Meaningfulness among frail older adults receiving home-based care in Finland

Summary

Meaningfulness is a fundamental aspect in the promotion of frail older adults’ health and well-being. From a salutogenic point of view, meaningfulness is a vital component of a sense of coherence (SOC), since having a strong SOC aids toward assembling the resources needed to cope with stressors and manage tensions with success. In order to respond to the challenges of population aging and the need to enable frail older adults to live at home for as long as possible, it is important to explore their meaningfulness in the context of home-based care. A salutogenic framework was used to study meaningfulness. The aim was to explore what promotes meaningfulness among frail older adults. The study uses a hermeneutical approach and has a qualitative design. In total, 17 frail older adults were interviewed. The data were analyzed by content analysis. The results uncovered four themes that the respondents considered important in enhancing meaningfulness in daily life: home care personnel, outdoor activities and green spaces, cultural activities and spirituality. Our study revealed the important role of home care personnel as a resource in promoting meaningfulness in the context of home-based care. Hence, this group should be given sufficient resources, knowledge and competence for enabling meaningfulness and thus a SOC amongst frail older adults.

INTRODUCTION

From a salutogenic point of view, meaningfulness is a vital feature of a sense of coherence (SOC) and is defined as an individuals’ experience of that life has emotional meaning and that challenges are viewed as worth investing in and engaging in Antonovsky (Antonovsky, 1979, 1987). In the promotion of frail older adults’ health and well-being meaningfulness becomes essential, since having a strong SOC aids toward assembling the resources needed to cope with stressors and manage tensions with success. Accordingly, meaningfulness could also be seen as especially important in the context of home-based care for frail older adults considering the emphasis on that older people should live at home as long as possible (Kröger and Bagnato, 2017). Whereas the policy of ‘aging in place’, that is continuing to live in your own home despite increased dependence, is seen as a sustainable social and healthcare alternative, an increased understanding of the resources needed in order to cope with challenges that frail older adults in home-based care often meet is still required. Additionally, research on the salutogenic model in older adults, especially the highly aged and those with lower health-status, has thus far been scarce (Quehenberger and Krajic, 2017). Quehenberger and Krajic (Quehenberger and Krajic, 2017) also state that studies that have explicitly used and scientifically tested salutogenic principles and concepts among community dwelling older adults are very limited. In this study, meaningfulness of frail older adults is explored in order to grasp how it can enhance their wellbeing and health. We use the definition of meaningfulness according to Antonovsky (Antonovsky, 1979, 1987), thus applying a health promotion perspective (since this is closely connected to the health promoting perspective.) However, earlier research often tend to use the concepts of meaningfulness and meaning in life (MIL) interchangeably (Martela, 2017), and in the following section, we included research focusing on both meaningfulness and MIL.

MIL refers to understanding the meaningfulness of a particular human life (Martela, 2017). MIL has also been defined as an intrinsic or personally important goal. It implies having a purpose and making every effort to reach these goals in life as well as making sense of one’s existence (Emmons, 2005). This makes people see life as worth living and develop an outlook on things that will support them to direct their course in the world (Dhanjal, 2019). MIL is also described as an understanding or belief regarding one’s life and actions and the worth and significance ascribed to them (Brandstätter et al., 2012). Furthermore, MIL encompasses the commitment to aims or a life structure and the consequent sense of contentment and satisfaction or lack thereof (Brandstätter et al., 2012). Overall, research on MIL of older adults has been limited (Hupkens et al., 2018), even though a few studies on this topic have recently been conducted (Dury et al., 2018; Duppen et al., 2019; Hupkens et al., 2019). According to an integrative review on MIL in old age, MIL is found through a developmental process, that is, meaning can be found by creating and discovering things in relation to oneself and others (Hupkens et al., 2018). In the study of Duppen et al. (Duppen et al., 2019), MIL amongst frail older adults was explored through seven different needs identified in previous literature: purpose, value/moral worth, efficacy, self-worth, coherence, connectedness and excitement. Their results showed that all of these needs could be distinguished in their study, but also that a fulfillment of all needs was not a prerequisite for experiencing MIL and that the lack of one need could be compensated by another (Duppen et al., 2019).

Furthermore, previous research implies that home care personnel can be important in enhancing meaningfulness for older adults. Hupkens et al. (Hupkens et al., 2019) state that MIL among older adults, for instance, can be realized with the help of the nurse–patient relationship so that the nurse can help the patient identify resources for meaningfulness in daily life. The potential of home care personnel as supporting meaningfulness among frail older adults is also corroborated by research which reveals that human relationships are the strongest source of meaning in later life (Hupkens et al., 2018) even if these relationships are only superficial (Stillman and Lamberg, 2013; O’Donnell et al., 2014).

On the one hand, Dury et al. (Dury et al., 2018) found that older adults could experience high levels of MIL despite being frail. On the other hand, Duppen et al. (Duppen et al., 2019) found that some respondents experienced a loss or lack of MIL due to older age or a decrease in their social network. Another study also revealed that older adults can experience the quest for MIL in the old age-stage as distressing, which limits wellbeing (Steger et al., 2009), indicating that further examination is warranted. In this study, we use the salutogenic framework to assess meaningfulness as a health promoting resource. The theoretical model by Antonovsky will help to identify positive resources supportive for frail older adults when they face different health-related challenges in the aging process. Earlier research concerning frail older adults has generally focused on risk factors for the cause of disease and illbeing (Nieboer and Cramm, 2018; Dahlberg et al., 2021), resources contributing to enhancing frail older adults’ wellbeing has so far received scant attention. The aim is therefore to explore what promotes meaningfulness among frail older adults. Next, the theoretical model will be discussed and examined in a gerontological context.

THEORETICAL FRAMEWORK

The central features of the salutogenic development are orientation toward problem solving, and the ability to use the resources on hand on the movements toward health and well-being (Lindström and Eriksson, 2005). A SOC reflects the ability to combine people’s skills in order to assess and understand a current situation they are involved in, as well as to discover a meaning in order to move in a direction that exhibits health promotion; and own the capability to do it. The capability thus here, according to Antonovsky, encompasses comprehensibility, meaningfulness and manageability (Antonovsky, 1979, 1987). Comprehensibility concerns the extent to which a person recognizes stimuli in front of them, that originates from internal and external environments. A high score for a person on the sense of comprehensibility assumes that future stimuli on their path will be predictable, well-organized and precise (Lindström and Eriksson, 2005). Manageability implies the degree to which a person believes that the resources available for them are satisfactory to be able to face the requirements created by the stimuli that assails them (Lindström and Eriksson, 2005). Meaningfulness is the motivational part of the SOC, and concerns the length to which a person experiences that life has emotional meaning and makes sense, that problems and demands are worth investing vitality in, and that such problems and demands are precious enough to commit and engage in. Thus, problems and demands are viewed as challenges rather than burdens. In this study, the primary focus is on meaningfulness, which according to Antonovsky (Antonovsky, 1979, 1987), is the most important aspect in strengthening SOC. The other key concept concerns the resources available to make a movement possible toward health (Lindström and Eriksson, 2005). Antonovsky used the term ‘general resistance resources’ (GRRs) that people could find, as resources, both in a material and non-material sense.

Wiesmann and Hannich (Wiesmann and Hannich, 2008) point out that a SOC can, from a gerontological perspective, be seen as a positive resource in the changes that are involved in the aging process. Wiesmann and Hannich (Wiesmann and Hannich, 2014) stress that if an individual is capable of understanding changes in physical health that are related to age as comprehensible, manageable and meaningful, or is capable of counteracting these losses by positively valuating other areas in life, then the individual might perhaps be able to maintain a high level of wellbeing and psychological health.

METHODOLOGY

Approach and design

This study was part of a larger project where the intention was to explore the quality of life, daily activities and loneliness amongst frail older adults through interviews. Nonetheless, meaningfulness emerged to a large extent in the utterances from the participants and was therefore explored inductively that will be explained in more detail in the analysis section. An interview guide was used in this project which placed focus on quality of life, social and cultural activities, experiences of loneliness and wellbeing. Three different themes were included in the interview guide: (i) activities and interests (previous and current), (ii) social contacts (previous and current) and (iii) experiences of loneliness, requests and opportunities for the development of these themes. The interview guide contained semi-structured questions to ensure that all the themes were covered during the interviews. The researchers were conscientious about raising different questions and themes in an open and neutral way so as not to influence the responses of the participants.

Context, participants and interview process

The interview data in this qualitative study was gathered through face-to-face interviews. To manage interviewer variation, the interviewers gathered to discuss the interview methodology before conducting the interviews. Seventeen participants (12 females and 5 males) aged from 72 to 95 years and in different life situations agreed to participate, whereby data saturation was considered to be achieved. The participants lived in one municipality in Finland, and all received community-based home care from the municipality. The inclusion criteria for study participation was being aged 65 years or older, being able and willing to give informed consent, and wanting to share experiences. The participants were chosen in collaboration with the home-care staff in the municipality where the study was conducted.

Initially, the home care personnel provided eligible participants with oral and written information concerning the aims of the study. The participants who decided to participate were subsequently asked to provide their telephone number and provide written consent on a form that was collected by the home care personnel on behalf of the researchers. The participants were later contacted by the researchers by telephone. The interviews were made in the older adults’ own homes. Each interview was digitally taped and transcribed and was 30–90 min long. The participants approved their participation in the study, as well as the data storage and handling for research purposes when providing their informed consent. The participants were informed about the aims of the study, withdrawal of consent, publication intent as well as confidentiality, both orally and in writing.

Data analysis

The text was subsequently analyzed using a latent content analysis approach inspired by Graneheim and Lundman (Graneheim and Lundman, 2004) and through a hermeneutical approach according to Gadamer (see Table 1). The hermeneutical approach [according to Gadamer (Gadamer, 2004)] was needed in order to interpret the data and to be able to compare the parts against the whole understanding of the text. The data material was approached, read and analyzed with an openness (an inductive approach and close reading), and subsequently interpreted using a reading ‘between the lines’ approach to uncover any hidden meaning (the latent part of the analysis). Meaningfulness, rather than the components of comprehensibility or manageability, emerged in the texts when reading between the lines in the latent phase. We also found results concerning comprehensibility and manageability; however, data on meaningfulness tended to be rich, with the potential for further analyses. The researchers reflected on the meaning uncovered according to the hermeneutical approach used in this study (a deductive approach was used in this part). The pre-understanding was formulated and repeated during the interpretation in order to ensure it was properly mastered and would not misdirect the interpretation. In this light, the pre-understanding could be contested. Subsequently, it became possible to compare the interpretation and understanding. At this stage, the main themes were discussed by the researchers and the findings (reflect against the whole) were verified. This procedure and hermeneutical movement of interpreting and understanding was conducted several times. All three researchers joined to discuss and generate the final analysis.

Table 1:

Example of the data analyze process

Meaning unit	Condensed meaning unit	Code	Main theme
‘They ask how I feel, and I tell them, and if it has been a worse night then I also tell about that as well [laughs]. And I get to ask them how it’s going with the kids…and stuff [laughs] yes…that is how it is [it’s all give and take]’.	Meaningfulness through home care personnel’s interaction	Interaction	Home care personnel for enhancing meaningfulness
‘I get to look at the forest and people moving around outside … and in the summer it’s like that, I can go where I want and take the rollator with me … I love it! … I want to do things my own way … that's just how it is … I have always liked flowers and birds since my childhood…’	Meaningfulness through visiting the forest and spending time outside Meaningfulness to be able to go outside on one own and enjoy flowers and birds	Spending time outdoors	Outdoor activities and green spaces for enhancing meaningfulness
‘I've also danced… but I can't do that now because of my heart [heart disease]… but I like music … I danced folk dances when I was young … it could be interesting to watch when someone performs folk dancing …’	Meaningfulness through watching others perform folk dances	Cultural activities	Cultural activities for enhancing meaningfulness
‘When I go to bed in the evenings, I read my evening prayer. I think that's good … and I always read for my husband as well. And I think that's the best thing … because if I fall asleep then, say if I would pass away, then I have done what I could. And I think that is so meaningful, because that’s something that should not be forgotten as well’.	Meaningfulness through spiritual rituals for participants for example through saying prayers in the evening for oneself and for her partner	Spiritual rituals	Spirituality for enhancing meaningfulness

Ethical considerations

This study is ethically defensible since it might help frail older adults understand their own meaningfulness in daily life and how this is related to wellbeing. The study is conducted by allowing the participants to express their meaningfulness in words, and so provides support in enhancing their understanding of their wellbeing and health. Permission to conduct the study was given by the municipality where the participants lived. It was important for the researchers that the study respected and treated the participants with dignity. This study followed the guidelines provided by the Finnish Advisory Board on Research Ethics (2012).

FINDINGS

The results uncovered four main themes, which are depicted and discussed in the following. This study is based on the understanding that frail older adults’ experiences of meaningfulness simultaneously provide them with wellbeing.

Home care personnel for enhancing meaningfulness

The first theme consisted of social contacts from home care personnel as an important source for enhancing meaningfulness. The older adults had a request for social contacts, for example from the home care personnel. Sometimes this social contact was the only contact during the day or even for a whole week. The social contact provided by the home care personnel thus had a major impact on the frail older adults’ experiences of meaningfulness as one participant bears witness to:

‘…it is probably very good [when the home care personnel comes], we discuss… what happens in the country and in the village and… everything possible… It is probably that without them I would be pretty… well now, I dońt know. That [that the home care personnel will come] is pretty important’. (P13)

For most older adults, in this study, the home care personnel was seen as a positive element and social interaction in everyday life which they waited for, and from whom they could also gain help with various chores. The home care personnel was described as friendly and pleasant and the encounter was both give and take, as one participant expresses:

‘They ask how I feel, and I tell them, and if it has been a worse night then I also tell about that as well [laughs]. And I get to ask them how it’s going with the kids…and stuff [laughs] yes…that is how it is [it’s all give and take]’. (P7)

The frail older adults often felt confirmed by the home care personnel, even when visits were brief, since the visits provided them with a sense of security and strength as well as ‘cheered them up’, which thus brought meaningfulness. Furthermore, the visits provided by the home care personnel were characterized as a natural and close connection. In this sense, the relationship was positive, light-hearted and the frail older adults were thus able to share their daily life in an ‘artificial’ way. Moreover, the frail older adults trusted the home care personnel so that they could tell stories to them and confide in them.

‘Yes, that's the kind of contact you get with those people … and the fact that they come in and they feel at home … and they come, like, it feels like they come home … and they say “good morning” and they say that “now we are here and now we’ll see how are things with you here today” … Yes it’s natural… and then when they have done what they should do … they say that “now we are ready for today and now you have a good day then” … so they kind of finish it too … and not only go out and be like that but … yes … they seem like part of the family…’ (P12)

The frail older adults especially appreciated those members of the home care personnel who were extra friendly and happy and showed that they cared about them, for example by asking how they felt. Another participant expressed how valuable the encounters were to her:

‘I think that these people are probably worth their weight in gold … oh yes … what if they didn’t exist … so yes - I don't know I … so these people gave a certain kind of power … they cheered us up and they are positive … you get some relief from the pressure and have a little fun with someone… to share with them … you get to be seen … because they also ask how I am doing and … even though they were actually here to take care of my husband…’ (P12)

The frail older adults stated that it also felt meaningful for them when the home care personnel ‘would go the extra mile’ and did something extra for those who were not directly included in the home care work, such as bring in the newspaper or allow the elderly person to get help with getting out in the garden or picking berries from the garden, which the elderly person longed to eat but had not been able to pick.

Some of the older adults however mentioned that they did not get much out of the home care visits, because the staff was often in a hurry or because they themselves did not need any additional social exchange, for example if they lived with their partner or were not interested in social contacts. Other participants stated that they felt that the personnel would need more time, or more staff would be needed. Time was seen as important in order for the frail older adults to be able to experience the encounter as a natural, or ‘human-to-human’, meeting, and not as a ‘human-to-professional’ meeting. One participant uttered:

‘To give a little longer time to the [home care personnel] who come … more staff [would also be needed]… because it is important that we [the elderly] get to feel like ordinary people… that it [should feel like] it is a person I have [here at home], not an official …’ (P16)

Outdoor activities and green spaces for enhancing meaningfulness

The second main theme concerned activities for older adults that could enhance meaningfulness in daily life, such as spending time in green spaces outdoors, that is sitting outside or taking a walk. This had a positive effect on them and brought meaningfulness.

Fresh air is also mentioned as something that the older adults appreciate a lot. The home care personnel also served as a support to help the older adults to get out and walk, as stated by one of the participants:

‘Yes … and last fall I asked [the home care nurse] if no one could start coming out with me. So then a girl came and she was really good … she came with me on certain days … so I got to go out … with her’. (P17)

Several of the older adults see the opportunity to be out in the nature as a health benefit that provides meaningfulness and substance to life:

‘I get to look at the forest and people moving around outside … and in the summer it’s like that, I can go where I want and take the rollator with me … I love it! … I want to do things my own way … that's just how it is … I have always liked flowers and birds since my childhood…’ (P17)

The older adults also mentioned gardening in green spaces as an activity that provides meaningfulness in daily life, such as taking care of flowers or bushes. Older adults would like to spend time in the garden, especially in the summer. One participant said the following: ‘Well in the summers, the best thing is to go out and potter around with the flowers …’ (P7)

There was also a request to travel together with a like-minded age group, and then you wish, for example, for trips to various beautiful gardens because it is experienced as a meaningful activity. Older people also want to get out to the archipelago, to the beach or to their summer cottage out on an islet in the archipelago. What was highly valued among participants was health, since it was mentioned that it enabled them to engage in different activities.

Cultural activities for enhancing meaningfulness

The third main theme concerned the request from older adults for activities, events and gatherings of a cultural kind, which was seen as providing meaningfulness in daily life. According to the older adults that participated in this study, there was a strong request for taking part in cultural happenings such as handicraft courses, painting courses, different social happenings such as music-events or dance events. Some mentioned that it would be meaningful if they would get to visit concerts or participate in other events arranged for older adults. One participant stated: ‘…but I would probably agree to come to everything… with a garden theme or song… or just to meet people… I’m positive about it…’ (P7).

One participant mentioned that his interest was music and dance, so watching dancing would bring meaningfulness to his daily life, even though his health would not allow him to dance himself. This is how he states this:

‘I've also danced… but I can't do that now because of my heart [heart disease]… but I like music … I danced folk dances when I was young … it could be interesting to watch when someone performs folk dancing …’ (P14)

Many of the older adults felt that they were satisfied with everyday life as it was … and didn’t think that they needed more meaningful activities. Another participant also said she was satisfied with life as it is but was also not opposed to spending time with several in a group. She said: ‘Well, I’m as satisfied with the way I have it… but if I could sometimes meet with some like-minded people… it would not be so bad …’ (P4).

Another mentioned that she didn't have much time left for socializing because she watches TV a lot. She stated the following: ‘And I’m glued to the TV every night … several hours … But the fact is that I’m pretty passive myself when I sit and watch TV’ (P16)

One participant mentioned that she didn’t think it would feel appropriate or meaningful to suddenly start to become active when you are old if you hadn’t been before. She thinks that the happiest and most meaningful thing as an elderly adult, is that you can continue to be as you have always been, and have the opportunity to continue your life as it has been and as you have enjoyed it.

Spirituality for enhancing meaningfulness

The fourth main theme consisted of spirituality for meaningfulness in daily life. The participants maintained that spirituality was an important aspect in their daily life, and it did not necessarily involve social contact, but it was still experienced as meaningful, and thus as a source for renewed strength. One participant stated the following: …yes that’s how it is… it [faith] gives you strength and protection… I’m not afraid of anything… (P10). Another participant mentioned the following:

‘When I go to bed in the evenings, I read my evening prayer. I think that's good … and I always read for my husband as well. And I think that's the best thing … because if I fall asleep then, say if I would pass away, then I have done what I could. And I think that is so meaningful, because that’s something that should not be forgotten as well’. (P8)

For some frail older adults, it wasn’t necessary to have any simultaneous social encounter in the spirituality that provided daily meaningfulness. An important element of spirituality was communion through spiritual songs, for example. This communion provides a protection to the older adults that was experienced as very meaningful. One participant also mentioned that he kept his faith at home and that it was meaningful. He stated:

When you get lonely you put on Channel 10 [a religious channel on TV] you are safe again… and it is as if you would get enlightenment inside, and you …hear …the wonderful spiritual songs and then you can listen and lie down and sleep … yes you get calm … and really relaxed … you feel that you are not alone anymore… and it is just as if you would be in the choir yourself … (P9)

Being a believer and active in the church was also mentioned as an important source of meaningfulness, where the social context was also part of the spiritual community. One participant expressed this:

‘The practical help I get from the children, but it is the spiritual community on Sundays that gives me the most emotional support … when I get to meet them in the church …’ (P11)

One participant mentioned that his dream today would be to visit a free church, and that this serves as a positive aspect of everyday life that gives meaning when he thinks about it, even though he may not be able at that time or on that day to have his dream fulfilled.

DISCUSSION

This study aimed at understanding what promotes meaningfulness among frail older adults. The study originated from the idea that aspects enhancing meaningfulness for frail older adults can also strengthen their health and wellbeing. Our results serve as a valuable complement to previous research on frail older adults’ MIL [e.g. (Duppen et al., 2019)], by applying an inductive approach to the study of meaningfulness as one important health promoting resource, that strengthens the possibility of aging well despite frailty. In line with the study of Duppen et al. (Duppen et al., 2019), who against a dominant background of negative health or adverse outcomes in frailty research focused on the experiences of MIL for socially frail community-dwelling older adults, our study also focused on frail older adults, but by exploring meaningfulness from a salutogenic, health promoting perspective where health is seen as a resource. Consequently, this study also contributes to the so far limited qualitative research within this field using the salutogenic framework. The four main themes found in this study (the home care personnel, outdoor activities and green spaces, cultural activities and spirituality) can be seen as supportive for frail older adults when they face different challenges.

The first main theme showed that the home care personnel played a significant role in enhancing meaningfulness for frail older adults. The fact that the home care personnel was experienced as being such a vital source for the enhancement of meaningfulness among frail older adults in this study might be influenced partly because some of those interviewed stated that sometimes the home care personnel were their only contact during a day or during the whole week. In a literature review, Hupkens et al. (Hupkens et al., 2018) likewise found that the main source for meaning amongst older adults was human relationships involving not only contacts with family and friends but also, as seen in our study, contacts with professionals. This study thus reveals that other relationships than family and friends can provide meaningfulness in daily life for frail older adults. Our study findings are also in line with Hupkens et al. (Hupkens et al., 2019), who discuss the opportunities home care nurses have in terms of integrating patient care with MIL by providing personal care.

The encounter with the home care personnel in this study was described as enhancing the frail older adults’ meaningfulness, since it was described by the participants as both receiving and giving, which can be compared to a reciprocal relationship (Kihlgren et al., 2015). This somewhat diverges from Baumeister (Baumeister, 2013), who found that meaning amongst older adults concerned an act of giving, not of receiving. We thus argue that home care personnel should nurture a reciprocal relationship where the frail older adults experience a social exchange where they can actively give and take in a relationship, which is likely to enhance meaningfulness.

This study revealed that the meaningfulness provided by the home care personnel took place in different dimensions; in a shallower dimension, for example, as the frail older adults experienced it as meaningful when the home care personnel tidied up the homes nicely. There was also a deeper connection that was mentioned, that is, a connection to the home care personnel who (when the connection was strong) made the frail older adults experience their contact with the personnel as very meaningful. These findings correlate with earlier research, which indicates that the residents’ meaningfulness is enhanced when the maintenance of close relationships, emotional support and provision of opportunities for purposeful activities are supported (Drageset et al., 2008). Earlier studies have also found that if the connection to the home care personnel is constituted by closeness and if the older adults feel that the home care personnel enjoy coming to see them or if they see them as members of their own family, then this is a positive experience for the older adults (Equality and Human Rights Commission Research report series, report 79, 2011). However, we want to underline that frail older adults want different depths on the contacts, which explains why it is particularly important to remember to care with ethical sensitivity, person-centeredness and perceptiveness (cf. Hemberg and Bergdahl, 2019). Pennbrant and Karlsson (Pennbrant and Karlsson, 2019) stress that older adults’ wellbeing and self-esteem can be strengthened by healthcare professionals eliciting a sense of MIL through diverse forums for connectedness.

The second main theme demonstrated that outdoor activities and green spaces are important for promoting meaningfulness. Bodman (Bodman, 2019) describes nature as a source for health and wellbeing, which can be compared to the findings in this study which shows that older adults feel that outdoor activities and green spaces provide them with meaningfulness. This source for meaningfulness was something that many frail older adults could enjoy themselves, without help, but sometimes they explained that their frailty meant that they needed a support person to be able to enjoy outdoor activities or green spaces. Monma et al. (Monma et al., 2017) also state that an increase in SOC of older adults is related to physical activities, indicating the importance of maintaining physical activities despite frailty. This study also indicated that it can be troublesome to perform activities outside the home due to frailty in old age. In line with this, Haak et al. (Haak et al., 2007) similarly point out that meaningful activities can be performed in the homes of very old adults. They stress that the home becomes the obvious locus for participation as the older adults’ health weakens. We argue that the home care personnel, in this sense, become an important ‘agent’ for enabling the support of activities in the homes of frail older adults, since this study revealed that the home care personnel have a key role to play and were positively viewed as enhancing meaningfulness, according to the frail older adults themselves. This would mean, for example, that home care personnel, in a person-centered way, can help frail older adults to discover what they enjoy and feel and provide them with meaningfulness by focusing on the resources on hand, as well as by supporting them with the activity found, and not on frailty as hindering participation in meaningful activities. This is in line with the salutogenic approach presented by Lindström and Eriksson (Lindström and Eriksson, 2005), who also mention that there is an orientation toward solving problems, and the ability to use the resources on hand in order to reach toward health. They mean that SOC helps individuals to manage tension, reflect about external and internal resources and to mobilize them in order to attain effective coping and find solutions in a health promoting way (Eriksson and Lindström, 2005). In this study, meaningfulness was also found to be a strong ‘motivational driving force’ and thus an important aspect for home care personnel to focus on in order to enhance the health and wellbeing of frail older adults. In line with this, Shuurmans et al. (Shuurmans et al., 2012) also highlight that MIL is considered a central concern in nursing.

The third main theme revealed that cultural activities were perceived as important for enhancing meaningfulness by the frail older adults. As found in this study, many frail older adults are, however, bound to their homes and need support, for example, from relatives, friends or home care personnel in order to be able to get outside or participate in cultural activities and experiences to enhance meaningfulness in daily life. This study revealed that it is not so easy for frail older adults to achieve meaningfulness from activities performed outdoors on their own or by participating in cultural activities due to a lack of health and a frail body. On the other hand, the frail older adults may find it easier to fulfill their spiritual needs, since the spirituality that provides meaningfulness is less dependent on health. In this situation, the home care personnel can also be a great resource and provide spiritual support in various ways. In line with this, Duppen et al. (Duppen et al., 2019) also found that spirituality and a deep connectedness to a deceased spouse can help in finding daily MIL for older adults. In our study, the fourth main theme also displayed spirituality as being important experiences of meaningfulness in daily life amongst frail older adults. However, we want to stress that particularly spirituality as a source for meaningfulness was a something that the frail older adults could easily enjoy themselves in their own homes. Bernard et al. (Bernard et al., 2017) also mention that MIL and spiritual wellbeing have positive correlations.

It is evident that meaningfulness is important for wellbeing throughout the life course and that the sources of meaningfulness for frail older adults are highly dependent on human relationships and having a purpose in everyday life, as well as experiencing value, self-efficacy and self-worth (cf. Duppen et al., 2019). Besides noting that the visits from the home care personnel in themselves were important for enhancing meaningfulness, we also saw that there is potential within the home care personnel to support meaningfulness in the main themes of outdoor activities and green spaces as well as in cultural activities and spirituality.

Limitations

In this study, the prominent focus was placed on home care personnel, but if we had included family and friends as sources for meaningfulness, for example, the results would have differed to some extent. Our interpretation has therefore partly been affected by this. In addition, we particularly focused on frail older adults receiving home care support and other studies might also focus on older adults without frailty, which may generate somewhat different findings. The fact that the home-care staff selected the participants and that different interviewers were involved in the study might be sources of bias. However, despite these limitations our study was based on a relatively large group of frail older people (17) that generated a rich amount of data. We have also produced some novel findings and offer several potential areas for further research. In the future, qualitative studies on frail older adults’ comprehensibility and manageability could be conducted.

CONCLUSION

This study found that home care personnel in particular, but also other aspects, played an important role for enhancing a sense of meaningfulness in the daily life of frail older adults, and that this can strengthen their health and wellbeing. Some of the sources seen as enhancing meaningfulness in this study could be enjoyed independently by the frail older adults, whilst others required assistance or support from a support person. Bearing this in mind, the home care personnel could also play an important part toward enhancing meaningfulness amongst frail older adults, and thus they should be given sufficient resources, knowledge and competence for enabling this. Future research should focus on studying meaningfulness from the perspective of home care personnel.

AUTHORS’ CONTRIBUTIONS

Jessica Hemberg contributed to the study conception and design, theoretical framework, data collection, data analysis, discussion, and drafted the manuscript at all stages. Fredrica Nyqvist and Marina Näsman contributed to the study conception, data collection and critical reflections.