises (discontinuity) are important.

Meaning in old age as a life stage

Many authors describe aging as a specific life stage in which a person can grow to another (higher?) level of functioning. Among them, Erik Erikson is the most influential author. He defined eight stages in life, from infancy to old age. In each stage, one has to deal with a crisis with a specific theme. If one overcomes this crisis, certain strength can be developed, although the tension will remain. If not, a core pathology will develop as a result. For old age, the theme is as follows: integrity versus despair. By overcoming this crisis, a person will develop wisdom. If one is not able to deal with this crisis disdain will follow.⁴⁰ Erikson did not mention how to overcome the crisis in a life stage. Several other authors have based their theories on Erikson’s work.^54
–56 Tornstam⁵⁶ describes a Theory of Gerotranscendence. Through analyzing qualitative interviews with Swedish seniors, he identified developmental changes in three main dimensions: the cosmic dimension (e.g. connection to earlier generations, life and death, and mystery in life), the dimension self (e.g. self-transcendence, body-transcendence, and ego-integrity), and the dimension of social and personal relationships (e.g. changed meaning of relationships, modern asceticism, and everyday wisdom). Tornstam views gerotranscendence as a possibility: old age can be different from person to person. In empirical research, a gerotranscendent meaning pattern was found in 27%–32 % of aging populations.^57,85 In a later edition of Erik Erikson’s life stages model, Joan Erikson added a ninth stage, a stage leading to gerotranscendence.⁴⁰ Bateson⁵⁴ describes old age as a life phase of active wisdom, in which individuals have both consciousness of mortality and a greater commitment to life. All of the above-sketched developmental changes may not be limited to aging. Several authors stress that the changes may as well develop earlier during adulthood.^8,55,56,89

Creation of meaning

Understand through reminiscence

In the process of finding meaning, persons use cognition, motivation, and emotion. Especially reminiscence, commitment, and optimism are important for meaning creation in a life-time perspective: reminiscence to create meaning from the past, commitment (or engagement) to derive meaning from the present, and optimism to have a basis for meaning in the future.^31,73 Older persons reflect on their life: through an inner dialog of thoughts and memories, older persons recognize what is really meaningful to them and may find peace of mind.¹⁸ Older persons can tell others, or write, their life story, but more often short fragments or comments about their life serve as an opportunity for reflection.⁷⁰ Reflections on (events in) one’s life can provide an explanation for identity and destination in life.^67,69
–71 In the metaphor of the river: by looking back over of the river in the landscape, one can understand its course. Older persons can recognize connection between separate events, which can contribute to (re)construction of a coherent life story.^69,70,94 In later years reminiscence, evaluation of experiences, seldom leads to new directions for life. The goal rather is integration.⁷³ One study illustrates this: younger adults seem more likely to actively redirect their behavior based on reflections of their past than old adults.⁸¹

Engagement

During old age, it is important to stay committed to what one holds dear: going on with living one’s life.^17,65 Older persons can create meaning by engaging in (multiple) activities, which express who they are.⁵⁴ De Lange argues that it is important for aging persons to engage in concrete projects and ideals to realize one’s potentials, even in difficult circumstances. He considers self-realization as the ultimate goal in post-modern life, also during old age: to strive to become a person as close as possible to one’s ambition or dream.⁶⁸

Learn through experience: virtues

Greenstein and Holland⁵⁵ explain that older persons have experience in creating meaning in good and bad times. As a result, they develop multiple virtues or character strengths. The authors describe the growth of virtues as an oak, growing thicker and having more branches through years of favorable and unfavorable circumstances, or in our metaphor: many streams that make a strong river. They identified seven virtues of older persons from literature and qualitative research. Wisdom (Erikson and Bateson) and transcendence (Tornstam) are two of these virtues. The other five are as follows: humor, humanity and social justice, courage, temperance, and passing to the next generation.⁵⁵ Moore et al.¹⁷ mention other virtues, as a result of living through negative conditions: inner strength, determination, resourcefulness, and resilience.

Adaptation to negative events

Although many older persons experience meaning in old age, this life period is also characterized by physical and emotional losses and the ending of life, which all may challenge meaning in life.^{8,17,18,52,68,75,80} In our image of the river, we recognize here the turbulences and waterfalls, sometimes caused by obstructions like stones or radical changes, in the landscape. In qualitative research regarding meaning in life, older persons speak about their losses, their struggle to overcome fear and depressive feelings, and the way they create meaning in adversity.^18,79,80 Especially when negative circumstances have impact on a highly valued social role, for example, mother or friend, it is difficult to find new meaning in life.⁸⁷ Older persons adapt to the negative situation based on their coping styles and using different coping strategies:

Coping styles. The way persons adapt to negative events (coping) is not the same for every person. Van Ranst and Marcoen⁸⁵ describe three groups of older persons with a different meaning orientation: a self-preoccupied, a self-realization, and a self-transcendent group, deriving meaning from different sources.^31,57 The groups differ in coping style as well. The three groups apply all of the mentioned (six) coping styles, but differ in prevalent style. The self-realization group more often applies an instrumental coping style: they actively try to solve the situation or turn to others for help. The self-transcendent group more often applies a religious or existential coping style: they search support in religious believes, philosophical reflections, and search for meaning. The self-occupied group applies all styles less than the other two groups.⁸⁵

Coping strategies. Research reveals strategies that older persons apply to cope with negative events.

Older persons often turn to the present. They value more highly what is already given and may still be available. They hope for maintaining the positive instead of fearing the negative.^17,80 According to Carstensen and colleagues,^93,95 turning to the present is a consequence of limited time perspective of older persons and may as well occur in other circumstances where time is constrained.

Older persons change their goals in life. Instead of having high expectations of life realization and self-development, they have maintaining goals: they want to preserve who they are and how they live now.⁸⁰ Carstensen’s Socio-emotional Selectivity Theory explains that in conditions when time is constrained, the most salient goals will be those that can be realized in the short-term. The author suggests that socio-emotional goals are more likely to be attained in short time than goals related to new experiences and knowledge. As a consequence, goals from which persons derive emotional meaning prevail for older persons.⁹³

Older persons shift to a positive self-attribute, often compared to others. “I look still good for my age.” Older persons are even grateful for lack of disaster compared to others. They become more self-accepting.^17,80

In negative events, older persons search for values that provide them with meaning. Marcoen⁵² describes three value categories, earlier described by Frankl:²⁸ creative values engage persons in activities in work, nature, or art; experiential values inspire a contemplative and receptive approach to what life brings; attitudinal values foster a more attentive self-transcendent approach to life: if suffering and losses are inevitable, the only thing to change is one’s attitude to it. People can give meaning to a difficult situation by connecting it to something beyond oneself: mankind, God, or the universe.⁵²

Discovery of meaning

Silence and contemplation

Finding meaning in life is not only about creating and taking action but also about being open and receptive: through a contemplative attitude toward life, a person may discover what is meaningful in life.⁵² Some authors argue that in later years, older persons may have a greater need for silence or solitude.^56,94 It enables a person to be open to what life brings, such as special moments with others, precious memories, nature, a beautiful work of art, or music.⁹⁴ In the metaphor of the river, this may be a quiet spot in the river where suddenly something bubbles up to the unruffled surface.

Daily meaning

Some authors pay attention to daily meaning. Marcoen explains how older persons can express what gives meaning to them in their daily activities, however small. As an example, he describes an old lady who is a good hostess. Even when ill, she can still receive her guests in style.⁵² Dittmann-Kohli⁸⁰ describes in her research how older persons turn to the present and enjoy the good things and activities that are (still) available for them as gardening, music, thinking of their children, sunshine, or learn something new. Moore et al.¹⁷ describe similar findings: older persons can find meaning in ordinary daily things like dancing or walking. Daily meaning may be connected to another (existential) level. Tornstam⁵⁶ provides examples from his research how small commonplace things, such as nature or art, may have a significant meaning: “I see the trees, buds, and I see how the leaves are coming—I see myself in the leaves.”

Connection

Through the way individuals create or discover meaning, they connect with self, others, and with something greater than oneself.^17,52,79 Meaning-finding is not an individual matter, it is interacting with society.^{8,54,66,68,72,73,75,94} In our image of the river, the river does not exist on its own, but is part of nature, the universe, for example, connected with clouds, the earth, vegetation, and animals.

Self

Dittmann-Kohli⁸⁰ and Moore et al.¹⁷ observe a positive self-accepting attitude toward self in older persons. Tornstam’s⁵⁶ Gerotranscendence Theory indicates that aging can come with a shift from egoism to altruism (self-transcendence) and coming to wholeness (ego–integrity).

Others

For finding meaning in later life, relationships with others, such as family and friends, are important.¹⁷ If relatives have passed away, or contact is difficult, older persons may miss the togetherness with family.¹⁸ Older persons may derive meaning from social roles performed with others, such as being a good grandparent or being an esteemed volunteer.^17,87 When these roles are highly appreciated by them, stressors in these roles may erode meaning. Support from others can help to restore meaning in life.⁸⁷ However, giving help to others, can provide meaning as well.⁸⁸

Something greater than oneself

Religion can be very important for older persons. A connection to God can be meaning-giving and help to transcend suffering¹⁷ and self.⁸⁵ However, without believing in God, old persons may as well experience being connected to something bigger: cosmic transcendence. According to Tornstam’s⁵⁶ Gerotranscendence Theory, cosmic transcendence is one of the changes that may come with aging: through later life, older persons may develop a broad view on knowledge and perceive an understanding beyond words. They may reflect on the mystery of life and death and of being part of the universe. Older persons may get another perception of life time, realizing their position in the chain of generations and passing on important values to the future. Braam et al.⁸⁹ demonstrated in empirical research that this cosmic transcendence is more pronounced in non-religious persons, in persons older than 75 years and in persons who were widowed.

Society

Values of persons, and as a consequence, their meaning in life, are embedded in the society they live in.^{8,54,66,68,72,73,75,94} There are important differences between, and within, cultures.⁶⁶ Older persons may have values that are rooted in a society which does not exist anymore and find it difficult to understand actual values.⁵² The socio-economic situation in a society has an impact on values as well and, as a consequence, on meaning of life.^75,91

Circumstances that are associated with meaning in life of older persons

The results of questions 2 and 3 are summarized in Figure 3. Meaning in life of older persons is related to the circumstances they live in. Pinquart conducted a meta-analysis of 70 studies regarding the correlates of purpose in life with other measures. Purpose in life of older persons is one of the dimensions of meaning in life (see section “The concept of meaning in life”). The meta-analysis included more than 23,000 respondents.⁵⁹ Health is an important issue: bad health in older persons is associated with less purpose in life,^59,60 although the decline is not as strong as could be expected considering the health conditions.⁵⁹ Authors suggest that meaning in life may provide a framework for coping with suffering. Later studies find as well higher scores in meaning in life in persons with better physical and emotional functioning.^46,88 Other factors associated with higher purpose in life scores of older persons are as follows: higher education, higher income,^59,60 good relational quality, social integration, high everyday competence, employment, and marriage.⁵⁹ Meaning in life is also positively associated with self-compassion,⁸⁶ helping others, and religiousness.⁸⁸

Sources of meaning in life of older persons

Human relationships are most important source

The main source of meaning in life of older persons is human relationships, especially the relationship with family.^{76,77,82

–85,92} Older persons who lived in a nursing home considered the relationship with nursing staff a source of meaning as well, although they experienced the communication as limited.¹⁸ Due to different methodology and different populations in the research literature, other common sources were not found, although many sources were mentioned, such as health,^76,77,83,92 pleasant activities in work, or leisure time,^{57,76,77,83,90,92} self-realization,^57,85 preserving values,^82,85 spirituality, and religion.^57,83 Reker and Wong⁷³ postulated that persons who have a broad range of values will have a greater variety of sources for meaning. If a source of meaning is hindered by physical or other limitations, there may be enough sources left to ensure meaning in life.

Differences in sources

Since values of persons in societies develop during the lifespan, sources for meaning evolve as well. Sources of meaning in later life are related to age,^{74,82
–84,91,92} culture,^{57,78,82,84,85,91} and cognitive functioning.⁹⁰

Age differences in sources in meaning in life

Although studies are heterogeneous, we recognize a rough pattern: older persons derive less meaning from their individual achievements, related to work and other activities than younger adults.^74,82,83,91 Instead, they experience more meaning from relatedness to others and to something greater than themselves: family, societal issues, traditions, nature, religion, and spirituality,^{74,82
–84,91,92} although they reflect less on self and their relations with others.^74,91

Cultural differences in sources in meaning in life

Older persons in different cultures derive meaning from different sources because they are embedded in other cultural pathways.⁷² Some studies illustrate these cultural differences: English and Indian men showed different metaphors related to their meaning in life: English men showed the metaphor of “a loner” in nature, while the Indian men showed a building metaphor embedded in social structure.⁷⁸ Zairean and Dutch older persons differed mainly in two domains of meaning in life: death and dying, and health and illness.⁹¹ Between Arabs and Jews were many, but small, differences in meaning in life sources: Arabs derived more meaning from materialistic concerns and communal values, while Jews derived more meaning in life from self-development and leisure.⁸⁴ Even between Western cultures, there may be differences, although few.⁸³ Furthermore, there are groups in society with different meaning orientation(s), among older persons as well, deriving meaning from different sources, for example, an individualistic, collectivistic, or transcendent meaning orientation.^57,85,97

Discussion

Discussion of methodology

The method of an integrative review proved appropriate for this subject, because texts on this subject are very heterogenic, ranging from philosophical texts through in-depth qualitative studies to quantitative and mixed methods designs. Strength of this methodology is that it enabled us to identify major themes in the vast amount of literature, find relevant answers to our review questions, and synthesize a large number of heterogenic sources into an overarching image. However, the heterogeneity of the texts limits the validity of results as well. We used general search terms to find literature, such as “meaning in life” and “age.” Although we reviewed many papers, the search terms may have limited our results. Meaning in life is a comprehensive construct, with many dimensions. A search strategy that included all these dimensions could have provided more information.

Discussion of results

Meaning in life is, during the lifespan, related to health, well-being, and “the good life.”^{2

–7,9,10,98,99} In later life, meaning in life is important as well: it is associated with well-being^4,41

–44 and quality of life.⁴⁵ However, to find meaning in later life may be challenging. Up till now, nursing literature scarcely covered the subject of meaning in life of patients. In our review, we identified texts from several disciplines, but only one study had a healthcare context.¹⁸ Our review provides a broad insight into the way aging persons find meaning in life, which is highly relevant for nurses.

Several authors describe finding meaning in life as part of a developmental process. Meaning can be found by creating and discovering. However, most literature is focused on creating meaning as an active purposeful process, especially as an adaptation to negative events. Only a few texts described the discovery of meaning through contemplation and silence. This may be a consequence of the origin of the literature, mainly from western countries, resulting in cultural bias. Another gap in literature is daily meaning: finding meaning in daily experiences. This is a relevant subject for nurses who interact with older persons on a daily basis. Meaning in life is connection with self, others, and with something greater than oneself. However, many studies offer only an individual perspective and lack insight into how meaning is created through relationships. Some authors, and the WHO¹, criticize society (and science): aging has been problematized as an individual concern, leading to ageism.⁶⁶ In today’s western society, much emphasis is placed on independence of older persons, neglecting the interconnectedness between people during whole life.^54,66,100 Post-modern societies have omitted to provide older persons with satisfying social roles through which they can find meaning.^54,66,68 Persons who are in a bad health condition, live alone, and have a low socio-economic status are socially isolated, have no activities, or non-religious older persons are at risk for loss of meaning in life.^59,60,88 Some of these influencing factors may be inevitable with reaching a (high) age: aging comes with health problems and with losses, for example, of persons who are dear to us. However, the determinants may open up possibilities for improvement: In old age, new relations can be found, improvement of health status may be possible, new inspiration can be found, activities from volunteering or helping others may promote meaning, and even for socio-economic problems solutions may be possible. The most important source of meaning in life of older persons found in existing research literature is human relationships. Sources of meaning in life of older persons differ according to age and culture, and cognitive functioning. The cross-sectional design in many studies concerning age differences in meaning in life is a limitation: the results could as well be due to cohort differences instead of age differences. Longitudinal design is needed to reveal whether there is a developmental change through aging. Another issue is related to cultural differences: Westerhof & Dittmann-Kohli argue that cultural differences may not always be the cause of different sources of meaning among different cultures. Socio-economic situation may have a larger impact.⁹¹ As said before, most of the studies in this review were done in western countries, resulting in cultural bias.

Nurses have a major role to play in prevention and in maintaining health and well-being of patients.^15,16 Meaning in life of older persons is an important concern for nurses with regard to this role:^17,18 Supporting older patients in maintaining, or attaining, meaning in life should promote well-being, health, quality of life, and “good life” of patients. However, many nurses seem to stick to the physical aspect of care. They lack the attitude, knowledge, and skills to provide care related to meaning in life of patients.^19

–23 Nurses interact, through their work, on a daily basis with older patients, in everyday life and at special life events. They have the opportunity to build strong connections with them.¹⁷ Especially in homecare, where nurses enter in the private life-world of patients, opportunities exist for incorporating meaning in life of patients in care.

From a moral point of view, “good care” encompasses: attentiveness, responsibility, competence, and responsiveness.¹⁰⁰ First, nurses and policymakers in healthcare should acknowledge that meaning in life is an important need for (older) people (attentiveness). We hope this review contributes to this attentiveness. A next step can be that nurses recognize meaning in life in daily practice as well. Second, nurses have to explore what their responsibility can be. Meaning in life is mentioned in the core competency profile of (Dutch) nurses. However, there is ample professional literature on this subject. To what extent can nurses be responsible for the care related to meaning in life of patients? And what is the role of other professionals like spiritual counselors? In the Netherlands, guidelines were developed for palliative care,¹⁰¹ but this is not the same as care for old persons. Third, nurses need the competence to recognize meaning in life of patients in their daily work setting. Nurse–patient interaction is crucial for care that is attuned to meaning in life of patients.¹⁰² To address meaning-in-life concerns, nurses need to develop attitudes and skills like openness, wondering, empathy, presence, communication skills, and reflectiveness.^{16,20,22,23,102,103} Responsive care is care that is provided according to the value system of the other.¹⁰⁰ Maybe this fourth and last is the most difficult ethic element to achieve. Can nurses perceive the “otherness” of old persons and provide the care that is “good” according to the patient, instead of care that meets the own standards. Training of nurses is needed to develop attentiveness, competencies, and responsiveness regarding meaning in life of old patients. Spiritual counselors could have an important role in training and further exploration of the responsibilities of nurses in this regard.

Implications for practice and research

Insights from this review may be a starting point for nurses to include meaning in life of patients in their work and contribute as so to “good life” of patients. Nurses should be aware of, and attentive to, patients related to

Personal values and meaning orientation;

Cultural and socio- economic context;

Personal coping style related to adverse events;

Virtues, or character strengths, of patients;

The life story of a patient and how the patient reflects on that;

Daily meaning in ordinary things;

Preserving of meaningful activities and roles;

Preserving health in order to maintain meaningful activities;

Connectedness to others (family and friends) of older patients and maybe to something bigger than oneself.

This attentiveness is especially needed for patients who are at risk for decline in meaning: those with a deteriorating health condition, living alone, with a low socio-economic status, social isolation, or non-religious persons.^59,61,88 Besides attentiveness, nurses should develop competencies to attune to meaning in life of old persons.

A need for more (empirical) research evolves from this literature review. Important questions are as follows: What is meaning in life of older persons who receive healthcare? How do they experience daily meaning in life? Do they find meaning by creation and/or discovery? Other questions explore the role of the nurse: What are situations in daily care in which meaning in life is involved; how can nurses attune to meaning in life of old persons; can training help nurses to develop competencies to address meaning in life of patients?

Conclusion

Older persons find meaning in life through different processes. Meaning in life is associated with the circumstances old persons live in. Human relationship is the major source of meaning. The knowledge from this review is a necessary knowledge base for nurses to include meaning in life of older patients in care, in order to further develop the nursing role of health promoter. The results of this review suggest that there are many opportunities for nurses to address meaning in life of older patients in their daily work that need to be explored, followed by further research.

Footnotes

Notes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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