'Meaning in life? Make it as bearable, enjoyable and good as possible!': A qualitative study among community-dwelling aged adults who receive home nursing in the Netherlands.

The population of adults ageing in place and using home-care services is growing rapidly worldwide. Meaning in life (MiL) of this group of clients is relevant for healthcare and social workers. MiL is associated with many positive outcomes, but can be challenging for aged persons. Objective of this study was to explore MiL in daily life of community-dwelling aged persons who receive homecare. A hermeneutic phenomenological approach was followed. Three waves of semi-structured interviews took place among 24 clients of a home-care organisation in the Netherlands between November 2015 and July 2018. Photo-elicitation was part of the interview procedure. Interpretative Phenomenological Analysis and dialogues enhanced understanding. Findings show that participants derived meaning from self, others, environment and living. The process of retaining MiL involved maintaining, adapting and discovering. We conclude that community-dwelling aged adults can draw MiL from many sources. Retaining MiL is interwoven in everyday life and requires continuous adaptation to ever-changing life conditions during later life. Although relevant general themes were sketched in this paper, the importance of each, and the connections between them, vary and come to light at the individual level. The themes in this paper and the cases in the appendices provide insights that may help professionals recognise MiL in their work. Besides listening to the stories of aged adults, person-centred interventions should support aged adult's strategy to retain MiL.

What is known about this topic?

Happiness is about ‘feeling good’; MiL is about ‘being or doing good’.

Several circumstances are positively associated with MiL: health, higher SES, cohabiting, good relationships, living independently, social integration and high everyday competence.

Loss (of: functions; preferred roles; personal growth; dear ones) compromises MiL in the later years.

What does this paper add?

Retaining MiL by adapting to conditions requires energy and perseverance of community‐dwelling aged persons.

Reciprocity in relationships fosters MiL of community‐dwelling aged persons.

The home and neighbourhood of community‐dwelling aged persons influence MiL.

INTRODUCTION

Older adults are a group of interest in healthcare and social care. The percentage of aged adults in population is growing worldwide, with a projected increase to 29% in high‐income countries by 2030 (WHO, 2015). Most older adults age in place (WHO, 2015). Many of them receive help from family and professionals. In the Netherlands, where this study was conducted, more than 90% of adults older than 75 age in place, with over 40% receiving informal and/or formal care or support (De Klerk, Verbeek‐Oudijk, Plaisier, & den Draak, 2019). Therefore well‐being of this group of clients is relevant for healthcare and social workers. Positive psychologists distinguish two philosophical approaches to well‐being (Deci & Ryan, 2008; Ryff, 2012): Hedonism, (subjective well‐being or happiness) is related to minimising discomfort and maximising pleasure and life satisfaction. Eudaimonia (psychological well‐being or meaning in life (MiL)) is related to identifying and fulfilling one's potentials. Although happiness and MiL appear connected in life (Shmotkin & Shrira, 2013), there are considerable conceptual differences: MiL is, more than happiness, related to giving than taking, to expressing the self (Baumeister, Vohs, Aaker, & Garbinsky, 2013; Esfahani Smith, 2017). Happiness is about ‘feeling good’ while MiL is about ‘being or doing good’ (Esfahani Smith, 2017). After decades of emphasis on happiness, MiL is gaining attention in contemporary research. Literature reviews (Bellin, 2012; Brandstätter, Baumann, Borasio, & Fegg, 2012) show the complexity of the construct of MiL. A comprehensive description of MiL 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 […] MiL comprises the engagement in or commitment to goals or a life framework and the subsequent sense of fulfilment and satisfaction or lack thereof (Brandstätter et al., 2012).

Literature about MiL comprises theories and research about four elements of the construct:

Content: What provides MiL: frameworks of components, needs or sources of MiL (e.g. Baumeister, 1991; Derkx, 2011, 2015; Wong, 1998);

Process: How MiL can be attained (e.g. Frankl, 1959; Reker & Wong, 2012)

The experience of MiL: How does it feel, what does it bring? (e.g. Baumeister, 1991; Brandstätter et al., 2012)

What circumstances promote MiL (e.g. Carstensen, 2006; Pinquart, 2002)

MiL is thus a multifaceted construct. Moreover, the relations between the elements of meaning are extremely complex (Bellin, 2012; Brandstätter et al., 2012).

Meaning in life of aged persons

Accumulating research shows positive association of MiL with many desired outcomes in older adults: quality of life (Haugan, 2013; Low & Molzahn, 2007), longevity (Boyle, Barnes, Buchman, & Bennett, 2009; Buettner, 2008; Zaslavsky et al., 2014), healthier lifestyle (Steptoe & Fancourt, 2018), use of preventive healthcare services and fewer hospital nights (Kim, Strecher, & Ryff, 2014) and lower prevalence of age‐related conditions (Zaslavsky et al., 2014) such as Alzheimer ‘s disease (Boyle, Buchman, Barnes, & Bennett, 2010) or stroke (Kim, Sun, Park, & Peterson, 2013). However, experiencing MiL seems increasingly challenging through later life. Ageing comes with physical constraints, loss of dear ones and loss of valued roles, which compromise MiL (Krause, 2004). Although many older individuals preserve MiL (Fagerström, 2010; Steger, Oishi, & Kashdan, 2009), others experience loss of meaning due to a decline in personal growth, loss of purpose or declined sense of coherence (e.g. Clarke, Marshall, Ryff, & Rosenthal, 2000; Lövheim, Graneheim, Jonsén, Strandberg, & Lundman, 2013; Ryff, 2014). Several circumstances are positively associated with MiL: health, higher education, higher income, marriage or cohabitation, good relationships, living in the community instead of an institution, social integration and high everyday competence (Hedberg, Gustafson, & Brulin, 2010; Pinquart, 2002; Steptoe & Fancourt, 2018). Literature reveals several processes through which aged persons find MiL: a developmental process, creating and discovering (Hupkens, Machielse, Goumans, & Derkx, 2018). Human relationships are widely regarded as the most important source of MiL (Hupkens et al., 2018). Although the body of knowledge on MiL is rapidly growing, we discovered two gaps in literature which are relevant for workers in the community: a dearth of studies on community‐dwelling aged persons who use home‐care services and on finding meaning in daily life (Hupkens et al., 2018). The purpose of this study was therefore to explore meaning in daily life of community‐dwelling aged persons who receive home nursing. Research questions were limited to two elements of MiL which are most salient for social and healthcare workers:

What sources provide MiL in daily life for community‐dwelling aged persons who receive home nursing?

How do they find meaning in daily life?

METHODS

Design

This study is part of a larger project about MiL of community‐dwelling aged persons, and how professionals can attune their care to MiL. We followed a qualitative hermeneutic phenomenological approach in order to understand MiL of community‐dwelling aged persons as they perceive it in their lifeworld. In hermeneutic phenomenology researchers explore by opening up, especially to ‘otherness’, through questioning and dialogue (Dahlberg, Dahlberg, & Nystrom, 2008; Gadamer, 1975, 2004; Malpas, 2018). The aim is to arrive at understanding (Verstehen), a ‘fusion of horizons’, from which both researcher and participants learn (Dahlberg et al., 2008; Gadamer, 1975, 2004; Malpas, 2018).

Data collection

Respondents were clients from a home nursing provider in Rotterdam, the second Dutch city. Four neighbourhoods were purposefully selected based on different socioeconomic status (as this affects MiL, see introduction). We asked community nurses in these neighbourhoods to select four to eight participants among their older clients that reflected client diversity (age, gender, cultural background, health status). From November 2015 to June 2017 participants were included in the study and between November 2015 and July 2018 respondents were interviewed three times, with 5–7‐month intervals, to arrive at a profound understanding about MiL of community‐dwelling aged adults. Four persons were unable to participate in a second interview, and four more in a third interview (Appendix A1). Reasons for drop‐out were: deteriorating health (3), death (1), moving to a nursing home (2) and ‘having nothing more to add’ (2). Data saturation was approached during data analysis (Appendix A2). However, in hermeneutic phenomenology researchers acknowledge that understanding is always timely and horizons are always moving (Gadamer, 1975).

Interviews

We developed a list of topics for semi‐structured interviews. Interview questions were open‐ended and asked about lived experiences and examples, rather than knowledge or opinions (Smith & Eatough, 2016; Thomas & Pollio, 2002). Photos were used as an elicitation method to facilitate deeper insight. We used a photo set that was specifically developed to discuss psychological well‐being (Cuijpers & Vooren, 2015). Photos can be a means towards emotions, thoughts and feelings that are difficult to express in words (Harper, 2002; Hupkens, Nijhuis, & Kuiper, 2011; Steger et al., 2013). After 10 interviews the topic list was evaluated. Minor changes were made in the formulation of questions. Main questions in first and second interviews were: ‘Please select a picture that depicts MiL for you at the moment’. and ‘Can you mention a recent situation in which you experienced MiL?’ We asked follow‐up questions to further explore with participants. In the second and third interviews dialogues about the insights of earlier interviews and preliminary interpretations took place to enhance mutual understanding. Much attention was paid to an open, attentive attitude towards respondents. The interviewer followed the flow of the conversation while preserving the orientation on the subject. We also gathered background data to enable transferability: gender, age, marital status, living alone or cohabiting, self‐reported health status, religion and cultural background. Background items were chosen based on relevance for MiL (see introduction). The main researcher (SH) performed all in‐depth interviews with the participants at their homes. Mean duration was 61 min (range: 32–112, Appendix A1). Most interviews were conducted with single participants. Two couples, all clients of the home‐care organisation, were interviewed together. Three respondents spoke limited Dutch and were assisted by their family during the interview.

Data analysis

Interpretation in hermeneutic phenomenology is characterised as a dialogue with the texts (Fleming, Gaidys, & Robb, 2003; Gadamer, 1975). We analysed the data in an iterative process at two levels: at the individual level to understand participants in context, resulting in cases which include all interviews of one participant (Figure 3, Appendices [Link], [Link], [Link], [Link], [Link], [Link]); at a general level, to find overarching themes. Analysis repeatedly moved in and out, from the parts (individuals) to the whole (all respondents) and back again (Dahlberg et al., 2008; Gadamer, 1975). See Figure 1. The six steps of Interpretative Phenomenological Analysis (IPA) were used as guidance, for their alignment to this approach and the philosophical background (Smith & Eatough, 2016). In this approach themes emerge from the data. Interviews were mostly analysed by the main researcher (SH). In all stages of the analysis further refinement took place in dialogues in two research groups. The first group consisted of nurses, spiritual counsellors, researchers and an aged adult who received home nursing. The second research group consisted of researchers (nurse/health scientist, health scientist, philosopher, philosopher/social scientist) and was university based. Researchers were aware of their pre‐understanding, which was derived from both professional work (research, literature, nursing) and personal experiences with aged family members. The introduction of this paper and our review article regarding MiL of older persons (Hupkens et al., 2018) sketch our preconceptions.

FIGURE 3

The river of meaning in life for community‐dwelling aged persons who receive homecare [Colour figure can be viewed at wileyonlinelibrary.com]

FIGURE 1

Schematic Presentation of analysis at individual and general level [Colour figure can be viewed at wileyonlinelibrary.com]

Rigour

To promote credibility we conducted multiple interviews with most respondents; findings were validated by respondents and through dialogues in research groups (Fleming et al., 2003; Thomas & Pollio, 2002). Dependability and confirmability were fostered through recorded and verbatim typed interviews, analytic steps and analytic software (Atlas‐ti 6.2.28)(Creswell, 2013; Smith & Eatough, 2016). We also utilised a diary to reflect on evolving understanding (Dahlberg et al., 2008; Fleming et al., 2003). The COREQ was used for the reporting of this study (Tong, Sainsbury, & Craig, 2007).

Ethical considerations

An ethical committee assessed the research proposal and found the research not to be subject to the Dutch Medical Research Involving Human Subjects Act (WMO). Respondents received written and oral information about the study on beforehand and signed an informed consent form. For this paper we changed names and minor details to protect anonymity. A data management plan was part of the study design, to meet the European General Data Protection Regulation. The researchers adhere to the national ethical codes for research of Dutch Universities (Andriessen, Onstenk, Delnooz, Smeijsters, & Peij, 2010).

FINDINGS

Participants

The 24 participants originated from four different neighbourhoods in the metropolitan area of Rotterdam. Mean age in the first interview was 82.3 (median 85). Most participants were women (18), lived alone (18) and had a Dutch background (18). Sixteen participants had a religious background, although one‐third of them were no longer practising. The majority (18) had a low educational level. Participants rated their health mostly as moderate (Table 1), although many of them spontaneously shared impressive lists of adverse health conditions with us during the interviews. In this paper participants can be identified by a code. As an example: A1 is the first participant from neighbourhood A. The second interview with this person is coded: A1.2.

TABLE 1

Background of participants

Age, years, first interview
61–65	1
66–70	1
71–75	2
76–80	5
81–85	5
86–90	6
91–95	3
96–100	1
Gender
Male	6
Female	18
Marital status
Married/cohabiting	5
Divorced	2
Widowed	15
Single	2
Living arrangement
Together	6
Alone	18
Cultural background
Dutch	18
Surinamese	4
Turkish	1
Cape Verdian	1
Religion
Christian	14
Non‐practicing	5
Muslim	1
Hindu	1
No religion	8
Highest educational level
No schooling	3
Primary school	5
Lower vocational	10
Medium vocational	2
Higher	4
Self‐rated health, first interview
Excellent	1
Good	8
Moderate	9
Poor	6
Very poor
Self‐rated health, second interview
Higher score than 1st	8
Same score	9
Lower score	3
Self‐rated health, third interview
Higher score than 2nd	4
Same score	7
Lower score	5

Results of two levels of analysis

As can be expected from our analysis, our results appear at two levels. We firstly present seven cases (individual level) and end with general findings.

Jill, Laetitia, Willy, Romeo, Ed, Yamini and Corinne

The cases in Figure 2 and Appendices [Link], [Link], [Link], [Link], [Link], [Link] are examples of the results of the analysis at the individual level. The cases represent respondents from different neighbourhoods and backgrounds. The cases provide the reader an in‐depth understanding of the meaning and interconnectedness of the general themes for aged individuals in context.

FIGURE 2

Jill [Colour figure can be viewed at wileyonlinelibrary.com]

General themes

Figure 3 is a representation of the general themes of the present study. We earlier represented MiL in the later years as a flowing river: ever‐changing by multiple processes, sources and circumstances that mingle together (Hupkens et al., 2018). Our actual findings support this metaphor; therefore we modified the image in order to depict the results of the present study.

WHAT: Sources of meaning in life

Most participants mentioned many different sources of MiL (Appendix A2). Main themes were: self, others, environment, living. Subthemes were highly interconnected. Several subthemes could be related to more than one main theme. An example is the subtheme ‘values’, which besides ‘self’ is also connected to ‘others’ and ‘living’. In this section themes are written in bold, subthemes italicised.

Self

Self was an important source of MiL of participants.

Values: All respondents mentioned important values that provided them with MiL, such as respect, friendliness and faith. These values were mostly adopted in their youth, through their upbringing or through a cultural or political background. Values that had guided them throughout life were reflected in respondents’ habits.

‘We are all equal. My father taught me: All groups have good and evil persons.’ (C6.2, age 82)

Character strengths: Many participants drew on their character strengths as a source of MiL, such as optimism, strength, perseverance, creativity and generosity. They told how these strengths had helped them before, in good and bad times. Some participants mentioned that they learned these virtues from beloved relatives who had passed away.

‘I am a giving person, just like my grandma. I always have something in my handbag to give to others.’ (C1.2, age 87)

Life story: Participants shared their life story with us during the conversations. They explained that beautiful memories of past life contributed to MiL in the present, while unfavourable events had shaped their character strengths and values. Photos and artefacts in the house reminded respondents of precious moments and persons.

‘The fact that I have been able to be of service to people in my professional life provides me with fulfilment.' (D6.2, age 86)

Physical and mental abilities: Many participants mentioned their good physical and mental abilities as sources of MiL, particularly as compared to other aged persons. Especially mental abilities were highly valued.

‘The doctor told me I am not demented. That’s the most important thing. I’d rather be dead than demented!’ (D1.2, age 86)

Autonomy: Several participants emphasised that living their life as they wanted it, and making their own choices, contributed to MiL. They enjoyed living (relatively) independent. Some expressed a feeling of freedom, which was especially meaningful after a long period of caring intensively for relatives.

‘I don’t want someone else to dispose of my life, to decide for me. As long as I can think independently, I stay who I am.’ (B6.3, age 73)

Others

Besides self, others appeared to be vital for MiL of our participants.

Personal relationships: For all respondents, other persons contributed to MiL: spouses, brothers and sisters, children/grandchildren, friends. Respondents still cherished relationships with loved ones who passed away. Daily rituals kept them in their lives. Participants who had pets highly appreciated their friendship. Many attached value to being a good mother, a funny grandfather or a good neighbour. They expressed that, for MiL, reciprocity in relationships was important. Despite age, several participants mentioned assisting family or neighbours, although this was becoming progressively strenuous.

‘That I can mean something for my wife, that’s my fulfilment…MiL is today: that’s all there is … that we can live this life together.’ (B1.1, age 90)

‘ That dog is my everything.’ (A3.1, age 78)

Community and society: A community, for example, of neighbours, provided meaning for some participants. Others felt a bit detached from society because of shrinking social networks or loss of a specific social role, such as being a brilliant professional or the perfect host. Respondents attached importance to staying informed about topical issues in the world through reading, television and radio. Some were concerned about social developments and, specifically, the future of their children and grandchildren. Several supported good causes.

‘I hope that all children that have been put on this world by our generation will enjoy prosperity like we did. We have to ensure that. (B5.2, age 73)

Religion: Some participants mentioned religion as a source of MiL. Religion provided them with a community and important values and habits, such as praying and lighting a candle. It connected them to something, or someone, ‘higher’.

‘For me, it is God in the first place. The narrow road is the good one. I walk this road of God.’ (C3.1, age 78)

Environment

Participants not only found meaning in others and self, but also in the environment where they lived.

Home and neighbourhood: Many participants told that their home and close neighbourhood contributed to MiL: their belongings, the convenient location, shops and other facilities. Many mentioned nature as a source of MiL, especially when it could be enjoyed through the window or on a short walk in the neighbourhood.

‘To live here again (after a hospital stay), in my own house! I love the view, especially the children’s playground.’ (D2.2, age 95)

Art and media: Some participants had works of art in their houses, which were valuable for them. Several adults mentioned music, films and media as important sources of MiL.

'When it’s silent in the house I watch television. And I imagine I’m there with those people … And I love music. It brings life into the house!' (C2.3, age 85)

Living

Participants expressed that living was a source of MiL.

Activities: Most respondents told us that their activities provided them with MiL in daily life. Moreover, ‘doing something’ helped them in adverse situations. Participants stressed that both beginning and finishing an activity were important. Meaning‐providing activities varied. For several respondents ‘just doing something’ was not enough to experience MiL: the activity needed to contribute to something they regarded as valuable, like supporting good causes in the community or making something beautiful or useful. Many aged persons mentioned a favourite activity like reading a good book, gardening or doing craftwork. For several, daily chores took more and more time, impeding favourite, MiL‐providing activities.

‘I have so many activities to do; I would like to make three days out of one!’ (B3.2, age 84)

Daily rhythm: Everyday rhythm provided some respondents with MiL. Precious habits like walking the dog or home organisation, filled them with MiL.

‘Well, most times I even don’t have the time to read the paper… I have other things to do. At the moment the washing machine is working as well. And when that is all set, that feel’s good. Yes, it provides me with fulfilment’ (B7.1, age 88)

Life itself: Some participants expressed that life itself provided them with MiL—waking up in the morning and being able to live another day. A few respondents experienced nature as a connection to the larger structure of life.

‘When I wake up I think: seize the day … I am still there! And that is always very important. And I make a cup of tea and sit here for a while.’ (D3.3, age 91)

HOW: the process of retaining meaning in life

Although most respondents experienced MiL almost daily, many saw it as an increasing challenge because of declining health and loss of many dear ones. Activities became problematic and loss of mobility limited going out and visiting others. Our participants explained that retaining MiL was a continuous process that fluctuated with life conditions. Most of them used several strategies, (Appendix A2).Three main themes evolved in the analysis for this process: maintaining, adapting and discovering MiL (Figure 3).

Maintaining MiL

Participants explained that they did not have to create new meaning every day. They rather maintained MiL through different strategies.

Being myself: Most participants emphasised that, to maintain MiL, they just ‘stayed who they were and did what they had always done’. When we asked follow‐up questions, they explained how they had overcome difficult periods before in their life. Just as in previous situations they used their character strengths and kept up daily rituals and favourite activities, which provided a structure for carrying on and maintaining MiL.

‘I go on as I always have. Because if you stick to your trouble it will determine you. You have to switch over’ (A3.2, age 76)

Taking care of myself: Respondents told that taking good care of themselves supported MiL. They paid attention to their appearance, maintained a healthy lifestyle (food, exercise), and did their best to make a nice day for themselves.

‘Some days I go up and down the stairs six times or more, otherwise soon I won’t be able to do that anymore.’ (A1.1, age 69)

Staying connected to MiL sources: Participants actively undertook steps to stay connected to their MiL sources, for instance by engaging in meaning‐providing activities. When receiving guests they did their best to be good company, show interest in others and enjoy their visits. Some told that they did not ask or expect too much from family carers, in order to keep the relationship healthy.

‘I always take care of myself to have this sociability of playing cards and so on.’ (B8.2, age 85)

Adapting

When maintaining MiL was impeded by deteriorating conditions, participants used several strategies to retain MiL through adaptation.

Adapting to conditions: Participants revealed that they adapted continuously to deteriorating health conditions. Several told, and showed, how they found creative solutions for lost abilities, for instance phoning relatives instead of visiting them. They accepted help from family, friends and home‐care services. Several turned to other sources of meaning. During our dialogues, participants provided insight into the increasing time and energy this process of adaptation costs as decline progressed. A few respondents expressed that adaptation had almost reached a limit, especially when they experienced too much pain or felt exhausted, or when meaning‐providing activities or preferred roles where hindered.

‘When I want to cook chili con carne, I plan it a day ahead. I do the shopping the day before, and start early in the afternoon. I take some bowls and cut peppers and leeks, and then I take a rest, because it costs energy. I take breaks and spare my other hand.’ (A2.3, age 64)

Looking ahead: Participants told that they look ahead. Some feared further decline and took precautions, like ordering a mobility scooter, which secured the ability to ‘walk’ the dog. Some hoped for the best for the future. For several aged persons, making final arrangements provided them with MiL, as they did not want to bother their family with that.

‘I want to call the funeral director. It is a very big step for me. You know, then you talk about the end of life … But I definitely want to do it, for my son. It would take away a lot of trouble from him.’ (B8.3, age 85)

Discovering

In dialogues with participants another process of finding meaning came to the surface: discovering.

Reflecting about life: Most respondents looked back on their past life, at times with relatives (or the researcher), often during the night. Participants observed the ‘pieces of the puzzle’ of their memories and discovered connections and meaning. Some wondered if they did the right thing in specific situations.

‘I have led a normal life, I didn’t do any evil, I have been an honest person. I have peace of mind.’ (C1.2, age 87)

Openness and sense of wonder: Many participants described an attitude of openness and wonder towards life, which enabled them to discover unexpected meaning in their daily life: in the beauty of nature, changes in the city, music, or unexpected encounters with others.

‘Meaning in life is seeing something that attracts or touches you. Little ducks in the water. Children on my daily walk.’ (D 5.2, age 97)

DISCUSSION

In this paper we explored MiL of community‐dwelling aged adults who receive home nursing. Through the hermeneutic approach, this research expanded our horizons and those of our study participants: many respondents told us they highly enjoyed the in‐depth conversations. Some missed this kind of exchange in their later years. Most of the themes that derived from our analysis support earlier literature, yet findings reveal a few interesting novel aspects. Main contribution of this paper is it is in‐depth first‐person's insight in MiL in the later years.

Our respondents showed that retaining MiL is interwoven in everyday life. Although general themes emerged from the analysis, MiL was something different for every individual in their own context, as also stated by Frankl (1959). In the participants’ stories, the elements of MiL are highly interconnected in an individual way: an overall structure was not found. However, the findings lent support to our overarching image of a river of meaning in later life (Figure 2).

Sources of MiL revisited

Although we expected many sources for MiL, we were impressed by the number of sources our respondents mentioned. As the broad themes show—others, self, environment, living—MiL can be derived from many things.

Meaning from relationships with others was frequently mentioned, both by our respondents and in previous research (e.g. Bar‐Tur, Savaya, & Prager, 2001; Duppen et al., 2019; Fegg, Kramer, Bausewein, & Borasio, 2007). Our study further contributes to insight into the reciprocal character of relationships, as receiving and giving contributes to MiL. Especially the capacity to fulfil favourite roles (e.g. mother, friend) was very important to our respondents. Loss of favourite roles erodes meaning, as shown in research by Krause (2004). His research provides a hopeful perspective: this loss of meaning can sometimes be restored by emotional support of others. Our findings reveal the importance of relationships with pets: for some aged adults they are a vital source of MiL.

Although we, like others, have highlighted personal relationships as a major source of MiL (Hupkens et al., 2018), we learned that other sources may be equally important. Loss of dear ones is inevitable in later life. Participants showed that, at that point, other sources become crucial. Self (character strengths, values and life story) can be a stable source. Most respondents relied on their selves to retain MiL, which confirms findings of other authors (Dittmann‐Kohli, 1990; Greenstein & Hollander, 2015; Nygren et al., 2005).

A new insight from our study is that home and the environment are a source of MiL. With an increasing population of adults ageing in place, this is a salient topic.

Our study puts activities of community‐dwelling aged persons in the light of MiL. Which activity is meaningful is different for each individual. Independence gave many respondents a sense of autonomy and freedom, contributing to their MiL. On the other hand, daily chores frequently demanded so much time and energy that they inhibited starting other, more meaningful activities. Beginning something is important to feel human (Arendt, 1958), and aged persons are no exception to this. Besides beginning, finishing the activity is crucial. As a respondent mentioned: activities have little meaning when one lacks the energy to finish them.

We expected daily rhythm to be a source of MiL for our respondents, as mentioned by others (Bellin, 2012; Dittmann‐Kohli, 1990; Moore, Metcalf, & Schow, 2006). Our findings show that, moreover, life itself can be a source of MiL: waking up in the morning and being able to live another day.

The process of retaining MiL revisited

Participants showed us that retaining Mil is a continuous process in old age, due to ever‐changing life conditions. In our review article we made a distinction, like Reker and Wong (2012), between creation and discovery of MiL. Through dialogue with participants in this study we learned that ‘creating’ MiL in old age is not a proper understanding: aged adults do not have to create meaning, they rather maintain MiL or adapt to changing conditions during old age in order to retain MiL. Participants explained that, to maintain MiL, they simply ‘are, and do, what they have always done’. This implies active involvement though: participants stay related to their initial value framework, their cultural path, according to Kaufman (1986); they also showed us, like previous authors (Dittmann‐Kohli, 1990; Moore et al., 2006), that MiL is retained by good self‐care and connecting to one's MiL sources. Yet MiL takes energy and perseverance when aged persons have to adapt to conditions, especially when pain and/or daily tasks make increasing demands from an older individual. The philosopher Gude emphasised, while struggling from terminal cancer, that retaining MiL required daily effort. MiL is sometimes an exhausting struggle, a ‘crafting endeavour’ (Steenhuis, 2017). Some participants explained that life turns meaningless when this struggle becomes too much. Retaining MiL, as described in our findings section, shows similarity to the Selection Optimisation and Compensation Theory (Baltes & Carstensen, 1996; Freund & Baltes, 1998). The processes of adapting (this study) and compensation (Baltes et al.) are comparable. However, for our participants, selection of goals and optimisation was frequently loss based: to keep the current level (instead of election‐based: deliberately choosing goals in order to attain a higher level).

Another way to find meaning is discovering it. Discovering is finding meaning by coincidence, not intentionally. Our respondents showed us that discovering meaning occurred by looking back, as described earlier (McAdams, 2012; Tromp, 2011), but meaning seemed to evolve foremost from a mindset of wonder (Derkx, 2015; van de Goor, Sools, Westerhof, & Bohlmeijer, 2017). Our participants confirm authors who wrote that openness and receptiveness towards life enables enjoying what crosses your path (Marcoen, 2006; Randall & Kenyon, 2004; Reker & Wong, 2012; Tornstam, 2005). The process of discovering MiL through wonder is seldom studied, but of high interest, as this mindset may remain largely unaffected by many deteriorating circumstances during old age.

Implication for practice and policy

MiL is associated with many positive outcomes such as health and quality of life. For this reason, MiL of aged persons ought to be on the agenda of professionals and policy makers in social care and healthcare. The themes in this paper and the cases in the appendices provide useful knowledge that may help recognise MiL in practice. Because every individual is different, a valuable next step should be listening to the stories of aged adults and learn from them, as we did. A phenomenological attitude of openness, questioning and attentiveness proved to be a good start for a conversation about MiL. Interventions in the community and in healthcare should not only focus on sources of MiL but also empower aged adults to retain MiL. The UK programme ‘5 ways to well‐being’ is influential internationally and mirrors some of our findings, although it is based on another definition of well‐being (‘mental well‐being’) (Aked & Thompson, 2011; The Government Office of Science, 2008). Furthermore policy makers should consider the impact their decisions have on MiL of aged adults, especially in relation to environmental and social aspects.

LIMITATIONS

Our study has limitations. Transferability is limited due to sampling, as well as by attrition, which is common in follow‐ups, especially among aged persons. Understanding of participants who dropped‐out may be limited. Although the photo‐elicitation provided us with many valuable insights, the use of photos was confusing for two persons who had limited cognitive functioning and not feasible for two others who had impaired vision. The presence of family in three interviews with non‐Dutch‐speaking respondents influenced the conversation—and thus the credibility—of those interviews.

CONCLUSION

Community‐dwelling aged persons can derive MiL from many sources. Retaining MiL is interwoven in everyday life and requires continuous adaptation to ever‐changing life conditions during later life. Although relevant general themes were sketched in this paper, the importance of each, and the connections between them, vary and come to light at the individual level. Besides listening to the stories of aged adults person‐centred interventions should support aged adult's strategy to retain MiL.

CONFLICT OF INTEREST

The authors declare having no conflict of interest.

Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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