Nurses’ attunement to patients’ meaning in life – A qualitative study of experiences of Dutch adults ageing in place


 Background Meaning in life (MiL) is considered to be an important part of health and is associated with many positive outcomes in older adults, such as quality of life and longevity. As health promotors, nurses may take patients’ MiL into account in the care process. There is a knowledge gap in terms of what constitutes good care in relation to older patients’ MiL, and what the benefits may be for patients when nursing is attuned to this aspect. The purpose of this study was to explore the experiences of home nursing older adults in relation to nurses’ attunement to MiL. Methods Gadamerian hermeneutic phenomenological design with semi-structured interviews. Participants were 24 aged home nursing patients. A framework of care ethical evaluation was used in the analysis. Multiple dialogues enhanced understanding. Results Patients did not expect nurses’ regard for their MiL. They rather expected ‘normal contact’ and adequate physical care. Nurses showed that they were open to patients’ MiL by being interested in the patient as a person and by being attentive to specific and hidden needs. Participants explained that the nurse’s behaviour upon arrival set the tone: they knew immediately if there was room for MiL or not. All participants had positive and negative experiences with nurses’ behaviour in relation to MiL. Valued nursing care included maintaining a long, kind and reciprocal relationship; doing what was needed; and skilled personalised care. Participants mentioned ‘special ones’: nurses attuned to them in a special way who did more than expected. Benefits of care that was attuned to patients’ MiL were experiencing a cheerful moment, feeling secure, feeling like a valuable person and having a good day. Older adults also stressed that consideration for MiL helps identify what is important in healthcare. Conclusion Aged homecare patients value nurses’ attunement to their MiL positively. Although patients regard MiL mostly as their own quest, nurses play a modest yet important role. Managers and educators should support nurses’ investment in reciprocal nurse-patient relationships.


Background
Because of ageing populations worldwide (1), nurses' patients increasingly consist of aged persons.
Healthy ageing is considered to be an important objective for both nurses and patients (2). What 'health' means depends on one's definition (3,4). 'Positive health' is regarded as most relevant in the care for chronically ill (older) patients due to its holistic and subjectivist character (3). Positive health is described as an individual multidimensional process that focusses on positive outcomes in order to enable adaptation to life's challenges (5)(6)(7)(8). Huber (5). She regarded MiL as the most important dimension (9). As suggested by adherents of positive health, research confirms that high levels of MiL in aged adults are associated with a higher quality of life (10), a healthier lifestyle (11), longevity (12)(13)(14) and a lower prevalence of age-related conditions (13,15,16). In this article we focus exclusively on MiL.
Human beings desire to live meaningful lives (17)(18)(19). MiL is a personal perception or understanding about one's life and activities and the value ascribed to them (20). MiL encompasses both the 'big questions in life' (existential meaning) and the meaning of experiences on a daily basis (daily meaning) (21,22). Nurses have a fundamental responsibility to promote and restore health (23).
Since MiL is an important part of health, nurses may take patients' MiL into account in the care process. Patients regard MiL as important and believe that health professionals, including nurses, can play a role (24). What this role should be and what the patient's benefits are, is scarcely discussed in empirical literature. Research in nursing homes shows that nurses play a role in patients' MiL by taking care of their physical and mental well-being, by promoting cherished activities (25), and by a confirming and kind relationship that includes careful listening and respect for the patient as a person (26).
A limitation of the few available studies is that they all have been conducted in nursing homes, whereas nowadays most people age in place (2), steadily using more home nursing services (27). In the Netherlands, where this study was conducted, 94% of persons over 65 age in place (28). People ageing in their own homes could provide a different perspective on care in relation to MiL than those living in nursing homes, as living at home is an important source of MiL among older adults (29,30).
There is a knowledge gap on the subject of home nurses' recognising and responding to older patients' MiL. Furthermore, the possible benefits of this care for patients are unclear.
Because MiL is different for every individual (19,29) and older adults have different strategies to retain MiL (29,31,32), good care with respect to MiL requires individual attunement. We chose Tronto's four elements of good care as a theoretical lens, as they clearly include this individual attunement. The elements are (33): Attentiveness: Recognising the needs of the other. Attentiveness requires suspending one's opinion or goals; it is concerned with the perspective of the other.
Responsibility: Includes responsibility of many persons in society and is rooted in one's cultural role: What can we do for the other from our position?
Competence: This is related to practical caregiving. If care is not provided adequately and tailored to the individual, it can never be good.
Responsiveness: Engagement with the position of the other (the patient) as he or she expresses it. In other words, does the care feel good from the patient's standpoint (34)?
To understand what good care is in relation to a patient's MiL, we clearly need insight into the patient's perspective. Hence the aim of this study was to explore the experiences of older adults who receive home nursing, in terms of nurses' attunement to patients' MiL. Research questions were: What do older adults who receive home nursing expect and value from nurses regarding attunement of care to their MiL?
What is the consequence of this care for the older adults? 2. Methods 2.1 Setting Setting for the study was a large care provider in the metropolitan area of Rotterdam, a large multicultural city in the Netherlands. Home nursing in the Netherlands is provided by neighbourhoodbased teams consisting of one or two registered nurses and 10-18 nursing assistants of various educational levels (in this paper all referred to as 'nurses' and 'she'). They work in shifts. Nurses of the care provider noticed that a growing number of home nursing patients confronted them with their MiL issues, which nurses found difficult to respond to. During the research period nursing teams followed a training and coaching programme on MiL. At the start of the programme patients from four teams were asked to participate in this study in order to explore their experiences with nurses' attunement to patients' MiL. In the research period the care provider went through several organisational transitions, which resulted in numerous changes in nursing personnel and modifications of many procedures.

Design
We chose a Gadamerian hermeneutic phenomenological approach for this study. This includes exploring the lifeworld of the participants through opening up, questioning and dialogue in order to arrive at a shared understanding, a 'fusion of horizons' (35-38).

Participants
We asked nurses of three home nursing teams to find 4-8 patients who reflected the diversity in their neighbourhoods in terms of age, gender, cultural background, socio-economic status and health.
When data saturation was approached we selected a last fourth team to include patients, resulting in 24 participants. Mean age of participants was 82.3 (median 85). Most of them lived alone (n = 18), were women (n = 18), and had a Dutch cultural background (n = 18). Sixteen participants had a religion, but five of them were no longer practising (Table 1).  (39,40). After ten interviews we evaluated the interview questions and made minor changes in formulation. In the interviews we firstly invited the aged person to share experiences on their MiL. These findings are reported in a separate article (29 together. Three participants were assisted by family members during the interviews because their Dutch language proficiency was limited. Most participants were interviewed three times (n = 16), four twice, and four once. Reasons for drop-out were deteriorating health (n = 3), death (n = 1), moving to a nursing home (n = 2) and 'having nothing more to add' (n = 2).

Data analysis
Interviews were transcribed verbatim. In the analysing process we followed the steps of interpretative phenomenological analysis (40). Data were analysed at two levels: firstly at an individual level and subsequently at an overarching level. At the individual level all interviews of each participant were analysed to arrive at a broad and deep understanding of the participant's unique experiences in context. Next, overarching themes were interpreted for all data. This movement from the parts (individual) to the whole and vice versa (36)(37)(38) was repeated several times.
To analyse the content of our data we used a modified framework of care ethical evaluation of Kuis & Goossensen (34). Both our study and care ethical evaluation intend to explore care from the perspective of patients and are inspired by Tronto's four moral dimensions of care (34). The framework consists of four main aspects: In accordance with our research questions this article focusses on aspects 1c-4a.

Rigour
Multiple interviews per participant and continuing dialogue promoted credibility of this study (39,41).
Dependability and confirmability were established by recorded and verbatim-transcribed data; analytical software (Atlas-ti 6.2.28); and analytical steps and an analytical framework (40,42).
Reflexivity was fostered through a research diary and dialogues (38,41). In reporting this article we follow the COREQ (43).  Table 1).
Next, we present our findings at the overarching level structured by analytical aspects and themes (see Table 2: Themes). The background of participants is summarised in Table 1. Many participants complained about the fact that home nurses were rarely on time. Others expressed their appreciation for nurses who were on time, so they could for instance go to church, which was important for them.

The special ones
Almost every participant mentioned a favourite nurse, 'a special one'. These were nurses with whom a special connection was felt; they were attuned in a special way to the personality and needs of the Although participants appreciated a reciprocal relationship with familiar nurses, for some of them the balance between giving and receiving was off: the attention they paid to nurses' worries overshadowed their own problems.
When they run into difficulties in their work they come to me. [Tells an example of another patient.] And then they turn to me for advice. Honestly, that puts a burden on me, because I keep thinking about it … There is hardly any focus on me. Well, on the other hand, I don't take the opportunity to tell about myself … (A1.3, age 76-80) Having a good day thanks to good humane care, or suffering due to bad care Emphasising what is important in healthcare Many participants considered healthcare services to be deteriorating. Participants stressed that nurses' concern for patients' MiL was not only important for them as individuals, but also for healthcare in general. They explained that the focus on patients' MiL also restored attention to what's really important in healthcare.
Well, I think that the higher you come in the organisation, the less focus there is on this aspect [MiL] and on emotions. And that is important for the people who give those trainings: that these very tiny spiritual notes are most important in the big picture.' (D4.3, age 76-80)

Discussion
The aim of this study was to explore the experiences of older adults who receive home nursing in terms of nurses' attunement to patients' MiL. To our knowledge, it is the first study on this subject from the perspective of adults ageing in place, which is the majority of ageing people (2,28). MiL is an important part of health (5) and is vital for healthy ageing (13)(14)(15)(16).  (51,52). Our participants emphasised that especially feeling as an equal person, instead of a patient, was important to them. The nurse-patient relationship provided them with the opportunity to enact favourite (social) roles and use their character strengths, which are pivotal for MiL (29,53).
In a reciprocal relationship both partners give and receive. Although patients experienced benefits from giving something in return to nurses, this gradually became a burden for a few of our participants when their support of nurses' problems started to overshadow their own. In reciprocal relationships, balancing giving and receiving is a continuous endeavour that affects both partners -in this case patients and nurses.

Methodological considerations
The Gadamerian hermeneutical phenomenological approach enabled us to arrive at a mutual understanding of this subject, together with the participants. Multiple interviews with participants deepened understanding. Diverse backgrounds (of participants and researchers) and in-depth dialogues contributed to new insights, a 'fusion of horizons', for both researchers and participants (36). Many participants greatly enjoyed our conversations, as they seldom had the opportunity to discuss topics beyond a superficial level. The theory of Tronto and the questions of care ethical evaluation proved to be a helpful framework to analyse nursing in relation to MiL.
Our study has limitations. Firstly, sampling and attrition limit the transferability of this research.
Secondly, the credibility of three interviews was compromised by the presence of family members of non-Dutch-speaking participants, even as this enabled us to include participants of more cultural backgrounds. Lastly, considerable organisational transitions during the research period definitely impacted the results of this study. But healthcare is always changing anyway. The organisational turmoil revealed the important role that management plays in safeguarding conditions that promoteor inhibit -good care in relation to patients' MiL.

Conclusion
In this study we explored what older adults who receive home nursing expect and value from nurses in terms of attunement of care to their MiL. We also investigated the benefits of this behaviour. We

Ethics approval and consent to participate
An ethics committee assessed the research proposal and found the research not to be subject to the Dutch Medical Research Involving Human Subjects Act (WMO). All participants received written and oral information about the study in advance and were encouraged to ask questions. The information was repeated in the second and third interviews as necessary. Participants signed informed consent forms for each interview. In the results section and the appendices we used codes for the participants and neighbourhoods, changed minor identifying details and referred to all participants as male and to nurses as female, in order to protect anonymity. Data was stored in conformity with the European General Data Protection Regulation. We worked following national ethical codes for research of Dutch Universities (54).

Consent for publication
Signed written informed consent was given by all participants for interviews and publication in relation to this research.