Between 1993 and 2012, the proportion of the population that was 65 years old or older in Taiwan grew steadily from 7% to 11.2%. Furthermore, between 2008 and 2012, the aging index soared from 61.5% to 76.2%. The 14.7% rise in this index in only 4 years (Department of Statistics, Ministry of the Interior, 2013) reflects Taiwan’s rapid demographic aging and the advent of an aging society. In addition, with changing family and social structures, elderly people experience less social contact and fewer interactions, weaker support from social networks, and various health problems during the aging process. These problems may cause interpersonal alienation, low intimacy, emptiness, loneliness, and even despair and the loss of meaning in life.
“Senior veterans” is a distinct group of elderly individuals in Taiwan (Veterans Affairs Council, 2014). This group is composed of both military-affiliated individuals from Mainland China who followed the Chinese Nationalist Party (Kuomintang) to Taiwan in 1949 and officially recognized veterans of the Taiwan Straits Battle of 1958 (Veterans Affairs Council, 2014). The two categories of senior veterans who currently reside in veterans’ homes in Taiwan include government funded and self-funded. The former group covers three primary subgroups: senior veterans who have returned to live in Mainland China, live outside veterans’ homes, and live in veterans’ homes. According to the Monthly Bulletin of Veterans’ Statistics, published by the Veterans Affairs Council, the 52,924 government-funded veterans in June 2014 averaged 80.9 years old, with 5352 of these living in veterans’ homes (Veterans Affairs Council, 2014). The number of government-funded residents of veterans’ homes has been diminishing over time (205 fewer in June 2014 than the 5557 reported in December 2013). Furthermore, 949 senior veterans died in veterans’ homes during 2012 (Veterans Affairs Council, 2014). The recent and rapid reduction in the population of veterans has made senior veterans a dwindling sector of society. Little research related to the nursing care of senior veterans has been published.
Most senior veterans are single men, have minimal education, and live in government-sponsored veterans’ homes. The passage of time and changing social structures have largely eliminated the social system that senior veterans once enjoyed in Taiwan (Chang et al., 2010). This problem is particularly acute for senior veterans living in veterans’ homes, many of whom rarely receive care or concern from friends or relatives. With increasing age, more and more senior veterans’ hometown friends and roommates have passed away, causing weaker interpersonal intimacy, solitude, illness, helplessness, depression, a loss of confidence in the value of life, and doubt about the meaning of life (Chiang, 2011). These negative feelings about life have led to depression and suicide among this population (Ku, Tsai, Lin, & Lin, 2009).
To enjoy living to a meaningful old age, senior veterans should have adequate opportunities and the capacity to help themselves plan for a satisfying future life. However, prior research on senior veterans has generally related to health status, depression (Chang & Chueh, 2011; Ku et al., 2009), life satisfaction (Wu, 2011a), suicide, and reasons for living (Chiang, 2011). Only three unpublished studies have considered the issue of meaning of life among veterans in Taiwan. Moreover, few studies have addressed the correlation between interpersonal intimacy and the meaning of life in senior veterans living in veterans’ homes. Therefore, this study investigates interpersonal intimacy and meaning of life among senior veterans in veterans’ homes to provide institutional caregivers with advanced information and to enable senior veterans to more positively and actively face the process of aging.
Interpersonal intimacy refers to the intimate, interpersonal relationships that are formed internally during interactions with other persons or groups. These kinds of relationships are close, safe, reciprocal, and sharing and involve not only sharing personal joy, anger, sadness, happiness, and subtle or intimate knowledge but also mutual understanding, trust, love, and care with others (Reis & Shaver, 1988). Furthermore, relationships of sharing exist not only among intimate partners but also among friends, parents, children, and others (Jamieson, 2002).
Interpersonal intimacy is the most essential part of human development. Maslow (1966) and Erikson (1982) have remarked that intimate relationships alleviate personal pressure, eliminate the sense of isolation, satisfy various psychological needs, provide the recognition required by individuals, assist elderly people in coping with a loss of meaning of and changes in life (Wu, 2011b), and reconfigure constructive responses to these problems. Most older people probably fulfill their fundamental needs through seeking mutual aid, emotional support, and a sense of belonging via intimate interactions with partners, friends, or family members (Cha, Seo, & Sok, 2012; Waite & Das, 2010).
Various studies have indicated that interpersonal intimacy in elderly people is influenced by age, educational level, relationships with family and friends, and self-perceived health status (Calhoun, Donald, & Suzanne, 2002; Liu, 2000; Wu, 2011b). Previous studies have further emphasized that elderly people who lack sufficient interpersonal intimacy experience solitude, the lack of self-affirmation, the lack of meaning of life, and the inability to adapt to changes in life brought on by old age (Calhoun et al., 2002). Consequently, further exploring the interpersonal intimacy of senior veterans in veterans’ homes is essential.
Meaning of life
The meaning of life considers the life missions, goals, and various values of an individual. Frankl, the first scholar to propose the concept of the meaning of life, emphasized the uniqueness of this concept (Frankl, 1963). This concept is composed of the entirety of an individual’s perceptions and feelings about his or her own life and may be explored through creations, experiences, attitudes, and values. Skaggs and Barron (2006), however, defined the meaning of life as the distinct values of an individual and as a process that generates positive or negative results under the influence of life experiences and situations.
Elderly people’s affirmation of life value often depends on whether they possess positive meanings of their present and past life experiences (Pinquart, 2002). Erikson (1982) divided human development into eight stages, with old age categorized as the last stage, in which one’s mission is to achieve self-integrity and to overcome despair. If an elderly person uses his or her accumulated wisdom to achieve self-acceptance, reflect on life, and integrate the meaning of life with personal values, he or she may consider life meaningful. Conversely, a lack of self-integrity results in doubt and despair in life (Erikson, 1982). Life is meaningful for senior veterans who have dedicated their whole lives to their military career, felt worthy of their nation and themselves, expanded their life values to involve their friends, and have known how to give and receive love to make life more valuable (Chiang, 2011). However, for senior veterans who were single when devoting their life to the nation, the ensuing tribulations such as a loss of reliance in old age, the loss of jobs after retirement, and illnesses influence their meaning of life and explanation for the values of life and further cause loss of confidence in life as well as despair (Hou, 2004).
In addition, demographics such as age, educational level, relationships with family and friends, and self-perceived health status have been shown to correlate with meaning of life in the older people at differing levels (Hou, 2004).
Interpersonal intimacy and the meaning of life
The four domains of interpersonal intimacy, including mutual aid, self-disclosure, acceptance with communication, and emotional support, have displayed positive and significant correlations with meaning of life. Lee (2008) indicated that lack of mutual aid and independence are important issues because of their influence on the meaning of life among older people residing in nursing homes. Krause (2007b) found that low levels of self-disclosure and greater feelings of self-suppression related significantly to low perceived meaning of life among older people. In addition, people who gave emotional support to their social network members reported having more positive perceptions of the meaning of life during late adulthood (Krause & Hayward, 2012). Furthermore, Krause (2007a) identified sufficient emotional support as significantly and positively correlated with meaning of life among older people.
The previous assertions indicate the increased importance of theories and knowledge related to the consequences of interpersonal intimacy and meaning of life in the older people. Recent surveys of the older people in Taiwan have centered on medical institutions and nursing homes, with comparatively few focusing on older people in veterans’ homes. In addition, little research has directly examined the correlation between interpersonal intimacy and meaning of life in elderly people. Consequently, an investigation of the correlation between interpersonal intimacy and the meaning of life in senior veterans is necessary. This topic was selected partly because of the importance and lack of exploration of this issue. The research was partly guided by the researchers’ previous work and research experience (Wu, Huang, Kao, & Kao, 2010) and partly guided by these researchers’ personal aspirations. Therefore, this study examined (a) the personal characteristics, interpersonal intimacy profile, and meaning of life of participants; (b) the relationship between personal characteristics and the variables of interpersonal intimacy and the meaning of life; and (c) the correlation between interpersonal intimacy and the meaning of life.
This study used a cross-sectional correlation research design and structured questionnaires to investigate the interpersonal intimacy levels and perceived meaning of life of senior veterans and then analyzed the correlation between these two variables.
Convenience sampling was used to recruit research participants from veterans’ homes in southern Taiwan. This region has five veterans’ homes, with male resident populations of between 322 and 861 residents. To avoid the potential influence of population size, this study recruited from the three homes with populations between 414 and 450 residents. The inclusion criteria were senior veterans who (a) were 65 years old or older; (b) had no evidence of cognitive impairment (Mini-Mental State Examination test score from 24 to 30); could communicate verbally with the researcher; (c) consented to participate; and (d) scored at least 75 on the scale of activities of daily living (ADLs), which reflects the independent functioning status of most senior veterans in these homes. Veterans who had a history of mental illness (e.g., major depression) were excluded from participating.
Samples were assessed according to Cohen’s (1988) bivariate correlation coefficient. The significance level was set as α = .05, the statistical power was set as .8, and the effect size was set as .30–.40 (Polit & Beck, 2008). The estimated required number of samples was 98–174, and the estimated rate of incomplete and rejected questionnaires was 20%. The total numbers of senior veterans who met the sampling criteria in each of the homes were 230 in Home A, 229 in Home B, and 349 in Home C. One hundred twenty-eight eligible participants were interviewed in this study, of which later two (one in Home B and one in Home C) canceled because of hospital visits and six (in Home C) withdrew because of fears of being emotionally disturbed upon learning that the questions related to the meaning of life. The total response rate was 93.8%, and a valid sample of 120 questionnaires was retrieved.
The face-to-face interviews were conducted in the veterans’ homes where participants resided. Before the interviews, the caregivers in the three veterans’ homes assessed the Mini-Mental State Examination results of their respective residents and listed the residents with no cognitive impairments as potential participants. The questionnaire required 30–40 minutes to complete, and the survey was conducted from June 7 to 16, 2013. Data were collected using three structured questionnaires: a personal characteristics questionnaire, interpersonal intimacy scale, and the personal value section of the Purpose in Life test.
Personal characteristics questionnaire
The researchers of this study designed this questionnaire to collect data on the background and current health status of participants.
Demographic characteristics were age, source of income or funds, educational level, religious affiliation, relationships with family and friends during the past year, residential institution, and length of residence.
The health status section contained three categories: self-perceived health status, diagnosed chronic diseases, and number of chronic diseases. Very good self-perceived health status was scored as “1,” and very poor was scored as “4.” The 15 chronic diseases listed included hypertension, diabetes, heart disease, stroke, lung or respiratory disease, arthritis or rheumatism, gastric ulcer or disorder, hepatobiliary disease, renal disease, cataract, hyperlipemia, gout, spinal bone spurs, and cancer.
Interpersonal intimacy scale
The interpersonal intimacy scale was originally compiled by Liu (2000). The 28 items on interpersonal relationships such as love, friendship, and familial affection in Liu’s scale were referenced, with some items revised to fit the needs of the current scale for elderly respondents. This revised scale contained four domains and 16 items, among which five items addressed mutual aid in daily life (e.g., someone gives me support and comforts me when I have trouble and distress), three items addressed self-disclosure (e.g., I feel free to express my feeling when I am with somebody), five items addressed acceptance with communication (e.g., I will not do things of which others disapprove), and three items addressed emotional support (e.g., when people around me are angry, I will comfort them). Participants were asked to score each item according to a 5-point Likert scale based on their actual interactions with family and friends, with higher scores indicating greater intimacy in these interactions.
Wu (2011b) found the interpersonal intimacy scale to be a reliable instrument in his study of 305 older people because of its acceptable content, construct validity, and internal consistency, with a Cronbach’s alpha coefficient of .85. The internal consistency of the developed senior veterans’ interpersonal intimacy scale was reevaluated by Cronbach’s α during the pretest and the formal research, with results of .94 and .91, respectively, which showed the satisfactory reliability of this scale.
Purpose in life test
Huang and Chung’s (1986) Purpose in Life test was employed in this study. The authors reviewed the international literature, translated the original items of this test into Chinese, and added one item, “posterity achievements,” to make the scale more suited for use with ethnic Chinese respondents. The nine items in the scale were distinguished into two factors using factor analysis: personal values and posterity achievements. The reliability of the scale was established in a previous study that calculated a Cronbach’s alpha coefficient of .71 (Wu et al., 2010).
The research participants of this study were all senior male veterans, and most were single, were widowed, or had little contact with their children. Therefore, the subscale of personal values of purpose in life test was adopted. The subscale of personal values contained six items (e.g., I feel I have a fulfilled and valuable life). Items 5 and 6 were reverse worded, and the 4-point Likert scoring method was applied, with total possible scores for the six items ranging from 6 to 24. Higher scores implied more positive perceptions of the meaning of life. Internal consistency was reassessed by Cronbach’s α during the pretest and the formal research, with results of .74 and .71, respectively, which indicated the acceptable reliability of this scale.
This research project was approved by the research ethics committee at National Cheng Kung University (Document no. NCKU-HREC-102-028-1). The senior veterans gave their informed consent and participated in the research by filling out questionnaires after the researchers explained the goals of this study. Data collected during the process of research were kept confidential and processed anonymously to respect the decisions of the participants and to protect their interests.
Data analysis was performed using the Chinese version of the statistical software package SPSS Windows 20.0 (IBM, Inc., Armonk, NY, USA). Statistical analysis was conducted using percentage, mean, standard deviation, t test, variance, and the Pearson correlation test, with the level of significance set to α = .05.
Personal Characteristics, Interpersonal Intimacy, and the Meaning of Life
As shown in Table 1, participants were 69–99 years old. The average age was 83.5 ± 4.6 years, most were 81–90 years old (80%), and the age group with the fewest members was the group of 91 years old and over (8.3%). Slightly over two thirds (64.2%) of the participants were government funded, 45% (n = 54) were uneducated, 51.7% did not hold religious beliefs, 95.0% had contact with members of the Veterans Affairs Council, and 42.5% had lived at their current veterans’ home for a period of 0–3 years. Eighty-five percent of the participants perceived their health status as average or above. Participants had an average of 2.6 ± 1.1 chronic diseases, 35% had at least one chronic disease, and 45% had hypertension. In summary, most of the participants were from older age groups, had frequent contact with members of the Veterans Affairs Council, had a low level of education, were not religious, received government funding, and self-perceived their health status as average.
As shown in Table 2, the average total score for interpersonal intimacy was 55.6 ± 13.1. Item scores averaged 3.5, with the emotional support domain scoring the highest (3.9) and self-disclosure scoring the lowest (2.6). The average total score for meaning of life was 17.9 ± 4.3.
Relationships Between Personal Characteristics and the Variables of Interpersonal Intimacy and Meaning of Life
Table 3 indicates that senior veterans who were self-funded; religious; in regular contact with family, friends, and institutional member; and a resident of Home C had a higher level of perceived interpersonal intimacy than their peers who were government funded; not religious; isolated from family, friends, and institutional members; and a resident of Home A or B. Table 4 reveals educational level and self-perceived health status as positively correlated with interpersonal intimacy, whereas the duration of residence correlated negatively with interpersonal intimacy.
Regarding meaning of life, Table 3 indicates whether contact with family and friends had a significant effect on perceived meaning of life. Table 4 reveals that educational level and self-perceived health status correlated positively with meaning of life, whereas duration of residence correlated negatively with perceived meaning of life.
Correlation Between Interpersonal Intimacy and Meaning of Life
A correlation analysis was conducted on senior veterans’ interpersonal intimacy and the meaning of life. Table 5 shows that interpersonal intimacy, mutual aid in daily life, self-disclosure, acceptance with communication, and emotional support correlated positively with meaning of life. In other words, perceived meaning of life increased with higher levels of these five factors.
Personal Characteristics, Interpersonal Intimacy, and the Meaning of Life
In June 2014, the Veterans Affairs Council (2014) reported the average age of veterans as 80.9 years and of senior veterans as 83.5 ± 4.6 years. Previous studies (Chang & Chueh, 2011; Wu, 2011b) reported the overall average as 81.34 and 82 years old, respectively. The aging of veterans in Taiwan will continue. Nearly all (95.0%) of the participants in this study had prior contact with staffs from the Veterans Affairs Council. We may thus infer that senior veterans require attention, people to talk with, and a feeling that they are respected, which, in turn, produces feelings of wellness and prepares veterans to cope psychologically with their daily situation and their ongoing processes.
Regarding level of education, 45% (n = 54) of participants were uneducated, which echoed the studies of Chang et al. (2010) and Wu (2011a) on institutionalized senior veterans. Furthermore, most of the participants were not religious (51.7%), which also echoed the findings of prior studies of male veterans in Taiwan (Chang & Chueh, 2011; Chung, Chiou, & Chou, 2009). Government funded were accounted for slightly over two thirds (64.2%, 120) of participants, which echoed the results of Chung et al. (2009). Participants had an average of 2.6 chronic diseases, which was similar to the 2.4 chronic diseases found by Wu (2011a) in his study of institutionalized senior veterans. In addition, 85% perceived their health status as average or above, which echoed the finding of Chang and Chueh (2011).
The level of interpersonal intimacy reported by participants was moderate (mean = 55.6 ± 13.1). Of the four domains of intimacy, emotional support had the highest score, and self-disclosure had the lowest, which corresponds to the results of the studies by Liu (2000) and Wu (2011b) on elderly people living in the community. Regarding the relatively low score for the self-disclosure domain, a main reason may be that ethnic Chinese are more reserved, less inclined to reveal themselves and share thoughts with others, and instead, work to understand each other gradually through interactions (Wu, 2011b).
The average score for meaning of life among senior veterans in this study was 17.9 ± 4.3, which is in the upper-middle range. Hou (2004) reported an upper-middle average score for meaning of life among 239 senior veterans in Yunlin and Chiayi counties. Ma (2014) indicated that senior veterans felt that they had done their duty, dedicated their life to the nation, accepted their past, and therefore, tended to assert personal values. The turbulent career experienced by many senior veterans encouraged their deep attempts to capture the meaning of life (Ma, 2014). This may explain the similarity of meaning-of-life scores with those of Hou. However, the personal value scores of the senior veterans in this study were greater than those in Wu et al.’s (2010) research on elderly people (15.1 ± 3.5). This difference may result from the better self-perceived health status of participants in this study, which completes the affirmation of personal values.
Relationship Between Personal Characteristics and the Variables of Interpersonal Intimacy and Meaning of Life
Personal characteristics and interpersonal intimacy
On the basis of the aforementioned analysis results, the quality of participant relationships with family, friends, and institutional members significantly affected their perceived interpersonal intimacy. This result conformed to those of other studies conducted in Taiwan and abroad (Liu, 2000; Waite & Das, 2010), indicating that elderly people obtained care and support, reduced loneliness, and found spiritual solace through interacting with family and friends. The results also revealed that being religious or not, the type of funding, and the specific residential institution all significantly affected the perceived interpersonal intimacy of participants. Cha et al. (2012) indicated that interpersonal relationships (β = 0.22) influenced successful aging among older adults. Krause and Hayward (2012) pointed out that religious elderly people tended to provide emotional support and practice self-disclosure to others. In addition, most self-funded senior veterans were financially stable. Liu (2000) also observed that financially stable elderly people possessed relatively high levels of independence and therefore had confidence and a sense of security in interpersonal interactions. A possible reason for the residential-institution-related impact was that Home C accommodated self-funded residents, which may have led to relatively high levels of independence and favorable social networks and thus to higher levels of interpersonal intimacy than at the other institutions.
The educational level and self-perceived health status of the participants correlated significantly and positively with interpersonal intimacy, which corresponded with Liu’s (2000) and Wu’s (2011b) research results and indicated that higher educational level and more satisfying health status led to superior social skills and improved the ability to resolve conflicts, therefore enhancing the quality of social interactions (Waite & Das, 2010). A significant negative correlation was found between duration of residence and interpersonal intimacy. One possible reason for this may be that senior veterans with shorter periods of residence were less familiar with the environment, system, and group culture in their veterans’ homes and thus more active in interpersonal interactions.
Personal characteristics and the meaning of life
This study showed that whether the senior veterans had relationships with family and friends significantly influenced their personal values with regard to meaning of life. This result conforms to Hou (2004) and Lee (2008) and indicates that elderly people obtained care and support, reduced loneliness, and found spiritual solace through interactions with family and friends. Therefore, being accepted in communications with family and friends related to meaning of life for participants.
Educational level and the self-perceived health status of participants correlated significantly and positively with meaning of life. This result corresponds with the research of Hou (2004) and Wu et al. (2010), showing that higher educational level and higher self-perceived health status result in higher levels of independence, which enables senior veterans to choose their desired lifestyles, to obtain support from others, and to achieve a more positive perception of the meaning of life (Traynor, 2005). Furthermore, this result reveals a significant and negative correlation between duration of residence and meaning of life. Longer periods of residence were associated with greater progression of the aging process, greater deterioration in bodily functions, declining health status, and decreased perceptions of meaning of life.
Correlation Between Interpersonal Intimacy and Meaning of Life
This study found significant and positive correlations between meaning of life and the variables interpersonal intimacy and mutual aid in daily life, self-disclosure, acceptance with communication, and emotional support. In other words, greater satisfaction with the communication of the participants led to more positive perceptions of meaning of life. On the basis of the aforementioned analysis results, senior veterans who had relationships with family and friends held more positive perceptions of meaning of life. As indicated by Huang and Chung (1986), elderly people obtain a sense of belonging and security through interactions with family and friends and thus further gain positive and meaningful feelings.
In addition, being accepted and emotionally supported during communications with family and friends is reflected in the perceptions of elderly people of the meaning of life (Krause, 2007a). Moreover, Dwyer, Nordenfelt, and Ternestedt (2008) observed that elderly people in nursing institutions gained a sense of belonging and felt needed by others through interactions with family and friends, thus creating life meaning. This result corresponds with the research of Stillman et al. (2009) in that loneliness resulted in lower positive perceptions of the meaning of life. Furthermore, with increasing age, senior veterans’ health status declined, and relationships with peers grew superficial. Superficial relationships among senior veterans in veterans’ homes are not conducive to deep sharing and thus increase the sense of loneliness among institutionalized senior veterans over time.
The results of this study indicate that the variables that cause statistically significant differences in the interpersonal intimacy of senior veterans living in veterans’ homes include source of funding, residential institution, religious belief, quality of relationships with family and friends, educational level, self-perceived health status, and duration of residence. The relevant variables that caused statistically significant differences in meaning of life among participants included quality of relationships with family and friends, educational level, self-perceived health status, duration of residence, interpersonal intimacy, mutual aid in daily life, self-disclosure, acceptance with communication, and emotional support. In other words, senior veterans who maintain regular contact with family and friends, have higher levels of education, have shorter periods of residence, have better self-perceived health status, have more interpersonal intimacy, have mutual aid in daily life, practice self-disclosure, accept communication, and receive emotional support tend to have more satisfying perceptions of meaning of life.
Limitations and Suggestions
This study used a cross-sectional research design. Therefore, the results are not generalizable to elderly people living in other veterans’ homes or nursing institutions in Taiwan because of restrictions pertaining to regional considerations, sampling method, and sampling criteria. In addition, this study recruited only senior veterans who were completely independent in terms of performing ADLs and excluded those who were partially independent or had varying levels of dependence. Consequently, the research results represent only the relationships between interpersonal intimacy and meaning of life among senior veterans with satisfactory ADL functions in the three veterans’ homes investigated in this study. Future studies may use enlarged sample sizes by randomly selecting senior veterans at various levels of ADL dependence to compare and analyze the differences displayed in interpersonal intimacy and meaning of life and increase the generalizability of the research results. Furthermore, future studies may conduct qualitative research and in-depth interviews to explore interpersonal intimacy and meaning of life among this population.
Implications for Practice
Health professionals involved in the care of senior veterans in institutions may use the results of this study to enable senior veterans to confront old age in a positive manner by providing intervention programs such as cooperating with other veterans’ homes or external organizations to hold regular life care, religion and spirituality, and leisure activities that expand the social circles of senior veterans, reduce interpersonal isolation, advocate a higher degree of interpersonal intimacy, and promote positive perceptions of meaning of life. Furthermore, this study suggests that the most meaningful life for a senior veteran may be achieved by overcoming the impact of the aging process through continuous contact with other human beings, including family members, friends, volunteers, and health professionals. This contact may provide caring, understanding, and support to senior veterans, and by doing so, these veterans may perceive a higher degree of interpersonal intimacy and a reduction in the negative effects on meaning of life of the duration of residence.
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Keywords:Copyright © 2016 by the Taiwan Nurses Association.
senior veterans; interpersonal intimacy; meaning of life; veterans’ homes