A Meaningful Daily Life in Nursing Homes: A Social Constructionist Study of Residents and Health Professionals' Perspectives and Wishes

Background: "Improved Elderly Life" is a rehabilitation concept at nursing homes in Aalborg municipality in Denmark, which aims to enhance the perception of a meaningful everyday life for the residents, and hereby maintain daily-life activities. In “Improved Elderly Life” a basic team which consists of a physiotherapist, occupational therapist and an activity employee, collaborate with the care staff at nursing homes. In this study our aim was to investigate the consistency of the meaningful everyday life and activities, from the perspectives of the residents as well as how the staff esteem and contribute to this at nursing homes. Methods: Semi structured, qualitative interviews were conducted with residents and staff at two nursing homes. Results: Residents` perception of a meaningful life in nursing home generated five significant themes; To use oneself and to be of use; Social communities; Meaningful activities; Self-determination and influence on daily life; Self-reliance. Findings showed that residents and staff at the included nursing homes, in some areas have different perceptions of what contributes to a meaningful everyday life. Conclusion: The residents wish for autonomy and individual activities that harmonize with their past lives. The employees and training staff concur with this, however in the daily routines at the nursing homes there is a discrepancy between what is spoken by the employees and what the residents experience.


Introduction
An increased focus on rehabilitation efforts have seen the light as the increased number of elderly affects public budgets [1,2]. In this view, maintaining abilities of having a meaningful daily life, including physical function as well as social and psychological wellbeing is essential for elder residents both in communities and in nursing homes.
According to a study from the Danish Institute of Social Research, elderly is generally happy with life at nursing homes, and quality of life was especially improved in relation to basic needs such as food, beverages and safety. However, the study also found that it is difficult to improve residents' quality of life with regard to social life and activities [3]. Other studies have shown that the elderly living in nursing homes participates in the activities, and that the activities are scheduled to suit the staff routines. Studies have also shown that residents are limited in doing what they truly like and that they engaged in far less activities than they wished to. Activities the elderly participated in was rarely something they found meaningful, and their general level of activity and motivation for participation decreased shortly after moving into the nursing home [4][5][6].
In order to rehabilitate and achieve the purpose of increased meaning in the everyday life of older people, knowledge is required of what is important for the individual. Steen Wacherhausen [7] uses the concepts true and untrue goals, to illuminate the residents' individual experiences of what contributes to a meaningful daily life. True goals, according to Wackerhausen, are the residents` own inner wishes, which are not compulsive, neither by the surroundings. A true goal can also be silent and implicit, so that the resident is not immediately aware of this, which also complicates the resident's goal of rehabilitation efforts. According to Wackerhausen [7], it is demanding for both the residents themselves and the environment to achieve true goals as it requires both the capacity of the hand, consisting of subject-based skills, and context-dependent functional capacity [7]. Untrue goals in rehabilitation efforts can be forced from outside, by relatives or staff, and may occur when the environment in rehabilitation efforts, in the best sense, focus on residents' risk of having limitations in their physical, psychological and/or social functional capacity.
A systematic review by Crocker et al. [8] and the National Board of Health [9], describes that the current evidence points in different directions regarding the significance of rehabilitation efforts to physical function for older people in long-term care. Regarding the impact of rehabilitation efforts on social participation and activity, as well as isolation and loneliness, the National Board of Health [9] concludes that there is evidence for a positive effect, although the extent of the effect is uncertain.
Rehabilitation efforts are largely context-dependent and have many involved professional groups working together on enhancing the citizen's personal goals and meaningfulness of a meaningful daily life [10]. What is meaningful for a citizen is not necessarily meaningful for other citizens. At the same time, achieving a wish or goal at, for example, participation level will be closely linked to the individual's function and activity level and be related to context and environmental factors [10].
In this study we aimed to investigate true goals for meaningful life and activities in nursing home residents and secondary we aimed to investigate the staff perspective of how they in their daily work and by means of "Improved Elderly Life" contribute to the fulfilling of these true goals.

Methodology
Interviews were generated in two nursing homes in the municipality of Aalborg. The one nursing home is located in a larger city and has 50 homes, and the other nursing home is located in a smaller town in the suburb and has 30 homes.
Two types of interviews were used. Ten individual interviews with residents and two focus group interviews with a total of nine employees (caregivers and members of the basic training and activity team).

Resident interviews
Residents were selected by the associated basic team, based on criteria that they should have lived in the nursing home for at least 2 months, have been in contact with the basic training and activity team and should be able to enter into a reflective dialogue on everyday living in nursing homes. This was in order to be certain of the residents` ability to carry through an interview session, due to physical and psychological strength and cognitive abilities. Finally, we strived for a selection of participants which was not distinctly homogenous and represented both gender. As the focus of this study was to describe, interpret and understand what true, meaningful activities and rehabilitation is to the individual nursing home resident, a qualitative method with a phenomenological hermeneutic approach was used. Semi structured interviews based on a semi-structured interview guide inspired by Kvale and Brinkmann [11] were carried out.

Focus group interviews with staff
In order to achieve group dynamics and social interaction during the interview, a total of 5 people working with the same residents were gathered in each interview. The number of participants was chosen based on a consideration that participants come from different professions and are organized under three different managers, and therefore may have many different perspectives and attitudes to be addressed during the interview situation. The basic training and activity team, consist of a physiotherapist, an occupational therapist and an activity employee. These were combined with the permanent nursing staff in order to create homogeneity as well as heterogeneity of perspectives during the interviews, which will contribute to interaction, but at the same time allow the participants to relate to each other and enter into dialog [12]. A semi-structured interview guide was used as the focus group's experiences of a particular phenomenon, the core task in relation to achieving a meaningful daily life partly by the means of "Improved Elderly Life", was in focus.

Data analysis
Interviews were recorded and transcribed verbatim. All interviews were analyzed based by thematic analysis including encoding of passages of where the informants constructed meaning, beginning with initial readings of both individual transcriptions and focus group interviews. Thereafter initial codes were identified and reviewed for themes. Themes were then defined and named. All authors were involved in the analytical process and differences were solved by rereading, reanalysis and dialogue.

Ethical considerations
Prior to inclusion, the patients were given written and oral information about the interview aim, content and practicalities. The participants were informed that they at any time before or during the interview could withdraw from participation. The study was conducted according to the rules of the Helsinki Declaration of 2002. The study was not within claim of notification with the local ethic committee.

Findings and Results
The interviews included six female and four male nursing home residents, aged 77-91 years, who had been living in the respective nursing home for six months to four years. The findings in nursing home are presented within the following five significant themes, used as headlines to the passages.

Resident's perception of a meaningful life to use oneself and to be of use
Residents find it meaningful to have good social relationships. They value having the feeling of being able to contribute to the community and to have close ties with their family. It is very important for them to be able to decide on their own lives and what activities they want to do and prioritize. Helping others is given great importance and contributes to the sense of meaningfulness. Being able to be self-sufficient, both in terms of cooking, doing the laundry and cleaning is meaningful, but routines at the nursing home mean that residents are not always involved to the extent they actually can. Residents express more focus on the goal of an interesting activity than to actual physical function.
The meaning of helping others, being something for others and contributing to the community as expressed by a male resident; "Yes, for example, if they (staff) need to have something moved (i.e in the yard), they ask me and of course I'll help. So yes, I feel I can make a difference for those around me".
It is also important to feel recognized, as a female resident describes; "The staff is setting the table for us, I cannot help clearing the table. There's a place in me, so I take both my own and those who are done. Then I take it straight up and put it (dishes) on the table, so the girls put it in the washer, I just cannot help myself. It's just me and the girls say "you're so good at helping us". Many times they have enough to see to anyways".
Most residents consider it important to remain self-reliant as it contributes to their perception of meaning. Several residents mention the importance of having a walking function, with the goal of doing what they want in everyday life, and to be able to participate in activities out of the house. A female resident reflects; "I've really become weaned off doing things myself, but it's important for me to get up and wash myself, and I feel most comfortable doing it without help".
Another female resident reflects on having help for housework; "Taking care of home and garden, has always been important to me, and I have always done the cleaning and cooking myself. Here I have someone to do it on a regular basis, and the laundry is taken care of for us". "I'm happy with everything here, -the way they come and knock on the door in the morning-they pour my oatmeal for me and they make my tea for me. Well-they do not do it every day, I do that too, I feel well treated here".
A male resident explains how he found it very difficult to be allowed to help around the place, when he first moved into the nursing home; "They had a little trouble when you'd start helping them even just a little. It was like "you don´t really get it-you are in a nursing home now". Now they don't say anything. For example, in the morning, now I fetch and pour my cereal myself. In the beginning, they would not let me. Now nobody says anything, so I can just go up and take what I need and then go back to the table".
Thus, there is a construction in the interaction between residents and staff that it is natural that residents receive help for everyday activities at the nursing home, although they may and may rather do the activities themselves. Thus, the residents, even doing what they can, while wanting to be a "good" caretaker, who does what they think, is expected, while at the same time wanting to live an independent life like before they came to a nursing home. The social involvement about the meals is the residents all happy and satisfied with, and most of them eat all the meals of the day together with the other residents.

Social communities
Being social is meaningful to all participants, although in different perspectives. Two residents mention that the social aspects of the activities mean much more to them, than the content of the activity itself.
"Sometimes they make social events here, -worship services and such things. But I would really like to have some more".
Residents mention the importance of having friends as something that gives content and recreation in life.
"Having and seeing good friends mean the world to me, -it's when you are in a crisis that you find out who are your true friends".
Being able to socialize, have friends and see their family is thus of just as great importance to residents of nursing homes, as to others.

Meaningful activities
The residents participate in activities at the nursing homes, but have suggestions for alternative activities because many of the offered activities are not interesting to them. Residents participate in less interesting activities because of the possibility to have social interaction with other residents. It is essential for the residents, who still can, to continue with known activities like getting out in the nature, out in the garden or activities that can be related to the residents' past lives. The value does not relate to the physical benefit of the activity, but the weighted content.
Many residents appreciate and participate in the activities taking place at the nursing home; "Yes, I had traditions at Christmas to bake and such, but it's over that time. They have baked here I have seen, but I cannot participate. One time the others peeled apples, and I cut them apart, and then we baked apple pie".
Most residents participate in the joint activities and the majority experience these as something positive. Another resident does not have a positive attitude towards these activities at all.
"Sometimes they have arrangements in the hall. The other day I was there for singing, but it was freezing down there. It does not make sense to me, I do not want to sit down and freeze. There is also a worship service every 14 days, with a priest coming from the outside, but I do not participate in that".
The understanding that the social aspect of the activity is often being more appreciated than the activity itself is common.
"I rarely do things with the staff, but today we are going to bingo at the activity center. Yes, I can walk over there myself.

ISSN 2574-2825
Vol.3 No.3:9 Yesterday we went to the worship service downstairs in the dining room. Worship service is not important to me, it`s alright as an opportunity to see some other people. No, I do not go to gymnastics, nor did anyone talk to me about it. I actually do not want it either ".
With regard to common physical activity sessions, one male says; "Sometimes I also play boccia, it's not something we usually do with the staff (caring staff). But when basic team (training staff) comes, we sometimes do, but there are many different staff coming, it's something like-they're here for a couple of months and then there's a new one because there have been a lot of people here". The same resident also mentions the many different people in the training staff and that he does not quite know who does what.
A woman tells how she wraps napkins when there is a party at the nursing home and how she helps the lady who provides the flowers at the nursing home. She and a couple of other residents also have a "knitting club" where they knit blankets for less mediated countries. This feature may be related to the informant`s former occupation in the catering industry. It can also, in line with what other residents mention, be seen as a need to feel useful and contributing to the community.
Needlework is an essential element to the existence in more residents, and it creates sadness and frustration when abilities decrease or when the demand for the activity is falling, diluting the social element.
One resident expresses the joy of nature. "The most important thing for me is to walk, so I can go out and enjoy nature, especially when the gardens green during spring. It's especially important for me to be able to go out, without them believing I ran away from here ".

Self-determination and influence on daily life
Most residents placed emphasis on having influence and self-determination towards the aforementioned activities and what makes sense for them is related to their feeling of who they are as persons, and what they have done earlier in life. The residents are very clear around the feel that it is important for them to have an influence on their own daily lives in deciding what to want and do. As one says: "It's very important for me to be able to decide when I'm going to bed". Most residents also mention the self-determination that lies in, for example, to go for a walk and decide what they want to buy. "It's important for me to go for a walk on my own, walking alone-just going for a walk-I'm not that weak yet. Otherwise, the staff will join if I need it. I also want to decide for myself what I want to buy".
Residents experience a range of meaningful activities, but would like to be more involved in the decision-making. This decision-making regards everyday activities and they would prefer more involvement in decisions on a more general daily life level, but also to achieve activities in the house and on out of house excursions that harmonize with their interests and past lives.
Many residents mention the experience of everyday activities such as to make the tea and put laundry together, that they could easily perform, but which are being done for them.

Self-reliance
Most residents consider it important to remain self-reliant as it contributes to their perception of meaning. Several residents mention the importance of having a walking function, with the goal of doing what they want in everyday life and activities out of the house; "I would like to go to the toilet myself, so I do not bother others with it. As long as I can, I'd like to be able to move and I get all the help I need ".
A resident feels she has become accustomed to doing nothing, but expresses the importance of being self-reliant thus; "I've really gotten used to doing nothing, but it's important for me to get up and wash myself, it´s wonderful though, I can do it without help".
A resident expresses the pain of no longer being self-reliant; "If I want coffee, they make coffee for me-it's hurtful not to be able to take care of these things anymore".
Another resident said she would like to continue to be able to go to the toilet on her own. She does not relate maintaining a walking function to the importance of the toilet visit until she, during the interview, becomes aware of the connection.
One male talks about the ability of walking; "I'm fine, I use a walking stick to support me. I go for a walk in the hallways, it's the coach lady who comes and helps me get started. Care staff do not have time for it, they are not too many here. I can go by myself, that's good enough ". Some residents make a connection between gymnastics and self-reliance. As a woman said; "Yes, I go to chair-gymnastics, and I go downstairs myself too. It keeps you going, that means a lot".

Health professionals' opinion of their contribution to the fulfilling of residents meaningful life and activities
The health professionals agree that a meaningful daily life should be related to the residents' own wishes and background. Activities and tools must be based on the residents' wishes and needs and must be adapted to changes made by residents. The respective professions are important for what they consider their own specific tools, but responsiveness to residents' life history, wishes and desires is considered a common core task.
As one employee puts it; "... to enable activities, i.e. if the resident needs a particular activity, then my professional angle will be to enable this activity. Aligned to both the nearest development zone in relation to where the resident is, but also to graduate the activity. For example, they would like to read a book, but they cannot see very well anymore, but we try an audiobook, so to graduate the activity, but still make it possible for them".
Another example illustrates how employees find their most valuable their task as listening, respecting and caring; "Listening, being responsive… We should listen every day to how the resident feels today and what they need from us. All the time be aware of the human angle, that we do this together. If it becomes a routine for me, then I need to find something else to do.... That and yes, to create confidence and trust, so that I feel that I have done a good job, and the resident is happy when I go home".
Another employee continues; "Yes, something to build on, because for instance-when you take her (a specific resident) to see the horses, she can talk about it for several days afterwards, and that's quality of life for her, I'll say it is".
The employees agree that it is important to maintain the residents' level of functioning so that they are as self-reliant as possible, which may be a dilemma for the sake of autonomy and what the residents themselves want and consider important.
All employees find that it is possible, with respect for residents' autonomy, to "nudge" residents to see value in new activities for their own good. It is okay to push the residents a little, in order to maintain their mental and physical functioning, so that they remain most self-reliant. Employees' own professional goals, which they consider to be in the longterm interests of residents, may therefore govern some activities. Professionalism thus drives residents in the direction that employees find best for them in the long term.

Discussion
In this qualitative interview study, we aimed to investigate the consistency of meaningful everyday life and activities in the perspectives of the residents and secondary to the staff´s perception of their contribution to this in nursing homes. Ten individual interviews with residents in two nursing homes were made, and two focus groups with staff including caring staff and training staff.
Residents were selected for interviews by the staff in collaboration with the nursing home manager. Since the purpose of data from residents has been to illuminate experience of what is meaningful for individual residents in nursing homes, the selection did not seek to be representative for the population of nursing home residents in general. Also, it is most likely, that we have not spoken to the most vulnerable residents, since we needed to interview residents with preserved cognitive function, who were able to reflect and elaborate on the questions. Thus, we have not spoken to the most vulnerable residents, who occupy part of the capacity of the nursing homes.
The residents who were selected were very positive about the nursing home and staff, which may mean that the general picture for nursing home residents is that they are experiencing a positive meaningful daily life at the nursing home. Meanwhile, a given possibility is that the most positive residents were selected for interview. Nevertheless, the study was not a quality assessment of the individual nursing home, and this was motivated neither in the interview sessions, nor in the presentations to the nursing home managers. We aimed to seek saturation of data, and found that this was enhanced within the ten interviews. However, we used a semi structured interview guide, and had the interview guide been more open, and had the residents had more strength for longer interviews, we might have found more diversity in data and thus not quite data satiety.
Emphasis in residents is placed on having influence and selfdetermination in what activities they are offered. Many individual perspectives were seen, which underlines the perspective of individuality in old age related to the residentsè arlier lives, rather than being a uniform group of nursing home residents. Nevertheless, the following five significant themes were found general within the nursing home residents: • Resident's perception of a meaningful life in nursing home.
• Self-determination and influence on daily life.
These findings are to some extent in line with earlier findings, where Boelsma et al. [13], found that "Personal Identity and Self-esteem" and "Personal Control and Autonomy" such as by having influencing on offered activities or participating in household work [13]. On a more general level, it can be seen as giving co-determination to residents and avoiding organizational routines and addictions that make the residents helpless, like not being able to make own tea or decide when to go to bed, as mentioned by our participants. Meaningful activities lead to cognitive and social stimulation and self-esteem for residents, for example to contribute socially to the family, community and life at the nursing home as well as to maintain the feeling of being appreciated and helpful [14].
"Meaningful leisure" can include many different activities that suit the needs of residents and that match their previous lives, ranging from watching TV, "knitting club" or taking walks. Participation can be both on an individual level as involvement or as participation at a more organizational level, or socially, as also suggested by Van Malderen [15].
While the most common understanding of rehabilitation, especially by therapeutic means, to a restoration of a damaged or deteriorated physical function, the physical deficiencies are rarely mentioned during the interviews as something that affects the resident's daily lives, and they seem to adapt and accept the limitations of their physical abilities. As in a study by Boelsma [13], findings were that the elderly did not talk about their physical flaws and poor level of function as something they would like to improve. When the health professionals however discussed their contribution, to improving the resident's meaningful life and activities, they acknowledge that this might not be a priority for residents. Nevertheless, while striving to contribute to the fulfillment of the residents' outspoken values in daily life, their professionalism demands that they act upon decreasing physical functioning by nudging residents towards maintaining their physical function. Despite this, there seems to be many possibilities for the basic team as well as the care staff to involve residents in daily household activities that might contribute to maintaining physical functioning as well as contribute to the residents' wishes for meaningful activities, self-reliance and self-determination in daily life.

Conclusion
In this qualitative interview study, our aim was to investigate the consistency of meaningful everyday life and activities primarily in the perspectives of the residents, and secondary to the staff's perception of their contribution to this at nursing homes.
The residents wish for autonomy and individual activities that harmonize with their past lives. The employees and training staff concur with this, however in the daily routines at the nursing homes there is a discrepancy between what is spoken by the employees and what really happens. To a large extent the employees serve on and perform activities for the residents that they might as well do for themselves. This is consistent with findings in the literature that emphasizes autonomy and to maintaining one's identity as important to nursing home residents.
The potential in our results can be beneficial to nursing homes in western countries, with regards to the context, since the subject of including nursing home residents in decisions regarding daily life activities is omnipresent.

Statement of Authorship
All authors equally contributed to the conception and design of the research. Lindholm, Lomholdt and Elmstrøm collected the data and made the primary analysis. Lindholm and Holst drafted the manuscript and all authors revised and wrote the final edition. Holst M, supervised the overall process.

Financial Disclosure
None declared.

Conflicts of Interest
None declared.