Suffering and mental health among older
people living in nursing homes—a
mixed-methods study
Jorunn Drageset1,2 , Elin Dysvik3 , Birgitte Espehaug1 , Gerd Karin Natvig2
and Bodil Furnes3
1 Faculty of Health and Social Sciences, Bergen University College, Norway
2 Department of Global Public Health and Primary Care, University of Bergen, Norway
3 Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Norway

ABSTRACT

Submitted 31 March 2015
Accepted 2 July 2015
Published 30 July 2015
Corresponding author
Jorunn Drageset,
Jorunn.Drageset@hib.no
Academic editor
Lia Fernandes
Additional Information and
Declarations can be found on
page 14
DOI 10.7717/peerj.1120
Copyright
2015 Drageset et al.
Distributed under
Creative Commons CC-BY 4.0
OPEN ACCESS

Background. Knowledge about mixed-methods perspectives that examine anxiety,
depression, social support, mental health and the phenomenon of suffering among
cognitively intact NH residents is scarce. We aimed to explore suffering and mental
health among cognitively intact NH residents.
Methods. This study used a mixed-methods design to explore different aspects
of the same phenomena of interest to gain a more comprehensive understanding.
The qualitative core component comprised a qualitative interview from 18 nursing
home residents (≥65 years) about experiences related to pain, grief and loss. The
supplementary component comprised interview from the same respondents using
the SF-36 Health Survey subscales, the Hospital Anxiety and Depression Scale and the
Social Provisions Scale.
Results. The individual descriptions reveal suffering caused by painful experiences
during life. The quantitative results indicated that symptoms of anxiety and
depression were related to mental health and symptoms of anxiety were related to
bodily pain and emotional role limitations. Attachment and social integration were
associated with vitality and social functioning.
Discussion. To improve the situation, more attention should be paid to the residents’
suffering related to anxiety, depression and psychosocial relations.
Subjects Geriatrics, Nursing, Psychiatry and Psychology, Palliative Care
Keywords Suffering, Mental health, Mix-methods, Nursing homes

INTRODUCTION
Nursing home (NH) residents without cognitive impairment comprise a minority of
NH residents and often have somatic and/or other mental health conditions (Nygaard,
Naik & Ruths, 2000; Linton & Lach, 2007; Selbaek et al., 2007). NH residents may also
experience stressful events such as relational losses, loss of home and loss of spouse,
relatives and friends. Such conditions may cause them to experience suffering (Morse,
2001; Cassel, 2004; Ferrell & Coyle, 2008) and affect both mental and physical health (Travis
et al., 2004; Garcia et al., 2005). Morse (2011) describes suffering as a basic emotional
experience that follows illnesses that threaten one’s physical or psychosocial integration.

How to cite this article Drageset et al. (2015), Suffering and mental health among older people living in nursing homes—a mixedmethods study. PeerJ 3:e1120; DOI 10.7717/peerj.1120

Thus, suffering refers to human existence as a whole, whereas experiencing suffering
can mean being unable to keep oneself together as a whole entity. Alleviating suffering
implies lessening people’s sense of vulnerability (Rehnsfeldt & Eriksson, 2004). Studies
from Canada (Daneault et al., 2004) and Finland (Kuuppelomaki & Lauri, 1998) found
that people report suffering in three dimensions; physical, mental and social well-being.
Physical suffering includes pain, mental suffering is mostly expressed as depression and
social suffering is often caused by disease that results in isolation and withdrawal from
social contact (Kuuppelomaki & Lauri, 1998).
Depression is common among older people living in NHs (Smalbrugge et al.,
2005a; Smalbrugge et al., 2006a; Drageset, Eide & Ranhoff, 2011; Drageset, Eide & Ranhoff,
2013); the prevalence is 34–41%. Depression is often experienced together with anxiety,
where anxiety tends to follow traumatic events and loss situations (Bland, 2012), such as
loss of significant others but also functional abilities and loss caused by disease.
Only a few studies of the associations between the experience of anxiety and depression
and quality of life among older cognitively intact people in NHs have been published
(Smalbrugge et al., 2006b; Rodriguez-Blazquez et al., 2012). In Spain, Rodriguez-Blazquez et
al. (2012) found that depression, health status and the interaction of age and institutionalization were related to well-being. In a study in the Netherlands among NH residents,
Smalbrugge et al. (2006b) studied the impact of depression and anxiety on well-being and
found that depression and/or anxiety were associated with significantly worse psychosocial
well-being.
Another source of suffering may be social isolation, resulting from difficulty in
maintaining social contact because of disabilities and loss of spouse and friends (Drageset,
Kirkevold & Espehaug, 2010). For some NH residents, it means that they no longer have
anyone close in their social network. The experience of suffering may be a reaction to the
lack of someone close (Morse, 2011).
Social support may alleviate the experience of suffering and, in turn, may affect mental
and physical health. Social support involves qualitative aspects of human relationships,
such as the content and the availability of relationships with significant others (Sarason,
Sarason & Pierce, 1990). Social support is conceptualized in the literature from three
dimensions (affect, affirmation and aid (Kahn, 1979)) to five dimensions (emotional
support, esteem support, material support, instrumental support and active support
(Cobb, 1979; Cohen, Lynn & Gottlieb, 2000)). Most authors include dimensions related
to emotional support, confirmation support and practical support. Few relevant studies of
social support and quality of life among mental intact NH residents have been conducted.
In a quantitative study, Tseng & Wang (2001) found that social support from nursing aides
and the frequency of interaction with family significantly predict the quality of life of
NH residents. In a qualitative NH study in Norway, Bergland & Kirkevold (2005) found
that residents reported positive peer relationships, and positive relationships with family
were essential for thriving. A qualitative study in Canada (Welsh, Moore & Getzlaf, 2012)
explored meaning in life for NH residents. Connectedness and engaging in “normal”
activities emerged as enhancing meaning in life for the residents. A systematic qualitative

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review of NH life in relation to residents’ quality of life reported connectedness with others
as being essential for residents’ quality of life (Bradshaw, Playford & Riazi, 2012).
We have recently found that NH residents reported symptoms of anxiety and depression
(Drageset, Eide & Ranhoff, 2013), and some dimensions of social support (attachment,
nurturance and reassurance of worth) have been shown to be important for health-related
quality of life (Drageset et al., 2009a). Based on our recent findings and the present
literature review, one may question that cognitively intact NH residents who report
symptoms of anxiety and depression and a lack of social contact are particularly prone to
reduced health-related quality of life (HRQOL) and the increased experience of suffering.
Some studies have investigated the association between anxiety, depression, social
support and HRQOL among cognitively intact NH residents (Kuuppelomaki & Lauri,
1998; Tseng & Wang, 2001; Bergland & Kirkevold, 2005; Drageset et al., 2009a; Bradshaw,
Playford & Riazi, 2012; Welsh, Moore & Getzlaf, 2012; Drageset, Eide & Ranhoff, 2013),
but we found no relevant studies about mixed-methods perspectives that examine this
association and the phenomenon of suffering. Better care and treatment for older people
with no cognitive impairment living in NHs requires focusing on well-being at a holistic
level. This means including emotional well-being and the availability of meaningful social
relationships. Meeting this challenge requires extending the perspectives beyond what one
specific research approach can give.

AIM
The aim of this study was to investigate suffering and mental health among cognitively
intact NH residents more broadly by using a mixed-methods design. The specific research
questions were as follows.
• How do older people living in NHs experience their life situation?
• What is the association between sociodemographic and illness variables and anxiety,
depression and health-related quality of life for NH residents?
• How can the quantitative findings extend findings from qualitative analysis for NH
residents?

METHODS
Design and population
Since we wanted to explore different aspects of the same phenomena, we used a qualitative
mixed-methods design with concurrently components: qualitative and quantitative (Morse
& Niehaus, 2009). The theoretical drive or the inductive direction of a research project
guides the qualitative methodological core (Morse et al., 2006) and allows researchers
to explore experiences qualitatively and to build a theoretical model of suffering during
anxiety, depression and social support subdimensions and health-related quality of life.
These methods differ from other approaches because the qualitative core component is
guiding the study, which may stand alone, and the supplementary quantitative component
is used to expand certain details of the findings to indicate the validity of the core findings.

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The qualitative core component in the study comprised a qualitative interview about
life experiences related to pain, grief and loss and psychosocial topics from 18 respondents.
The supplementary component in the study comprised the same 18 respondents, in which
we interviewed the participants face to face using the SF-36 Health Survey subdimensions
bodily pain, vitality, social functioning, role–emotional and mental health; the Hospital
Anxiety and Depression Scale (HADS); and the Social Provisions Scale (SPS). The
supplementary component (findings from the quantitative analysis) enabled us to explore
significant relationships and may inform the qualitative findings.
This study used a simultaneous design (Fig. 1). Once we analyzed the qualitative core
component and completed the supplementary components, we first described the findings
on the core component. We then integrated the final descriptions from the quantitative
components, and these constitute a results narrative on which the discussion is based
(Fig. 1).
This study is part of a study conducted in 2004–2005 (Drageset et al., 2009b), with
follow-up until 2011. At the end of follow-up, 19 NH residents were still alive, and 18 were
included based on the inclusion criteria: aged 65 years and older, cognitively intact, capable
of carrying out a conversation and residing in the NH for at least 6 months. Cognitively
intact was defined as having a Clinical Dementia Rating (CDR) ≤0.5 (Hughes et al.,
1982). CDR was developed as a staging instrument for dementia and is scored as no (0),
questionable (0.5), mild (1), moderate (2) and severe (3) dementia, and the overall level
of dementia is derived by using a standard algorithm (Morris, 1993). Trained nurses who
had observed the residents for at least 4 weeks assessed CDR and were instructed to base
their CDR scoring on mental functioning and not to include physical frailty. The CDR has
shown high interrater reliability for physicians and other health professionals (McCulla et
al., 1989). Exclusion criteria were: lived shorter than 6 months in an NH, CDR score >0.5
and those who had their general health status assessed by a doctor or nurse, who indicated
that the residents could not converse with the researcher. A primary care nurse invited
them to participate.

Ethical approval
The project involved a sample collected during 2010–2011. We obtained informed
consent. The Western Norway Regional Committee for Medical and Health Research
Ethics and the Norwegian Social Science Data Services approved the study (REK.Vest nr.
62.03/2009/1550).

Data collection
Qualitative data
We collected data through individual interviews. We developed a semistructured interview
guide based on our previous research findings. We asked informants about mental health
and physical health (including their experience of depression, anxiety, loss and pain). We
performed interviews in the residents’ room, and they lasted 45–90 min. The interviewer
(first author) conducted conversations in which participants were encouraged to describe
their experience regarding the questions in the interview guide. The respondents’ answers

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Figure 1 Schematic overview. The left pathway illustrates the core component of the project (qualitative
data). The right pathway illustrates the supplemental components of the project (qualitative data). The
point of interface is the position at which the core and supplemental components meet. The “results
narrative” refers to the write-up of the core-component findings with the addition of the results of the
supplemental components.

to the questions also led to spontaneous follow-up questions from the interviewer.
The 18 interviews were taped and transcribed verbatim. In all, this resulted in detailed
descriptions.
Quantitative data
We obtained the quantitative data through face-to-face data collection. The 18 interviews
took place in the respondent’s room or at another appropriate location in the NH. The
principal investigator (JD) performed the quantitative interviews: read the questions to the
participants, circled the indicated answer and recorded the demographic information. This
was necessary, since many of the residents have problems holding a pen and have reduced
vision.

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Assessment instruments
We collected sociodemographic variables such as age, sex, marital status, education level
and comorbidity from patient records. We scored comorbidity using the Functional
Comorbidity Index, a clinically based measure (Groll et al., 2005). This index includes
18 diagnoses scored “yes = 1” and “no = 0.” A maximum score of 18 indicates the highest
number of comorbid illnesses.
We measured health-related quality of life using the SF-36 (Ware & Sherbourne,
1992; Ware, 2005). The SF-36 comprises 36 questions along eight dimensions: physical
functioning (10 items), general health (five items), mental health (five items), bodily
pain (two items), role limitation related to physical problems (four items), role limitation
related to emotional problems (three items), social functioning (two items) and vitality
(four items). An additional item, reported health transition, notes changes in general
health during the past year. The response scores for each dimension are added, and the
total is converted to a score on a scale from 0 (poor health) to 100 (optimal health) (Ware,
2005). In this study, we used the subdimensions bodily pain, vitality, social functioning,
role–emotional and mental health. The SF-36 has been used in numerous studies in
geriatrics and appears to be reliable: Cronbach’s alpha: 0.68–0.94 (Lyons et al., 1994;
Berlowitz et al., 1995; Pit et al., 1996). It has also demonstrated good construct validity
(Lyons et al., 1994) and convergent validity (Andresen et al., 1999).
We used HADS (Zigmond & Snaith, 1983) to assess depression and anxiety symptoms.
HADS is well validated (Bjelland et al., 2002). HADS has seven items for anxiety (HADS-A)
and seven for depression (HADS-D). Each item is scored on a four-point scale from 0 (not
present) to 3 (considerable). The maximum score is 21 on each subscale, and a higher score
indicates a higher symptom load (Zigmond & Snaith, 1983). A score of 8–10 indicates
possible cases of anxiety or depression, and a score ≥11 indicates cases of anxiety or
depression that require further investigation and possibly treatment (Zigmond & Snaith,
1983). HADS has been translated into Norwegian and has been found to be reliable and
valid for older people (Stordal et al., 2001; Stordal et al., 2003) and reliable and valid among
NH residents (Haugan & Drageset, 2014).
We assessed social support using the revised SPS (Cutrona & Russell, 1987). The scale
contains 24 items, four for each of the six social provisions worked out in detail by Weiss
(1974). Russell et al. (1984) simplified the response format to a four-point rating scale:
“strongly disagree,” “disagree,” “agree” and “strongly agree.” According to Cutrona &
Russell (1987), Andersson & Stevens (1993) and Mancini & Blieszner (1992), four of the
original six subscales were selected: “attachment” (emotional closeness from which one
drives a sense of security); “social integration” (relationships in which the person shares
concerns and common interests); “opportunities for nurturance” (being responsible for
the care of others); and “reassurance of worth” (a sense of competence and esteem). High
scores indicate high social provision. The SPS, with four subdimensions “attachment,”
“social integration,” “nurturance” and “reassurance of worth,” has been used in studies of
older people living in the community (Andersson & Stevens, 1993; Bondevik & Skogstad,

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1996; Saevareid et al., 2010) and among NH residents (Bondevik & Skogstad, 1998;
Drageset, 2002; Drageset et al., 2009b).

Data analysis
Qualitative data
We analyzed the interview data by using elements of qualitative content analysis
(Graneheim & Lundman, 2004; Kvale & Brinkmann, 2009). The analytical process occurred
in six stages (see Table 3 for details): (1) transcribing the interview; (2) open independent
reading of all material to gain an overall impression of the text; (3) identifying meaning
units; (4) categorization; (5) abstracting two subthemes and a theme (Table 3); and (6)
reflection and discussion.
Quantitative data
We used descriptive statistics for the demographic variables and the comorbidity variables.
We applied nonparametric test statistics to test for distributional differences in SF-36
subscales among groups defined by sex (Mann–Whitney U-test) and marital status
(Kruskal–Wallis test). We calculated Spearman correlation coefficients to study associations between comorbidity, age, anxiety, depression, social support dimensions and SF-36
subdimensions: bodily pain, social functioning, role–emotional, vitality and mental health.

RESULTS
Respondents’ characteristics
Table 1 presents descriptive statistics for the demographic variables and the comorbidity
variables. Of the 19 NH residents, 18 (95%) met the inclusion criteria; 1 (5%) declined to
participate.
Of the 18 respondents, 11 (62%) were women. The mean age was 84.8 years (SD 7.6).
The mean number of comorbid illnesses was 1.9 (median 2.0, SD 1.3, range 0–5).

Qualitative data
During the interviews, the informants often strived to express their feelings verbally.
Nevertheless, the qualitative data reveal many previous and current life experiences related
to psychosocial aspects and suffering. Among these, the informants described several loss
and traumatic experiences related to death (of parents, siblings, relatives and friends), war,
starving and isolation. During the conversation, the individuals often return to stories
from childhood and upbringing. According to the qualitative analysis, one main theme
was lifelong suffering as a complex psychosocial entity, with two subthemes: “pain from
experience in early life” and “painful experience in recent life” (Table 4).
Such early-life experiences are often related to loss by death, instability and lack of
hope in their upbringing. Several descriptions reflect this psychosocial complexity, and
representative quotations are presented here to give the participants a voice:
• “I have a lifelong grief caused by traumatic experiences from the war.” (P)
• “I feel grief caused by difficult experiences during my childhood.” (Q)

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Table 1 Characteristics of the respondents.
n

%

18

100

7
11

38.9
61.1

3
7
8
0

16.7
38.9
44.4
0

11
4
3

61.1
22.2
16.7

8
4
4

44.4
33.3
22.2

17
1

94.1
5.9

Sex
Male
Female
Age (years)
65–74
75–84
85–94
≥95
Marital status
Widowed
Married or cohabiting
Unmarried
Education
Lowest: primary school
Middle: <3 years after primary school
Highest: ≥3 years after primary school
Illnessesa
Yes
No

Notes.
a
Functional Comorbidity Index includes 18 diagnoses scored “yes = 1” and “no = 0.” A maximum score of 18 indicates
the highest number of comorbid illnesses.

• “Unstable upbringing and hopelessness have been painful.” (F)
The interviewees strongly emphasized earlier painful life experiences. Loss and grief seem
to be especially attached to these.
Current life experiences are also related to loss by death, and lack of social relations, lack
of courage to live and lack of hope are prominent. Many descriptions revealed resignation
and hopelessness:
• “I just sit here.” (O)
• “I am in despair and lonely, but that’s life for us old people, and I cannot do anything
about it.” (F)
• “I feel like a prisoner and several times I wish that I did not exist. I have had enough!” “I
live in a cemetery.” (Q)
• “I am crying all day long.” (A)
• “I lie in bed, feel totally isolated, and cannot take care of myself.” (F)
• “Noise from other people all the time is quite stressful.” (D)
The qualitative data reveal clear patterns and similarities in the descriptions. In their
present life situation, loneliness, despair and depressive thoughts are prominent, and they
express several attempts to endure their situation.

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Table 2 Means and standard deviation (SD) for each of five subscales of SF-36 according to sociodemographic and comorbid illnesses, and correlation coefficient for anxiety, depression and social
support dimensions (n = 18).

All
Sexa
Women
Men
P*
Age (years)b
P*
Marital statusc
Widowed
Married
Unmarried
P*
Anxietyb
P*
Depressionb
P*
Attachmentb
P*
Social integrationb
P*
Reassurance of
worthb
P*
Nurturanceb
P*
Grolls indexb,d
P*

Bodily pain

Vitality

Social
functioning

Role limitations,
emotional

Mental
health

64.1 (27.4)

43.9 (12.7)

81.2 (17.3)

72.2 (36.6)

68.4 (13.1)

61.7 (28.2)
61.7 (28.2)
0.791
−0.14
(0.572)

46.8 (11.9)
40.0 (13.4)
0.211
0.125
(0.684)

78.4 (17.8)
85.7 (16.8)
0.425
0.10
(0.684)

66.7 (42.2))
80.9 (26.2)
0.659
0.08
(0.745)

66.2 (13–2)
72.0 (13.1)
0.425
0.04
(0.883)

69.5 (29.4)
61.2 (31.1)
48.3 (6.4)
0.71
−0.56
(0.018)
−0.05
(0.845)
−0.145
(0.566)
0.391
(0.109)
−0.407

45.0 (13.6)
47.5 (8.7)
35.0 (13.2)
0.41
−0.23
(0.385)
−0.23
(0.157)
0.562
(0.015)
0.014
(0.957)
0.334

83.0 (16.7)
81.2 (21.7)
75.0 (21.7)
0.83
−0.34
(0.178)
−0.26
(0.309)
0.257
(0.304)
0.536
(0.022)
0.258

69.7 (40.7)
75.0 (38.5)
77.8 (38.5)
0.94
−0.58
(0.016)
−0.16
(0.535)
−0.111
(0.661)
−0.108
(0.670)
−0.243

68.0 (13.6)
70.0 (16.5)
68.0 (10.6)
0.93
−0.86
(<0.001)
−0.62
(0.007)
0.214
(0.395)
−0.146
(0.564)
0.005

(0.094)
0.430
(0.075)
−0.412
(0.101)

(0.175)
0.035
(0.889)
−0.48
(0.050)

(0.301)
0.030
(0.907)
−0.15
(0.555)

(0.331)
−0.486
(0.041)
−0.40
(0.108)

(0.983)
−0.125
(0.622)
−0.44
(0.078)

Notes.
a
Mann–Whitney U test.
b Spearman correlation coefficient.
c
Kruskal–Wallis test.
d Functional comorbidity index. A maximum score of 18 indicates the highest number of comorbid illnesses.
* bold, statistical significance at 0.05.

• “If you are unable to come into contact with others, you will feel the loneliness strongly
and you also feel invisible.” (P)
The current life experiences also contained several contradictory descriptions:
• “[Life] is very sad, it is terrible, but I have nothing to complain about.” (J)
• “. . . , I just have to accept.” (H)

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Table 3 Stages of the qualitative analytical process.
(1) Transcription
(2) Open reading

(3) Identifying meaning units
(4) Categories

(5) Forming themes

(6) Reflection and discussion

Data were transcribed and organized according to the
interview guide
Two co-authors carefully and independently read and
discussed the interview text to obtain an overall impression
of the participants’ experiences
Patterns in the data were identified by dividing the text into
meaning units
Important nuances were discovered by searching for common
and distinctive features as well as variation and agreement
about suitable categories
Two subthemes were formulated
Thereafter, analytical reflection and abstraction were
performed by searching for an overall theme
Dialogue was searched for relevant theory to illuminate and
deepen understanding of the findings

Table 4 The qualitative content analysis.
Categories

Subtheme

Theme

Earlier life experiences
Loss by death
Instability
Lack of hope
Mental strain
Traumatic events
Present life experiences
Loss by death
Loss of health
Lack of social relationships
Lack of courage to live
Lack of hope

Painful experiences in earlier life

Suffering as a lifelong complex psychosocial entity

Painful experiences in recent life

The individual stories consistently described existence as a state the informants have to
endure and adapt to. In this process, several expressed that good relationships (staff and
relatives) and mobility are very important. The relationships with health care providers are
especially important.
• “I do not always trust the health care workers, but they are okay.” (F)
Or more explicitly stated: “We need health care workers who care for us.”

Quantitative data
In general, residents scored highest on role–emotional and social functioning and lowest
on vitality (Table 2). Women reported lower, but not statistically significantly lower, scores
than men on all subdimensions except for vitality and bodily pain.

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The health-related quality of life subdimensions bodily pain (P = 0.02), role–emotional
(P = 0.02) and mental health (P < 0.001) were negatively associated with anxiety.
Increasing depression scores were negatively associated with mental health (P = 0.007).
Attachment was positively associated with vitality (P = 0.02) and social integration with
social functioning (P = 0.02). Nurturance was negatively associated with role–emotional
(P = 0.04).
Cronbach’s alpha for the SF-36 subscales ranged from 0.60 to 0.85, with role–emotional
showing the highest values and vitality the lowest.

RESULTS NARRATIVE
The results narrative summarizes the core component findings, with the supplementary
component adding certain information to specific areas (Morse & Niehaus, 2009). Both
data sets showed that suffering is prominent and that anxiety and depression predict
worse mental health. Findings from both the qualitative findings and quantitative data
highlight social relationships as important for mental health and, conversely, lack of social
relationships as a source of suffering. The qualitative data provided many descriptions
of the life situation in an NH in which many difficult experiences throughout a long
life are prominent. As such, the qualitative data provided detailed information about
several psychosocial aspects and experienced suffering. Additional, the supplementary
component, quantitative data, showed that emotional closeness and relationships with
people who share concerns and interests is important.
The combined findings call for several improvements in care among the residents, which
more accurately reflects their concerns aimed at alleviating suffering.

DISCUSSION
This study among cognitively intact NH residents showed that the individual stories
reveal that psychosocial aspects and the phenomenon of suffering are related to painful
experiences during life. The quantitative data showed that symptoms of both anxiety and
depression were related to mental health. The association between anxiety and depression
and mental health may suggest that more symptoms of both anxiety and depression
contribute to worse mental health. Other studies among NH residents (Smalbrugge et al.,
2005b; Smalbrugge et al., 2006b; Rodriguez-Blazquez et al., 2012) reported associations
between the presence of depression and/or anxiety symptoms and worse well-being.
One explanation for our results could be that most of our respondents were widows or
widowers, have multiple diagnoses and were dependent in the activities of daily living. All
these circumstances may be experienced as losses, contribute to symptoms of depression
(Bland, 2012) and influence mental health (Ferrell & Coyle, 2008) and the experience
of suffering (Kuuppelomaki & Lauri, 1998; Ferrell & Coyle, 2008; Morse, 2011). The
informants also clearly expressed the experience of suffering by telling stories containing
both earlier and current life events. Morse (2011) emphasizes the significance of assisting
the residents in moving from endurance to emotional release when coping with suffering.
Interpersonal encounters seem to play an important role here to help the person who is

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suffering in this process (Yalom, 2005), and nurses must maintain a culture that includes
such basic elements of nursing.
Symptoms of anxiety were related to the bodily pain subdimension of the health-related
quality of life. This dimension of the SF-36 measures the intensity of bodily pain and
the extent to which bodily pain interferes with normal activities (Ware, 2005). Among
older NH residents, Smalbrugge et al. (2006b) found associations between anxiety and
well-being. But in contrast to our study, the diagnosis of anxiety was reported and the study
did not explicit focus on pain. Pain is a source of suffering (Cassel, 2004; Ferrell & Coyle,
2008) and a primary source of physical suffering (Kuuppelomaki & Lauri, 1998).
Our study indicated that higher levels of attachment and social integration are
associated with higher levels of vitality and social functioning, or conversely, a lower level
of attachment and social integration corresponds to lower levels of vitality and social
functioning.
The positive relationship between attachment and vitality suggests that the emotional
content of the relationship with significant others is an important component of vitality.
In addition, the stories from the residents underline the importance of social relationships
and mobility as important aspects of this. Our extended findings are in accordance with
other studies that report positive associations between social support and well-being
(Tseng & Wang, 2001; Bergland & Kirkevold, 2005; Drageset et al., 2009b; RodriguezBlazquez et al., 2012). Weiss (1973) and Weiss (1974) emphasizes that significant others
are spouses and very close friends who provide the feeling of intimacy, security and peace,
and a lack of significant others contributes to experiencing negative feeling as emotional
loneliness. Because of the respondents’ advanced age, disability and dependence, they are
more likely to have difficulty in maintaining close social contact. Social and emotional
support seems to be important in combating depression in the general population (Grav et
al., 2012) and loneliness among NH residents (Drageset, Kirkevold & Espehaug, 2010).
The relationship between opportunity for nurturance and emotional role limitations
(whether emotional problems interfered with such social activities as visiting friends
and relatives) suggests that providing more support for others would contribute to
increasing role limitations. Weiss (1974) emphasizes that nurturance differs from the other
provisions by enquiring whether older people themselves provide support. Responsibility
for someone, usually children, gives meaning to an individual’s life in meeting obligations
in various activities. One explanation for our results could be loss of the ability to give the
necessary support: the relationship does not make sense to the extent that one wishes.
The individuals detailed many stories that reveal existential experiences related to
suffering. These findings clearly give nuances in a holistically way and with information
from the results from the quantitative supplementary component the researcher is
able to build synthesis of the qualitative findings to the quantitative results which is
necessary to draw conclusion. This could also clarify clinical significance and contribute
to more clinically meaningful approaches. Such extended findings represent a valuable
contribution in planning individual care.

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Methodological considerations
There are quantitative studies examining anxiety and depression, social support and the
quality of life, but this type of study has limitations. Suffering is a life phenomenon that
provides deeper understanding and different types of knowledge. Integrating quantitative
and qualitative results using mixed methods could therefore provide more meaningful
findings than one method alone (Tashakkori & Creswell, 2007).
Because we used a cross-sectional study design, we cannot firmly conclude on the
direction of a possible causal effect or preclude that these associations are effects of other
unmeasured determinants. However, the supplementary component can explain and
contribute to deeper knowledge about psychosocial aspects and well-being so that this
relationship appears more clearly. Further, because the study followed a cohort (n = 227,
30 NHs) of frail cognitively intact NH residents from 2004–2005 to 2011, the sample size
was small at the end of follow-up. Despite the small sample size and low statistical power,
we found meaningful statistical associations that inform the qualitative findings.
As discussed, the research problem is multifaceted and complex. The integrated
research strategy offered by a mixed-methods design therefore enabled us to clarify
different aspects of the phenomena (Richards & Morse, 2007). This tradition maintains
that one method alone will not comprehensively answer our research questions. As
such, both qualitative and quantitative methods are used to collect and analyze the data
(Morse & Niehaus, 2009). In our study, the core component is qualitative data consist of
details and important qualitative date about experiences related to suffering in NH. The
supplementary component (the quantitative results), by clarifying the connection between
anxiety and depression, informed and supported the core component (the qualitative
data), as described by Morse et al. (2006). In this way, the mixed-methods design validated
our findings while conforming to the rules inherent in each paradigm. Further, using a
mixed-methods design with the use of a semistructured qualitative interview may increase
the subjectivity of evaluation and create difficulty in replicating the study.
Two of the authors have skills primarily in the quantitative core method, and two
authors were primarily qualitative researchers. In addition, a statistician was responsible
for the quantitative data analysis. In this way, the researchers represented the different
and overlapping research fields necessary for using a mixed-methods design. In terms
of validity, we believe that our different platforms and expertise represented a critical
contribution in the continuous discussion about possible interpretations during the whole
research process.

CONCLUSION AND CLINICAL IMPLICATIONS
The individual stories reveal that psychosocial aspects and the phenomenon of suffering
are related to painful experiences during life. Symptoms of anxiety and depression were
negatively associated with mental health, and symptoms of anxiety were associated with
bodily pain. Attachment and social integration were associated with vitality and social
functioning. As demonstrated, the supplementary component informed and supported
the core component and contributes to extending knowledge about the study topic. To

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improve the situation of residents, more attention should be paid to the residents’ suffering
related to anxiety, depression and relationships. The challenge for health care providers is
to grasp the individual experience of the patients and the meaning these experiences may
have for them. This requires that health care personnel listen to each individual and help
them to find their own strategies to live with the losses. By building on earlier successful
strategies, patients can be helped to understand current suffering. Listening to the patients
in this way requires time, patience and professional competence. A management structure
that focuses on how to meet each resident’s needs individually, such as a care plan for each
patient and a primary contact, is also essential. Further, it is also important that health
care personnel help the individuals to participate in meaningful activities and interactions
with peers, friends and family. Future studies are needed to corroborate or analyze more in
depth the present results about suffering.

ADDITIONAL INFORMATION AND DECLARATIONS
Funding
Bergen University College and the University of Bergen supported this research. The
funders had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.

Grant Disclosures
The following grant information was disclosed by the authors:
Bergen University College.
University of Bergen.

Competing Interests
The authors declare there are no competing interests.

Author Contributions
• Jorunn Drageset conceived and designed the experiments, performed the experiments,
analyzed the data, contributed reagents/materials/analysis tools, wrote the paper,
prepared figures and/or tables, reviewed drafts of the paper.
• Elin Dysvik and Bodil Furnes conceived and designed the experiments, analyzed the
data, contributed reagents/materials/analysis tools, wrote the paper, prepared figures
and/or tables, reviewed drafts of the paper.
• Birgitte Espehaug analyzed the data, contributed reagents/materials/analysis tools,
wrote the paper, prepared figures and/or tables, reviewed drafts of the paper.
• Gerd Karin Natvig conceived and designed the experiments, wrote the paper, prepared
figures and/or tables, reviewed drafts of the paper.

Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body
and any reference numbers):

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The project involved a sample collected during 2009–2010. We obtained informed
consent. The Western Norway Regional Committee for Medical and Health Research
Ethics and the Norwegian Social Science Data Services approved the study (REK.Vest nr.
62.03/2009/1550).

Data Deposition
The following information was supplied regarding the deposition of related data:
According to the Norwegian ACT 2008-06-20 no. 44: Act on medical and health research
(the Health Research Act) regulated in the paragraph 7 Duty of confidentiality and 13 Main
rule on consent, we cannot make the raw data available.

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