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2.1 Introduction

In reviewing the literature on spiritual well-Being in the Chinese context, it becomes clear that Chinese spirituality has not yet been systematically studied. Not only is there a lack of theoretical discussion of its conceptualization, but the underlying mechanism has not been studied or developed. Against this background, one can identify three features that deserve special attention. The first is the strong influence of Confucianism on the Chinese people over the past few thousand years. On top of that, however, Chinese society also includes followers of Buddhism, Taoism, Christianity, Islam, Hinduism, Sikhism, Judaism, and Chinese folk beliefs (Hong Kong SAR Government 2013). Secondly, according to Confucianism, life and death are two sides of the same coin. As one Chinese proverb puts it, “only when we know what is life can we know what death is” (Wei Zhi Sheng Yan Zhi Si). There is no deliberate discussion of life after death in Confucianism. Therefore, it is more desirable to define spiritual well-Being by focusing on the concepts of the meaning of life or life energy. The third point refers to the self-constructions of the Chinese people. Spiritual pursuits are always self-fulfilling processes where one seeks to achieve meaning through a series of practices. Accordingly, the interdependence and social orientation of the Chinese people must be taken into consideration in the understanding of their spirituality.

Even with the above three observations in mind, it must be admitted that we still know very little about the meaning of spiritual well-Being, or the meaning of life, to Chinese older adults. The best way to find answers to these questions is through qualitative research. I, and my research team, therefore decided to conduct a qualitative study using focus groups and in-depth interviews. We treated older adults and other stakeholders (including both family and formal caregivers) as experts and jointly constructed the meaning of spiritual well-Being through the research process. We also shared a clear and strong passion for our ultimate goal: to develop effective interventions to enhance spiritual well-Being among Chinese older adults.

2.2 Method

2.2.1 Design

The research team originally proposed to conduct focus groups in both Hong Kong and Shanghai among four groups of stakeholders (community-dwelling older adults, residents of institutions, family caregivers, and formal caregivers). After conducting some focus groups, however, some of our research team members observed that a group setting might introduce barriers to some older participants sharing their views openly. Hence, individual in-depth interviews were also conducted with older adults.

2.2.2 Participants

Eight focus groups were conducted with members of the four stakeholder communities identified above. Participants were recruited from service providers for older adults in Hong Kong and Shanghai. Additionally, agencies in Hong Kong were used to recruit interview participants. The validity and usefulness of focus groups is affected by the extent to which participants feel comfortable and can openly communicate their ideas, views, and opinions (Stewart and Shamdasani 2014). It is therefore very important to select the right people to participate. Purposeful sampling using strata was adopted in the process of recruiting participants. The literature suggests that gender, health, financial status, and religious background are relevant factors (Gomez and Fisher 2005; Lawler-Row and Elliott 2009). For older adults, special attention was paid to age, gender, health, financial status, and religious affiliation. For family caregivers, the focus was on their relationship with their care receivers and religious affiliation. For formal caregivers, the priorities were their professional training, work experience, and religious affiliation. Bringing together participants with diverse backgrounds and/or socioeconomic characteristics can stimulate the sharing of different views, ideas, and opinions during the discussion so as to balance the diversity and depth of the data (Stewart and Shamdasani 2014).

On this basis, four inclusion criteria for older participants were identified: (1) aged 65 or above; (2) cognitively intact; (3) able to communicate in Cantonese (Hong Kong) or Shanghainese (Shanghai); and (4) willing to take part. We tried to recruit equal numbers of men and women among community-dwelling older adults and a ratio of 2:1 male:female among institutional residents, as suggested by a Census report on gender distribution (Census and Statistics Department 2009). Moreover, the team also tried to recruit equal numbers of participants with different financial status (claiming social security vs. not claiming), health status (healthy vs. frail), and religious affiliation (yes vs. no).

The inclusion criteria for family caregivers were given as: (1) aged 18 or above; (2) having at least two years of caregiving experience; (3) cognitively intact; and (4) able to communicate in Cantonese (Hong Kong) or Shanghainese (Shanghai). The ratios of spousal and child caregivers, and religious affiliation (yes vs. no) were fixed at 50:50. For formal caregivers, the inclusion criteria were having at least two years’ experience taking care of older adults professionally. The aim is to recruit from diversified professional backgrounds (such as nurses, occupational therapist, physiotherapists, social workers), status (including both professional staff and frontline workers), and religious groups. A total of 65 informants were successfully recruited, all of whom participated in either a focus group discussion or in-depth interview. Table 2.1 summarizes the characteristics of the participants.

Table 2.1 Participant characteristics
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2.2.3 Procedure

The focus group and in-depth interviews were guided by semi-structured discussion/interview guidelines. These attempted to shape a focused, conversational, open, and two-way approach to communication (Harrell and Bradley 2009). The focus group guidelines were drafted based on a literature review and discussed by the research team. Two pilot groups were then conducted with 11 institutional residents (4 in Hong Kong and 7 in Shanghai) in December 2009 and January 2010. The researcher and a research assistant have co-facilitated these groups. Each lasted for around 120 min, with 90 min of discussion in accordance with the proposed guidelines followed by a 30-min discussion of the logic of the procedure, the appropriateness of the questions, and the openness of the discussion. The pilot groups and debriefing sessions supported the feasibility and applicability of adopting the proposed guidelines.

Four theme questions with follow-ups were shared among the four focus groups. Table 2.2 lists these questions for the older adults. For family and formal caregivers, the questions were rephrased accordingly (for example, “based on your experiences, what is the meaning of life for the older adult(s) you are taking care of?”). During the discussion, the researcher interjected follow-up questions when necessary.

Table 2.2 Theme and follow-up questions for older adult participants
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After discussing the four main questions, two general questions about religiosity and spirituality were also asked:

  • What is your view of the role of religious ritual (such as worshiping God, the Buddha, or ancestors) in relation to the process of actualizing your meaning of life or gaining life energy?

  • We will say a word and ask you to share any thoughts and feelings that come to mind after you hear it. The word is spirituality (Ling Xin).

Participants were invited to share their perceptions and feelings freely. These questions were intentionally placed at the end of each session, considering the lack of familiarity in Chinese culture of these topics and/or the diverse practices and understanding of religiosity and spirituality.

All the focus groups and interviews were audiotaped and the researcher also took notes to record observations and reflections in the process. Furthermore, supplementary notes were made immediately afterward where the researcher had identified something else which might be significant to the data collection and analyses.

2.2.4 Data Analysis

The data analysis followed an interpretive approach with the aim of examining the conceptualization of spiritual well-Being among Chinese older adults. It suggested a three-step procedure with preunderstanding, interpretation, and understanding as the central elements (Alvesson and Skoldberg 2009).

The preunderstanding in this context was the conceptualization of spiritual well-Being established by the literature review, as discussed in Chap. 1. In summary, the preunderstanding the research team developed suggested the following three themes. Firstly, since Chinese older adults will have been strongly influenced by Confucianism, meaning and purpose, self-transcendence, and harmonious relationships were expected to be the core elements of their conceptualization of spiritual well-Being (Vachon et al. 2009). Secondly, the Chinese translation of “meaning of life” (Sheng Ming Yi Yi) could be used interchangeably with “spiritual well-Being” (Ling Xin) in the qualitative inquiry. Although the key questions asked are about the meaning of life, it is still worthwhile to explore the understanding of spiritual well-Being (Ling Xin) within these Chinese older adults’ own discourses. Thirdly, according to a recent review of spirituality at the end of life, spiritual well-Being is a multidimensional construct that includes values, beliefs, attitudes, and behaviors (Vachon et al. 2009). It is thus suggested that spiritual coping be included as a component of this initial stage of the inquiry. Such a preunderstanding laid the foundations of the focus group and in-depth interview guidelines. However, all members of the team kept an open mind throughout to allow new discourses to emerge from the data to balance and shape this preunderstanding.

The interpretation and centering process consisted of five further steps (Alvesson and Skoldberg 2009; Willis et al. 2007). At the beginning, the researcher reviewed the focus group and interview processes with the field notes. This was done as a check that the process overall had facilitated open sharing and discussion, the researcher had taken a natural role, and the guidelines had been constructively followed. The audiotapes were then transcribed verbatim by trained research assistants familiar with Cantonese and Shanghainese. The transcripts were proofread by another research assistant to ensure accuracy. Open coding was then conducted by one researcher and two research assistants independently to identify themes emerging from the data. While the theme questions were treated as reference points to probe answers, it is always possible that discussion and sharing can take place across questions and new themes emerge. After the first round of coding, the researchers compared the similarities and differences of their coding and agreed the use of 512 codes. At step three of the processes, the team members read through these 512 codes to identify primary (categorical) and corresponding secondary themes. The transcripts used to code for the secondary themes were then reviewed to ensure that an appropriate interpretation had been achieved. In the last step, the research team interpreted and discussed the data and compared them against the preunderstanding and findings of prior studies.

The trustworthiness and accuracy of the data were ensured by adopting the following strategies. Firstly, the inclusion criteria for focus group and interview participants were decided on the basis of a literature review so as to ensure its appropriateness. Secondly, the data from the focus groups and interviews were used to supplement each other so as to maximize the diversity of views and opinions gathered. In fact, after the focus groups, it emerged that the group setting might be a barrier to older participants sharing certain concerns, in particular negative experiences with family members, since Chinese people tend to believe that “family matters shall not be shared with outside people” (Tse et al. 2012). As a result, the use of in-depth interviews was also proposed. Finally, a balance was struck between the preunderstanding of the concept of spiritual well-Being and how it is pursued in the Chinese context at all stages of the analytical process (Morse et al. 2002).

2.3 Findings and Discussion

Table 2.3 summarizes the primary and secondary themes emerging after the data analysis was complete. There were 6 primary themes, in line with the preunderstanding, and 16 corresponding secondary themes, all supported by the verbatim transcripts of the focus groups and in-depth interviews.

Table 2.3 Primary and secondary themes of spiritual well-Being
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2.3.1 Meaning of Life

According to the verbatim transcripts, the meaning of life manifests itself in the process of lifespan development. This emerged from the discourse of three secondary themes: life appreciation, purpose in life (no regrets), and harmonious family. While many informants tended to say that the pursuit of the meaning of life is a highly individualized process, there was also a consensus that social expectations of individuals, or in other words the recognition of those around us, serve as a reference point for what it means to live a meaningful life. Hence, being cared for and loved when in need was cited as examples of life appreciation. As one community-dwelling man said, “I feel that life is meaningful when I sense love and care from the people around me when I am in need. Otherwise, I feel very sad and meaningless” (M, 90–99 years, living with spouse, no religious affiliation, not claiming social security).

Having a purpose in life that can energize one to meet responsibilities was another secondary theme. Participants felt that in order to have a meaningful life, older adults should be able to have a purpose, jointly constructed from cultural and social expectations, family background, gender, and life course development. As one daughter caregiver said, a meaningful life “just means that you have done your basic tasks in your life (according to social expectations). Sometimes, you are not even aware or have time to reflect. But you know that you have fulfilled your responsibility and feel no regret for your life” (F, 50–59 years, family caregiver, Buddhist, not claiming social security).

A harmonious family was the third secondary theme emerging as a manifestation of the meaning of life. Participants felt that having a family with whole features (Wan Wan Zheng Zheng) including good interpersonal relationships, filial children, and good child development was associated with a meaningful life. One community-dwelling older adult said that “after so many years of hard work, my children all have decent jobs, are financially independent, and show their filial responsibility. I feel satisfied and happy. You know, it is not easy to have every one of your children achieve these things” (F, 75–79 years, living with spouse, not claiming social security).

2.3.2 Spiritual Affect

The data also showed that both positive and negative emotions were associated with feelings of spiritual well-Being and distortion. On the positive side, the feelings mentioned include joy, satisfaction, comfort, lack of regrets, and freedom. One institutional resident said that “I have been living here (long-term care facility) for six years, I participate in various activities and have met new friends. I feel very contented (Man Zu)” (M, 80–89 years, Christian, claiming social security). Similarly, one community-dwelling older adult said that “now I feel peaceful and joyful (An Le), I feel from my heart so that I say it. I will have no regrets if I die shortly.” (F, 80–89 years, no religious affiliation, not claiming social security).

On the negative side, participants expressed hopelessness, unhappiness, and a sense of emptiness. One spousal caregiver said that “sometimes we feel so desperate; in other words, we cannot see our future and dare not hope for any positive change” (F, 60–69 years, no religious affiliation, not claiming social security). An institution resident said that “when I lost my life energy, I felt unhappy” (F, 90–99 years, no religious affiliation, claiming social security) and a care worker said “I can feel their emptiness when residents lose their life meaning. Their heart is gripped (by negative life energy)” (F, 40–49, Catholic).

2.3.3 Transcendence

The primary theme of transcendence was supported by three secondary themes, which referred to the transcendence of the past, present, and future. Using time as a frame of reference to define transcendence was regarded as more relevant to the life experiences of Chinese older adults in a nonreligious sociocultural context. Time is fair to everybody, with or without a religious affiliation. These informants showed their wisdom and desire to achieve time-directed transcendence by consolidating their life experiences and letting go, living fully in the present moment, and preparing for the future.

As one institutional resident said, along a person’s lifespan “interpersonal conflicts usually happen and are unavoidable. Sometimes it is due to personality, and sometimes it is due to the environment. I have thought this through and let go (Kan Kai Le)” (M, 70–79 years, no religious affiliation, not claiming social security). Another community-dwelling older adult echoed this, saying that “I have looked through this (Kan Kai Le). My life has no regrets even though I have unfulfilled dreams. But I understand reality has always been with constraints and I have learned to let go” (M, 80–89 years, living alone, not claiming social security).

Another community-dwelling older adult said that “it is so important that I can enjoy my everyday life by going to the community elderly service centre. Now my children are all grown up and have their own lives. I can put them down and focus on engaging in different activities to enrich my life, such as going on outings, having my blood pressure and blood sugar level regularly checked, consulting on my medication, and so on” (F, 75–79 years, live with spouse, no religious affiliation, not claiming social security).

Most of the informants said that they wished to have a peaceful dying process. They all understood that they could not know what would happen when death comes to them. Therefore, they expressed their strong will not to be a burden to the people around them, particularly their children. One institutional resident said that “it is unwise to wait for my children to deal with arrangements after my death. They may not know what I want. Therefore, it is wise (to tell them what I want when I am still alive)” (F, 80–89 years, not claiming social security).

2.3.4 Relationship Harmony

Under the primary theme of relationship harmony, the transcripts showed that the discourses can be differentiated in terms of at least four types of relationship: with self, family, others, and death. In regard to the relationship with the self, the basic themes were self-care to maintain physical and mental health, taking responsibility according to moral standards, and self-management to ensure interpersonal harmony. One institution resident said that “the most important thing is to keep your physical and mental health. Love and care from others then can add extra joy” (F, 80–89 years, Buddhist, not claiming social security). Another participant who lived in the community echoed this, saying that “keeping healthy is very important. I do morning exercise daily including jogging for 15 min. I also pay attention to my diet and keep my heart open (Kai Long)” (F, 70–79 years, living alone, no religious affiliation, not claiming social security). An institutional resident said that “I have tried my best to fulfill moral standards. I am rational, avoid conflict, and am conscious of what I say… I feel I have really achieved this and feel proud” (F, 80–89 years, no religious affiliation, not claiming social security). A daughter caregiver explained that “sometimes older adults will say no in order to fulfill others expectations (it is always desirable to be humble in a Chinese context). My mother is this type of person” (F, 50–59, no religious affiliation).

In terms of the relationship with family, the basic themes emerging included having a complete family (Wan Zheng Jia Ting), enjoying harmonious interactions with family members, and having a supportive family who show respect and care. An institutional resident felt that “the most important thing is encouragement and respect from family members. You may say I am old stuff. But I still want to say this” (M, 70–79 years, no religious affiliation, not claiming social security). This was echoed by another respondent who explained “I feel happiest when my children come to visit me. We then go out for a meal and chat during our meal time. Usually I will bring some food back home after the meal” (F, living alone , 80–89 years, no religious affiliation, not claiming social security). Another adult living in the community explained that “my children are not living in Hong Kong. My grandchildren are also living somewhere else. They are not close. Now I have my spouse only and wish the government would care more about us” (F, 89–89 years, living with spouse, Daoist, claiming social security).

The themes emerging around relationships with people other than family members included the importance of interpersonal interactions in the community (outside the family), gaining recognition through social participation and interaction, and possible differentiation between friends and other people. One community-dwelling older adult said that “my son visits us occasionally. Other than that, we visit the community elderly centre almost every day. I know people there. We chat and feel happy” (F, 80–89 years, living with spouse, no religious affiliation, claiming social security). A care worker said that “through participating in our interest group, Mr Chan learned how to send e-mails. He was then able to teach his daughter-in-law and felt very proud of this” (F, 50–59, no religious affiliation). An institutional resident said that “it is important not to gossip. Today you gossip about others, tomorrow you will be the person that is gossiped about. Hence, I will not engage in gossip (I will talk with friends but not those who gossip)” (F, 90–99 years, no religious affiliation, claiming social security).

Finally, the secondary theme of the relationship with death was focused around the concepts of expectations of a good death and a sense of destiny. The predominant theme was strong expectations of a good death, which was linked to dying peacefully and quickly. As one community-dwelling older adult put it, “a good life is no better than a good death. It is OK if I suffer, but burdening my children is the worst thing that I could imagine” (F, 70–79 years, living with spouse, no religious affiliation, not claiming social security). Death was also associated with a sense of destination by nonreligious informants. One said that “life and death is all by destination. Just like the Chinese proverb says, you ‘cry three times when you were born, then your life follows your destiny’ (Luo Di Ku San Sheng, Hao Chou Ming Sheng Cheng” (F, 70–79 years, living alone, no religious affiliation, not claiming social security).

2.3.5 Spiritual Coping

Participants described using both self- and others-oriented coping strategies when they felt spiritually disturbed or that they had lost a sense of meaning. Self-oriented coping strategies included self-transformation and patience, while others-oriented approaches included help seeking and expressing needs directly. As one community-dwelling older adult explained, “I will stay away from him (her husband, with whom she had a conflicted relationship) during the daytime. But I have nowhere to hide in the evenings. He continuously annoys me and I continuously restrain myself. Sometimes I feel very fearful and have a headache” (F, 80–89 years, living with spouse, no religious affiliation, not claiming social security). An institutional resident said that “when I feel hopeless, I will approach the nurse in charge of the nursing home for a discussion” (F, 70–79 years, Buddhist, not claiming social security).

2.3.6 Contextual Factors

Class and gender were two of the dominant secondary themes in this category. Their influences usually intersected one other, influencing resources and constraints as the individual searched for meaning and sought development throughout the lifespan. For example, a care worker said that “for me, it is obvious that some older adults have allocated more resources to their sons and grandsons as compared to their daughters and granddaughters during their life course. Now they are old, they have higher expectations and sometimes biased perceptions towards their sons’ family as well” (F, 20–29 years, no religious affiliation). An institutional resident said that “the most important thing (for the meaning of my life) is having sufficient financial support. I am lucky that I could afford to pay the fees for my institutional care. On top of that, I still have some pocket money to buy my favorite foods or eat out occasionally. If I didn’t have money, I would feel hopeless” (M, 80–89 years, no religious affiliation, not claiming social security).

Responses to the last two questions (the role of religion on spiritual pursuits and understandings of the word spirituality) confirmed that religious practice is associated with a contextualized understanding of spirituality among these Chinese older adults. For some of those who had a religious affiliation, spiritual pursuits were associated with corresponding rituals and religious practices. One institutional resident said “I strongly believe in Christianity. The meaning of my life comes from God. God gives me everything and I wish God’s blessings to be spread to every resident in this nursing home” (M, 80–89 years, Christian, claiming social security). This was echoed by a care worker who explained that “when older adults have religious belief, no matter whether it is Christian, Catholicism, or Buddhism, they will gain meaning of life from it. For example, Christianity teaches believers to serve others. Then older adults would have this as their purpose in life” (F, 20–29 years, Christian). However, some informants had a more pragmatic perspective on the association between religion and spirituality. One community-dwelling older adult said that “formal religious belief can generate benefits. Traditional worship can also generate benefits. Just like the proverb says, ‘human beings worship for God’s protection; grass grows when spring arrives’” (F, 80–89 years, religious, not claiming social security). The analyses further confirmed that spirituality itself was regarded as a strange term by most participants. It is often associated with space or a feeling of being outside the material word. The words or phrases which came to mind included odd, floating, superpower, intuitive, beyond knowledge and thinking (that is, when you think, then you do not have spirituality).

In summary, these qualitative data analyses have identified 6 primary themes of the conceptualization of spirituality, manifested through 16 secondary themes. This chapter has set out exemplar verbatim quotes from various participants which support and illustrate each secondary theme. These findings seem to support the preunderstanding proposed by the research team at the outset, based on a literature review. The empirical work has added secondary and basic themes in support of the six primary themes, reflecting a more contextualized understanding of the meaning of life. For example, relationship harmony appears in almost all the primary themes and is also supported by over a third of the secondary themes.

2.4 Limitations

The qualitative inquiry provided an excellent opportunity for the research team to examine the concept of spiritual well-Being in a Chinese context. However, it has several methodological limitations. Firstly, even though the preunderstanding of spiritual well-Being was based on a thorough literature review, it is impossible to completely exclude any bias from the research team. Secondly, while the data collection and analyses followed a five-step approach, underpinned by three strategies to ensure truthfulness and accuracy, the unfamiliarity of the topic and the small sample size must still be borne in mind when interpreting the results. Thirdly, the ultimate goal of the overall project was to develop an effective intervention for the enhancement of spiritual well-Being among Chinese older adults. This requires a well-established conceptual framework acceptable to the various professional stakeholders working with this client group. As a result, the research team elected, at the conclusion of the qualitative work, to conduct an additional Delphi study that was not included in the original research plan. This forms the subject of the next chapter.

2.5 Conclusion

In order to examine the concept of spiritual well-Being or the meaning of life among Chinese older adults, a qualitative inquiry was carried out. Eight focus groups were held in Hong Kong and Shanghai with a total of 61 members of four key stakeholder groups (community-dwelling older adults, institutional residents, and family and formal caregivers). The researchers also reflected on whether or not there might be barriers to older adults sharing family concerns in group settings, and accordingly also conducted four in-depth individual interviews after the group work was complete. Semi-structured interview and focus group guidelines were developed and piloted in both Hong Kong and Shanghai. The data collection and analyses followed an interpretative approach with four strategies adopted to generate truthful and accurate results. The findings support a framework of spiritual well-Being comprising 6 primary and 16 secondary themes. Having considered the implications, in order to achieve the ultimate goal of the project (e.g., to develop an effective intervention to enhance spiritual well-Being), the research team suggested a Delphi study to achieve consensus among a multidisciplinary professional group.