The aim of the present study was to explore 1) the influences of nurse-patient-interaction on self-transcendence (ST1, ST2) and meaning, and 2) the associations between these constructs in cognitively intact NH patients. In all, five hypotheses were tested and supported at the 5%-level. By doing so, we sought to contribute to a holistic nursing perspective of promoting wellbeing of older adults in NHs in three ways. First, research focusing on the dimensions of self-transcendence, meaning and nurse-patient interaction in NHs is scarce, and still in its infancy (81). The importance of these dimensions to older adults and NH patients has recently been identified (27, 34, 35, 82, 83). However, the fundamental relationships between nurse-patient-interaction, self-transcendence and meaning in NH residents are scarcely documented.
Second, by examining the associations between self-transcendence and meaning, new theoretical understanding and new approaches to nursing intervention bolstering wellbeing can emerge. By means of advanced statistical analyses, the present study suggests that nurse-patient-interaction directly and indirectly (mediated by self-transcendence) affects NH residents’ meaning-in-life. Accordingly, this study provides more specific insights about the mechanisms involved in the relationships between these vital dimensions, as well as on nurse-patient-interaction’s associations to them. Finally, the present study suggests that finding ways to enhance NH caregivers’ way of interacting and communicating with NH patients will significantly influence residents’ self-transcendence and perceived meaning. As self-transcendence and meaning are found to be intertwined with individuals’ health, QoL, and global wellbeing (84-86), nurse-patient-interaction might influence not only on NH residents’ emotional and social wellbeing, but also on their physical wellbeing (49, 87-91).
Nurse-patient-interaction relates to Self-Transcendence and Meaning.
More specifically, a significant impact of nurse-patient-interaction on interpersonal (ST1), intrapersonal self-transcendence (ST2) and meaning was found, as well as significant indirect relation to meaning-in-life, mediated by self-transcendence (ST1, ST2).
Nurse-patient interaction seems to have an outstanding position as a resource for self-transcendence and meaning in this vulnerable population. 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 (29, 32, 83, 92-95). Moreover, dignity significantly predicts older adults’ satisfaction with NH staff (34), and has been related to the nurse-patient relationship (29). Consequently, nurse-patient interaction involving time for listening with interest to NH residents, supporting self-acceptance, dignity, and adjustment, as well as meaningful engagements in hobbies and interests, emerge as vital for self-transcendence and meaning (35, 96-99), both of which found to boost global wellbeing (25, 49). Consequently, nurse-patient interaction influences on NH residents’ wellbeing; physically, emotionally, socially, functionally and spiritually.
Resulting from their frailty, vulnerability and dependency, NH residents stress their need for connectedness or belongingness with the nurses (27-29, 100, 101) highlighting the relationships to their caregivers as essential for wellbeing (102, 103). Correspondingly, NH residents characterise the nurse-patient interaction by the nurses’ attitudes, appearance and behaviours (99, 104), acting as a confirmation of their worthiness or worthlessness (95, 105, 106). Connectedness in a trusting nurse-patient relationship reduce anxiety and depressive symptoms (48), 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 (95, 107) which negatively impact residents’ mental and physical symptoms or plagues (25, 48).
Therefore, older adults’ self-worth and perceived 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 (104, 108, 109), 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 (110).
The interrelations between Self-Transcendence and Meaning
The second research question aimed at investigating the inter-relationships between the constructs of inter- and intra-personal self-transcendence and meaning. The latter is internationally most often seen to be an explicit goal of NH care. If looking at the total and indirect effects, interpersonal self-transcendence (ST1) showed a great influence on meaning; ST1 includes being involved with others and the society, having hobbies or interests and sharing one’s wisdom with others (51). Accordingly, facilitating these aspects among NH residents will increase meaning, 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 (ibid.). This indicates that supporting self-acceptance and adaption to this 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, which are defined as essential goals of NH care.
STRENGTHS AND LIMITATIONS
A notable strength of this research is the empirical examination of associations of various constructs that hardly have been tested previously. This study expands previous research by testing the associations between nurse-patient-interaction, self-transcendence and meaning in a NH population by means of structural equation modelling. Using SEM accounts for random measurement error and the psychometric properties of the scales involved are more accurately derived. The study builds on a strong theoretical foundation with use of scales demonstrating good psychometrical properties. Nevertheless, the present findings must be discussed with some limitations in mind.
The SEM-model tested comprises 17 variables, indicating a desirable sample size of minimum N=170 (76-78). In the present study listwise N was 180, which should be efficient. Nevertheless, a larger sample would significantly increase the statistical power of the tests. Information input to the SEM estimation increases both with more indicators per latent variable, and with more sample observations. However, in respect to sample size, the indicators for the latent constructs were reduced. Including more indicators per latent variable, and thus more sample observations, would have strengthened the composite reliability and the Cronbach’s α, but weakened the statistical power. Nevertheless, composite reliability was acceptable to good, with ST1 (three items), showing lowest reliability (α/ρc=.63).
The cross-sectional design of this study implies that we cannot make conclusions on the causality. The direction of the paths in the SEM-model tested cannot be defined with certainty; these paths might be reversed, or even contain feedback loops (78) entailing that the latent variable performs both as a predictor and an outcome of another single construct. Conversely, good fit does not mean that some alternative model might not fit better or be more accurate. However, no problem with discriminant and convergent validity was shown, indicating that the theoretical plausibility was good; all paths corresponded well to the theoretical basis, which support the findings. Also, the model revealed good factor loadings, good-acceptable composite reliability, and a good fit to the data, underpinning the present results.
The fact that the researchers visited the participants to help fill in the questionnaires might have introduced some bias into the respondents’ reporting. The scales used were part of a larger questionnaire comprising 120 items. Thus, frail, older NH residents might tire when completing the questionnaires, representing a possible bias to their reporting. To avoid such a bias, experienced researchers were carefully selected and trained in conducting the interviews following a standardized procedure including taking small breaks at specific points during the process. This procedure seemed to work out well.
IMPLICATIONS TO NURSING PRACTICE
A philosophical shift from care and protection of the physical body to a holistic and person-centred care based in a health promoting nurse-patient interaction would be beneficial (108, 109, 111). However, in general NH staff members are not well trained in nurse-patient-interaction, have limited time, and often NH caregivers perceive a lack of autonomy in their job performance, feeling that they are not respected and cared for by the management (112-115). To become a compassionate, attentive, and sensitive caregiver, one needs to be treated in a caring manner by the management as well as one’s colleagues (116, 117). To facilitate self-transcendence and meaning, a sound and health-promoting working culture should be facilitated and nurtured (118, 119). Both NH residents and NH staff will benefit from transforming the traditional institutional model of care into a responsive, patient-centred, homelike approach (111).
Educational nursing curricula should highlight and enable nurse-patient interaction as a resource for wellbeing, mediated by self-transcendence and meaning. Frequently long-term NH care includes residents with complex health problems. Average residing time in Norwegian NHs is about 1 year; many NH patients are on ‘the very edge of life’. This might be challenging to the caring staff as professionals and human beings. Providing high-quality nurse-patient interaction involves the need for further education and support for caregivers (120-122). Therefore, pedagogical approaches for advancing caregivers’ presence and confidence in health-promotion interaction should be upgraded and matured. Proper educational programs for developing interacting skills, including assessing and providing self-transcendence and meaning among older adults in NHs should be utilized and their effectiveness evaluated (123, 124).