Nurse-Patient Interaction and Self-Transcendence: Assets for a Meaningful Life in Nursing Home Residents?

doi:10.21203/rs.2.13599/v1

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Nurse-Patient Interaction and Self-Transcendence: Assets for a Meaningful Life in Nursing Home Residents?

https://doi.org/10.21203/rs.2.13599/v1

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published 07 May, 2020

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Background. Today, we face a shift to an older population worldwide and its consequences; a noteworthy part of older adults will need 24-hours nursing home care at the end of life. Finding new and alternative approaches to increase wellbeing among nursing home residents is highly warranted. Knowledge about nurse-patient-interaction, self-transcendence and meaning-in-life seems vital in order to guide clinical practice in how to best and efficiently boost wellbeing among older adults in nursing homes.

Methods In a cross-sectional design, 188 (92% response rate) out of 204 long-term NH patients representing 27 NHs responded to the nurse-patient interaction, self-transcendence, and the purpose-and-meaning-in-life scales. Inclusion criteria were: (1) municipality authority’s decision of long-term NH care; (2) residential time three months or longer; (3) informed consent competency recognized by responsible doctor and nurse; and (4) capable of being interviewed. The hypothesized relations (five hypotheses) between the latent constructs were tested by means of structural equation modelling (SEM) using Stata 15.1.

Results The SEM-model yielded a good fit (χ2=146.824, p=0.021, df=114, χ2 /df=1.29 RMSEA=0.040, p-close 0.811, CFI=0.97, TLI=0.96, and SRMR=0.063), showing significant relationships between the constructs of nurse-patient interaction, inter- and intra-personal self-transcendence and meaning-in-life. Nurse-patient interaction significantly relates with both inter- and intra-personal self-transcendence and meaning in NH patients. Self-transcendence revealed a fundamental influence on perceived meaning, while nurse-patient interaction demonstrated a significant influence on meaning, mediated by self-transcendence

Conclusion According to the rapidly growing number of people over 65 in the world, and the growing segment of people 80-100, the present results are significant in their suggestions that nurse-patient-interaction is a crucial resource in relation to nursing home residents’ wellbeing. Knowledge of how nurse-patient-interaction, self-transcendence and meaning relate to each other among older adults in NHs is important for researchers, nurses, caregivers, nursing educators, and clinicians. Health professionals in nursing homes should learn how to competently use the nurse-patient interaction as a health promoting asset for self-transcendence, meaning and thus well-being. Nursing home nurses should be given more time for interacting with the residents, continuity and mutuality in nurse-patient relationships should be prioritized and facilitated.

Geriatrics & Gerontology

interpersonal and intrapersonal self-transcendence

meaning-in-life

nursing

nurse-patient interaction

nursing home

older adults

wellbeing

The world’s population is rapidly aging. In 1950, there were 205 million persons aged 60+ in the world; by 2050, this group will reach 2 billion. The document An Aging World (1) highlights a shift to an older population worldwide and its consequences: the population aged 80+ grows faster than any younger age group, and those aged 100+ are growing fastest (2). Increased age is followed by an increased incidence of functional and chronic comorbidities and diverse disabilities (3). Hence, a noteworthy part of older adults will need 24-hours nursing home (NH) care at the end of life. The NH population is characterized by high age, frailty, mortality, disability, powerlessness, dependency, vulnerability, poor general health and a high symptom burden (4, 5).

Accordingly, moving to a NH results from numerous losses, illnesses, disabilities, loss of functions and social relations, and facing the end-of-life, all of which increases an individual’s vulnerability and distress. In particular, loneliness and depression are identified as risks to the emotional well-being of older people (6, 7). Consequently, this population is at a high risk of declined meaning and quality-of-life (QoL) (8), and finding new and alternative approaches to increase wellbeing among older adults in NHs is highly warranted.

Spirituality has been perceived as a major resource for well-being in late life (9), particularly among frail and vulnerable older people such as NH residents (10). As an essential aspect of spirituality, meaning is commonly addressed in the nursing literature (11), and is seen to be of particular importance to wellbeing and QoL in older adults (9, 12-14), in NHs (15-19), and at the end of life (16, 20-23). The literature presents a trichotomy of meaning comprising of three facets: (1) coherence, which means a sense of comprehensibility, (2) purpose, directing a sense of core goals, aims, direction in life, and (3) significance, implying a sense of life’s inherent value and having a life worth living (24). Recent research implies that meaning is important for maintaining not only mental/emotional wellbeing, but physical and functional wellbeing as well (5, 25). A novel study demonstrates humans’ holistic existence showing that life meaning as well as loneliness affected older adults’ brain function (26). These findings advance our understanding of phenomenon such as meaning and loneliness which operate not only by emotions or experiences but represent physical states in human’s brains (ibid.). Loneliness and meaning-in-life are reflected in the intrinsic network architecture of the brain.

Social relationships imbue life with meaning, whereas loneliness diminishes one's sense of meaning-in-life. The ‘search for meaning and finding answers’, ‘feelings of support and trust’, ‘a perspective beyond death’ (10), along with a sense of belonging (27-30) are fundamental to perceived meaning, spiritual-emotional wellbeing (31, 32) and life satisfaction (33) in older adults. Perceived meaning predicts life satisfaction among NH residents (34), and is crucial to the experience of dignity in this population (35).

The concept of self-transcendence addresses an enhanced understanding of wellbeing in late adulthood (36) and among different vulnerable populations, such as NH residents, cancer and aids patients as well as homeless individuals (ibid.). In accordance with human developmental theory, emphasizing maturity as the developmental task in later life (37), self-transcendence is defined as a “characteristic of developmental maturity wherein there is enhanced awareness of the environment and an orientation toward broader life perspectives” (36). Self-transcendence allows the individual to overcome personality concerns, and search for new perspectives, meaning and wellbeing. Self-transcendence is seen to be a powerful coping mechanism involving adaption to physical, emotional and spiritual distress, leading to personal transformation and maturity, wellbeing and QoL. Expressions of self-transcendence are positively related to mental/emotional wellbeing, health and functioning in adults confronting personal mortality because of advanced age and/or enduring illness (38-43). Connectedness is the core of self-transcendence (36).

The experience of connectedness for older people in long-term care settings is linked with QoL and successful ageing (44). Fundamental prerequisites of connectedness for older people are: self-awareness, meaningful relationships with family and friends, involvement in meaningful activities and connections with wider society. However, barriers to these prerequisites are evident for many residents in long-term care settings (44). Largely, the nurse-patient relationship represents the main resource for connectedness while staying in a NH. Therefore, the nurse-patient interaction might be crucial for well-being in NHs. Accordingly, perceived nurse-patient interaction has shown to influence on meaning (32, 45), self-transcendence (46) and hope (47), as well as anxiety and depression (48) among cognitively intact NH patients. Moreover, self-transcendence and meaning have demonstrated significant relations with both physical, emotional, social, functional (25, 49) and spiritual (50) wellbeing among cognitively intact NH residents, indicating that enhancing self-transcendence and meaning positively influences on all aspects of wellbeing.

To summarise, the literature suggests that self-transcendence, meaning and nurse-patient interaction are vital to wellbeing among older adults in NHs. Thus, we expected meaning and self-transcendence to be correlated, and that nurse-patient interaction would influence on both constructs. To get further insights into how self-transcendence and meaning relate with each other, as well as with nurse-patient interaction, this study investigates the associations between nurse-patient interaction, self-transcendence and meaning. Such knowledge can guide clinical practice in how to best and efficiently boost wellbeing among older adults in NHs.

Aims and hypotheses

The present study was therefore designed to investigate the relationships between nurse-patient-interaction, self-transcendence and meaning among cognitively intact NH patients by means of structural equation modelling (SEM). The research questions were: (1) Does the nurse-patient-interaction affect inter- and intra-personal self-transcendence and meaning in cognitively intact NH residents? and (2) How do the constructs of interpersonal (ST1) and intrapersonal (ST2) self-transcendence and meaning interrelate?

Recent psychometric studies revealed a two-factor construct (ST1, ST2) showing the best fit for self-transcendence (51), while nurse-patient interaction (46) was found to be a one-dimensional construct. Thus, the two-factor construct of self-transcendence along with the one-factor models of purpose-and-meaning (PIL) (52) and nurse-patient-interaction (46) were applied in the present study. Based on the theoretical and empirical knowledge of nurse-patient-interaction, self-transcendence (ST) and meaning-in-life, the following hypotheses were formulated:

Hypothesis 1 (H1): Nurse-patient-interaction positively affects ST1 (inter-personal ST).
Hypothesis 2 (H2): Nurse-patient-interaction positively affects ST2 (Intra-personal ST).
Hypothesis 3 (H3): Nurse-patient-interaction positively affects meaning-in-life (PIL).
Hypothesis 4 (H4): ST1 positively affects PIL.
Hypothesis 5 (H5): ST2 positively affects PIL.

A hypothesized structural equation model (SEM) with bases in existing theory and previous empirical research was tested. Figure 1 shows the hypotheses representing the relationships implying the influences between the latent constructs in the model. Significant associations have been demonstrated between nurse-patient-interaction and self-transcendence (46) and meaning (32). H1-H3 in Figure 1 reflects the hypothesized associations between nurse-patient interaction, self-transcendence and meaning. ST1 and ST2 involve aspects such as having interests and hobbies, involving and caring for others, adapting well and self-acceptance; hence, these dimensions were hypothesized to associate with purpose-and-meaning (PIL), shown as hypotheses H4 and H5 in Figure 1.

Participants

The total sample consisted of 188 (92%) out of 204 long-term NH patients representing 27 NHs, located in two small and one large urban municipality in Mid-Norway (N=88, JoLNH), along with a large urban municipality in Western Norway (N=100, ordinary NHs). Participants ages ranged between 63-104 years, with a mean age of 87.4 years (SD = 8.57). The sample consisted of 132 women (73.33%) and 48 men (26.67%); 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 37 were divorced. Long-term NH care was defined as 24-hour care; short-term care patients, rehabilitations patients, and patients diagnosed with dementia were not included. Inclusion criteria were as follows: (1) municipality authority’s decision of long-term NH care, (2) residential time 3 months or more, (3) informed consent competency recognized by responsible doctor and nurse, and (4) capable of taking adequately part in an interview situation.

Procedures

A cross-sectional design was employed, and data were collected during 2017 and 2018. Approval was obtained by the Regional Committee for Medical and Health Research Ethics in Norway (ref.nr 2014/2000/REK Central) as well as by the Management Units at the 27 NHs. Each participant 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 identical professional background (RN, MSc, trained and experienced in communication with 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. The scales used in this study were part of a larger questionnaire comprising 120 items including sociodemographic data; thus, small breaks at specific points during the interview process were adopted to avoid tiring the participants.

Measures

The Nurse-Patient-Interaction Scale (NPIS) was developed in Norway to assess vital characteristics of NH residents’ experiences of the nurse-patient-interaction (46). 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. The NPIS comprises 14 items identifying essential relational and caring qualities stressed in the nursing literature. 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 (46). In this study, Cronbach’s α=.88 (Table 2) and composite reliability=.89 Table 3) of the NPIS construct were good.

Self-transcendence was assessed by items from the Self-Transcendence Scale (STS), developed to identify experiences characteristic of later life and reflecting expanded boundaries of the self (36, 53). The STS comprises 15 items rated on a 4-point Likert-type scale from 1.0 (not at all) to 4.0 (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 (51), which is used for the purpose of 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 growing older’ and ‘Adjusting well to my present life situation’. In former studies, Cronbach’s α for the total scale ranges between 0.80-0.88 (54-56). In this study, Cronbach’s alpha/Composite reliability for ST1 and ST2 (both including 3 items) were 0.63/0.63 and 0.78/0.80, respectively.

The Purpose-in-Life-Test (PIL) contains 20 items. Based in Frankl’s logotherapy the PIL was designed to be a general tool assessing purpose and meaning-in-life (57-59), and has been commonly used for this purpose (60-62). In the following, the shorter notion ‘meaning’ is used. 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 1-7 where 4 represents a neutral value; whereas the numbers from 1-7 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 (57). The PIL was translated into Norwegian by Bondevik (63), and has previously been used and validated with older adults in Norway up to 104 years old (64-69). In this study, Cronbach’s α and composite reliability were .71 and 0.64, respectively.

Statistical Analysis

The data were analyzed by descriptive statistics using IBM SPSS version 25. The hypothesized relations between the latent constructs of nurse-patient interaction, ST1, ST2 and meaning-in-life were tested by means of a structural equation model (SEM) using Stata 15.1 (70). Using SEM accounts for random measurement error and the psychometric properties of the scales involved are more accurately derived. Since the standard errors are estimated under non-normality, the Satorra-Bentler-scaled chi-square statistic was applied as a goodness-of-fit statistic, which is the correct asymptotic mean even under non-normality (71). In line with the rule of thumb of conventional cut-off criteria (72) the following fit indices were used to evaluate model fit: chi-square (χ²)-a small χ² and a non-significant p-value corresponds to good fit (73), the root mean square error of approximation (RMSEA) and the standardized root mean square residual (SRMS) with values below 0.05 indicating good fit, whereas values smaller than 0.08 are interpreted as acceptable (72, 74). Also, the comparative fit index (CFI) and the Tucker Lewis Index (TLI) were used with an acceptable fit at 0.95/0.90 respectively, and good fit at 0.95/0.97 and above (ibid.). Missing data was low in frequency and were handled by means of the listwise procedure.

Before examining the hypothesized relationships, the measurement models were tested by confirmatory factor analysis (CFA) using Stata 15.1 (70). A sufficient power analysis is dependent on the ratio between the total number of variables (error measurements, observed and latent variables) and the sample size; one observed variable per 10 participants is given as a rule of thumb (75-77). Thus, in order to reduce model complexity, the measurement model for nurse-patient-interaction was tested by CFA reducing the indicator variables to six (χ²=8.850, p=0.451, df=9, RMSEA=0.000, p-close 0.748, CFI=1.00, TLI=1.00, SRMR=0.021), while meaning-in-life (χ2=5.066, p=0.408, df=5, RMSEA=0.008, p-close 0.643, CFI=0.999, TLI=0.999, SRMR=0.030), were represented by five indicators. Furthermore, for the ST-construct (χ²=3.886, p=0.867, df=8, RMSEA=0.000, p-close 0.961, CFI=1.00, TLI=1.00, SRMR=0.022) the three-indicator rule (78) was applied, including three indicators for ST1 and ST2, respectively, (totally six indicators).

Descriptive Analysis

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 (79); however, ST1 comprised only three items and consequently displayed a lower α coefficient of .63. A substantial body of research has indicated that Cronbach’s α cannot be generally relied on as an estimator of reliability (80). Thus, composite reliability was estimated by means of the formula by Hair and colleagues (78), as shown in Table 2 – displaying fair to good estimates.

Table 1. Mean, Cronbach’s alpha, and correlation coefficients for the study variables
Construct	Mean (sd)	Items	Cronbach’s Alpha	¹ST1	²ST2	³PIL	⁵NPIS
ST1	2.54 (.711)	3	0.63	1
ST2	3.20 (.675)	3	0.78	.26**	1
PIL	4.11 (.613)	5	0.71	.37**	.27**	1
NPIS	7.98 (1.91)	6	0.88	.30**	.33**	.19**	1
Note: ** p-value < 0.01, *p-value < 0.05. ¹ST1= Interpersonal self-transcendence. ²ST2=Intrapersonal self-transcendence. ³PIL=Purpose-in-life. ⁴NPIS=Nurse-Patient-Interaction

Model testing and model fit

SEM-analyses

To investigate how the nurse-patient-interaction related to ST1, ST2 and meaning, as well as how the dependent latent variables were inter-related, a SEM-model comprising 17 indicators was estimated. For scaling the variances of the dependent latent variables were set at 1. Table 2 lists the measurement models with factor loadings, t-values, R²-values, and composite reliability. All factor loadings were significant, showing fair to good estimates ranging from 0.41 to 0.89, with R²-values between 0.22 and 0.80.

Table 2. Measurement models for Nurse-Patient-Interaction (NPIS), Self-transcendence (ST1 and ST2) and Purpose in Life (PIL).
Items	Parameter	Stata Estimate¹		t-value²	R²
NPIS Nurse-Patient-Interaction
NPIS3	λx3,1		0.80	24.80*	0.64
NPIS4	λx4,1		0.73	18.16*	0.53
NPIS5	λx5,1		0.77	21.23*	0.58
NPIS11	λx11,1		0.79	23.79*	0.63
NPIS13	λx13,1		0.84	28.89*	0.70
NPIS14	λx14,1		0.52	08.90*	0.27

ST-1 Interpersonal Self-Transcendence
ST1	λx1,2		0.56	7.64*	0.31
ST3	λx3,2		0.56	7.94*	0.31
ST6	λx6,2		0.72	10.81*	0.52

ST-2 Intrapersonal Self-Transcendence
ST2	λx2,3		0.54	8.89*	0.29
ST4	λx4,3		0.87	20.32*	0.76
ST5	λx5,3		0.82	18.49*	0.67

PIL Meaning and Purpose-in-life
PIL5	λy11,2		0.48	6.46*	0.23
PIL8	λy11,2		0.49	6.51*	0.24
PIL10	λy12,2		0.53	7.23*	0.29
PIL18	λy11,2		0.54	7.76*	0.30
PIL20	λy13,2		0.54	7.60*	0.29

ρ_cJOL	ρ_c		0.80
ρ_cST-1	ρ_c		0.63
ρ_cST-2	ρ_c		0.80
ρ_cPIL	ρ_c		0.64
ρ_cNPIS	ρ_c		0.89
Note. *Significant at the 1 % level. ¹Completely Standardized Factor Loadings. ²The Bentler-Raykov squared multiple correlation coefficient = R². Listwise, N=180, 17 items included. ³Composite reliability 𝝆_C =

Figure 2 portrays the SEM-model showing the completely standardized factor loadings, Bentler-Raykov squared multiple correlation coefficients (R²), structural regression coefficients, composite reliability for the latent constructs (ρ_c) and the fit indices.

The SEM-model yielded a good fit to the data (χ²=146.824, p=0.021, df=114, χ²/df=1.29 RMSEA=0.040, p-close 0.811, CFI=0.97, TLI=0.96, and SRMR=0.063). Table 3 shows the standardized regression coefficients of the directional relationships, whereas Table 4 lists the total and indirect effects between the latent constructs in the SEM-model. As hypothesized, the directional paths from nurse-patient-interaction to ST1 (γ1,1=0.41) and ST2 (γ2,1=0.43) were significant. Furthermore, the direct relationships (Table 4) between the dependent variables displayed significant values from ST1 to PIL (β1,3=0.56) and from ST2 to PIL (β2,3=0.30). Looking at the indirect influences (Table 4), nurse-patient-interaction revealed a significant indirect effect on PIL, mediated by ST1 and ST2 (0.34, total effect 0.37*) (Table 4). Thus, the hypotheses H1-H5 were supported.

Table 3. SEM-model. Direct and indirect relationships between Nurse-Patient-Interaction (NPIS), Self-Transcendence (T1 and ST2) and Meaning-in-life (PIL).
Construct	Parameter
Direct relationships between NPIS and the dependent latent constructs NPIS
ST1	γ 1,1	0.41
	t-value	3.59*
ST2	γ 1,2	0.43
	t-value	4.37*
PIL	γ 1,3	0.031
	t-value	0.27
Direct relationships between the dependent latent constructs
		PIL
ST1	β 1,2	0.60
	t-value	3.47*
ST2	β 3,5	0.24
	t-value	2.10*
Note. *Significant at the 5% level. Listwise N=180. ¹Gamma (γ); standardized regression coefficients representing directional relationships between Nurse-Patient-Interaction (NPIS) and ST1 (Interpersonal Self-Transcendence), ST2 (Intrapersonal self-transcendence) and PIL (Purpose in life). ²Beta (β); standardized regression coefficients representing directional relationships between ST1, ST2 and PIL.

Table 4. SEM-Model. Total¹ and Indirect² effects on the latent study variables.
Total Effects¹ of Nurse-Patient-Interaction Indirect Effects²of Nurse-Patient-Interaction
	NPIS⁷		NPIS⁷ - - 0.34 3.13*
ST1³	0.41
	3.59*
ST2⁴	0.43
	4.37**
PIL ⁶	0.37
	3.13*
Total effects between the dependent variables of ST1, ST2 and PIL
	ST1	ST2
ST1	-	-
	-
ST2	-	-
	-
PIL	0.60	0.24
	3.47*	2.05*
Note. *Significant at the 5% level. Listwise N=180. ¹Total Effects represent the total influence of the explanatory variable Nurse-Patient-Interaction (direct + indirect effects). ²Indirect effects represent the influence of Nurse-Patient-Interaction mediated by intervening variables (mediators). ³ST1=Interpersonal Self-Transcendence. ⁴ST2=Intrapersonal Self-Transcendence. ⁵PIL=Meaning and Purpose-in-Life. ⁶NPIS=Nurse-Patient-Interaction. Standardized Stata estimates and t-values.

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/ρ_c=.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).

According to the rapidly growing number of people over 65 in the world, and the growing segment of people 80-100, the present results are significant in their suggestions that nurse-patient-interaction is a crucial resource in relation to NH residents’ wellbeing. Knowledge of how nurse-patient-interaction, self-transcendence and meaning relate to each other among older adults in NHs is important for researchers, nurses, caregivers, nursing educators, and clinicians.

This study indicates that nurse-patient-interaction relates to NH patients’ inter- and intrapersonal self-transcendence and meaning. Accordingly, the nature of nurse-patient-interaction involving NH caregivers’ interaction, attitudes, and behaviours are essential to wellbeing in NHs. Therefore, advancing nurse-patient-interaction to facilitate NH patients’ sense of worthiness, self-acceptance, adjustment, and connectedness seems obligatory, as these might foster patients’ self-transcendence and meaning. NH staff nurses should be given more time for interacting with their residents, continuity and mutuality in nurse-patient relationships should be prioritized and facilitated.

CFI = Comparative Fit Index

NH = nursing home

QoL = quality of life

NPIS = Nurse-Patient-Interaction Scale

PIL = Purpose-in-life test

RN = registered nurse

RMSEA = Root Mean Square Error of Approximation

SEM = Structural Equation Modelling

SD = Standard Deviation

SRMS = Standardized Root Mean Square Residual

ST = Self-Transcendence

ST1 = Inter-personal Self-Transcendence

ST2 = Intra-personal Self-Transcendence

STS = Self-Transcendence Scale

TLI = Tucker Lewis Index

Ethics approval and consent to participate

Ethical approval was obtained by the Regional Committee for Medical and Health Research Ethics in Norway (ref.nr 2014/2000/REK Central) as well as by the Management Units at the 27 nursing homes which participated in this study.

Consent to publish

Each author participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to Norwegian Act on medical and health research (ACT 2008–06-20 no. 44):§ 38 but are available from the corresponding author on reasonable request. All raw data is in Norwegian.

Competing interests

The authors declare no conflict of interest.

Funding

This study received funding from the Norwegian Council of Research

Authors' Contributions

All authors made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data, and were involved in drafting the manuscript or revising it critically for important intellectual content.

Acknowledgements

The authors want to acknowledge the nursing home residents who voluntarily participated in this study.

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Nurse-Patient Interaction and Self-Transcendence: Assets for a Meaningful Life in Nursing Home Residents?

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