The statements of ten qualified participants were divided into three categories, including nine sub-themes with relevant theme clusters. The three categories include protective factors for suicide prevention, risk factors for suicidal attempts, and strategies for suicide prevention (see Table 1).
Table 1 Categories and sub-themes
Categories
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Sub-themes
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Theme clusters
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Protective factors for suicide prevention
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Family bonds
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·Memory
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·Persuasion
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Relational factors
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·Help of nursing homes
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|
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·Support and needs of loved ones in the family
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Religious belief
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·Filial piety
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|
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·Unforgivable sin
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Risk factors for suicide attempts
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Family situation
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·Children diseases
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|
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·Financial burden
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|
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·Siblings living far away
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|
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·Spouses diseases or death
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Physical conditions
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·Chronic conditions
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|
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·Physical impairments
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Psychological conditions
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·COVID-19 related fear and anxiety
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|
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·Distrust in society
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|
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·Loneliness
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|
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·Low self-esteem
·Pain
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Residential care
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·Delays in support providing
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|
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·Lack of group activities
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|
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·Personal conflict
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|
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·Poor living settings
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Strategies for suicide prevention
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Seek outside assistance
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·Family members
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|
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·Nursing home residents
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|
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·Nursing home staff
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|
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·Psychiatrists
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Self-care techniques
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·Prayers
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|
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·Self reconciliation
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3.1 Protective factors for suicide prevention
There was agreement among the ten participants regarding the fact that they were no longer struggling with suicide attempts or suicidal ideation due to many factors, including family bonds, relational factors, and religious belief. These factors actually bonded together like a rope to prevent their deaths. The words with double quotation marks were taken directly from the participants’ answers to the interviewer’s questions.
3.1.1 Family bonds
Families give each other the greatest gift by spending time together. Nevertheless, nursing home residents did not have many opportunities to share their ups and downs with family members. During the COVID-19 pandemic, visitations were primarily restricted except the end-of-life situations. As a result, the drastic differences between life in the nursing home and that of living with family members often drove them to recall happy memories. Participant 10 made the statement that thinking about his past events was of frequent occurrence in his old age: “I was a breadwinner for the whole family in the past and also did something meaningful. I shall live a happier life in the future.” Their memorable event experiences strengthened their relationships and family bonds.[17] As Participant 6 described: “I am proud of my past, and my kids are also proud of having a dad with a positive attitude towards life.” These positive memories serve as the impetus to a stronger family bond, which in turn reduces the risk of suicide. Those who participated in this study reported that persuasion from family members within spoken interactions helped manage their mood swings. Participant 3 stated clearly: “I no longer have suicidal thoughts after my kids talked some sense into me and visited me regularly.” Six participants, including Participant 3, 4, 5, 6, 7, and 9, made a similar statement that their negative emotions were alleviated through the gentle persuasion of kids. Participant 10 now has controlled suicidal ideation and does not attempt suicide because his wife reminded him of “looking at the bright side, the only person you can rely on is yourself.”
By developing persuasive strategies during family discussions, it is possible to assist nursing home residents in preventing suicide when they are experiencing suicidal ideation.
3.1.2 Relational factors
A nursing home provides custodial care, including not merely feeding, bathing, and dressing.
In this study, many participants encountered the nursing home for the first time after a sudden change and accepted help of nursing homes. Participant 2 shared the experience of accepting help from the nursing home: “I tell the staff that I want to commit suicide in my room. Soon afterward, the staff lets a friendly, talkative resident live and talk with me to distract me from the thoughts of taking my own lives.” Live-in nursing home staff are considered to be residents’ companions and offer 24-hour care services. When they find that residents verbalize suicidal ideation, they will spare effort to understand residents’ needs and provide relevant care. Participant 4 was trying to swallow tears when she mentioned the staff’s efforts: “The nursing home director is always nice, and takes special care of me. Here, I’m happier than at home. It’s good to live longer when I’m here.” When the interviewer asked whether she was satisfied with the residential care, she reiterated her desire to live longer and spend time with the staff. Although loved ones in a family are not trained professionals to help, they still have a role to play in suicide prevention. When participants felt loved and needed by others, they began to overcome suicidal thoughts. For example, Participant 10 stated: “There is value in my presence with my children. I can still make my own contributions to the whole family.” Suicide could “put kids under too much pressure and they might feel overwhelmed.”(Participant 7) Therefore, “I learned to stop thinking about suicide when my children raised my spirits and gave me support.”(Participant 3) and suicidal feelings or thoughts are largely reduced when “I want to see my children's lives get better in the near future.”(Participant 8)
3.1.3 Religious belief
In accordance with the interview content, religious service attendance is a part of their daily life, especially for those who have difficulty in moving. Religious belief emerged as a protective factor for suicide prevention in this study. Christians believe that suicide is an unforgivable sin, and those who commit suicide will go to hell.[18] Similarly, Participant 9 shared her experience of stopping suicide: “I was thinking of killing myself at that time. A resident, who was a Christian, stayed with me, talked with me, and I then converted to Christianity. My spirits were lifted when I realized suicide was an unforgivable sin.” Although religious diversity is welcomed in China, filial piety (xiao, 孝, Chinese) still maintains a dominant position as the fountain-head of morality.[19] Filial piety is frequently associated with the practice of belonging, security, and surveillance in contemporary China.[20] Following this filial doctrine, children are expected to show respect and care to their parents. In this study, filial piety reached the highest coding coverage of 0.60% among other belief. The majority of participants indicated that they no longer experienced suicidal ideas as a result of their filial children. As Participant 9 mentioned, “My children came to see me every week, and brought me what I wanted to eat. I was touched by their filial devotion.” In addition, other participants considered the negative impacts of their suicide attempts from the perspective of filial piety. Participant 6 stated, “My suicide attempts will probably become the subject of gossip, and people will criticize my kids wherever they go.” As Participant 3 described: “When I thought of their filial piety, I stopped trying to kill myself.” Meanwhile, some participants did not want their kids to live under an undeserved reputation and chose “not sharing my suicidal thoughts with my children”. (Participant 7)
3.2 Risk factors for suicide attempts
Risk factors on facilitating suicide attempts involve many areas of life experience. The presence of one or more of these risk factors in life does not directly and inevitably lead to suicidal behaviors. A number of suicide attempts serve as the result of multiple risk factors for suicide in later life.[21] In this study, risk factors fall into four sub-themes and fifteen theme clusters. Participants’ utterances are denoted by double quotation marks.
3.2.1 Family situation
One of the leading causes of suicidal feelings among the ten participants was the illness or death of a spouse; they found “no one sits here and keeps me company for a while after he died.”(Participant 4) Some participants felt that they were deprived of their spouses’ presence and companionship , and “life was deadly dull and I had been very down for a long time after he passed away.”(Participant 3) Similarly, Participant 9 shared her decision to live in the nursing home: “I used to live here with my hubby. I still chose to live here because trained staff provided round-the-clock care. However, his sudden death made me feel dull and tedious, and thus I wanted to commit suicide.” Those who still had spouses stated that “she suffered from a serious illness, so she needed hospital therapy.”(Participant 10) Therefore, it was arduous and difficult for them to meet face-to-face and check up on each other. Another frequently mentioned factor was the financial burden. For many participants, a greater proportion of this burden was attributed to the costs in the nursing homes.[22] Participants reported suicidal ideation, especially when “they were under great financial pressure, and they were laid off from their jobs.” (Participant 4) Most of the participants did not have much money to meet basic needs because “I did not have retirement pensions.” (Participant 3, 5, 8) Several participants expressed their feelings as follows, “My family did not have enough money, and I did not have sufficient retirement savings. Moreover, it was difficult to cure my diseases and I began thinking about committing suicide.” In addition, nursing home residents were also confronted with financial concerns when their retirement savings were kept by other family members. Participant 1 described: “My nephew held my pension, and sent it to my daughter. But I cannot see the transferred fund in detail. ” Meanwhile, participants expressed their concerns about the children’ s conditions: “my daughter was sick, and my son had to run the business to support the family even he was seriously ill.” (Participant 4) Many participants attributed their suicide attempts to the fact that “both daughter and son-in-law frequently get sick” (Participant 5), and their worse condition led to the consequence that “I really wanted to end my life at that time.”(Participant 1) Some of the ten participants have siblings living far away, and whenever they were in need of comfort, they resorted to them. However, hopes were gone when “my older wife did not allow them to come here and chat with me,”(Participant 10) and some siblings “lived very far away and had to go to work every day.Therefore, they were unable to visit me here.”(Participant 9) As mentioned by Participant 5, her kids “worked both a full-time and a part-time job in another city which was 3000 kilometers away from Jinan.” As a result, the non-appearance of siblings brought about the suicidal ideation among these nursing home residents.
3.2.2 Physical conditions
There is a long list of physical problems, involving chronic conditions and physical impairments, which are very common among older adults. In the older adults community, chronic diseases and objective losses in functionality are strongly associated with low levels of life satisfaction, increasing the possibility of suicidal behavior.[23] In this study, participants remained pessimistic regarding their chronic conditions: “I suffered from sickness and was in agony,” (Participant 7) including myocardial infarction (Participant 7, 8), Parkinson's Disease (Participant 7, 10), diabetes (Participant 2, 8), cardiac disease (Participant 1, 2, 8), cerebral thrombosis (Participant 8) and Alzheimer's disease (Participant 7). It was also noted that these negative attitudes directly contributed to the rise in suicide attempts and deaths by suicide.[24] Besides, older residents were confronted with physical impairments, which led to the activity limitation (Participant 4, 5, 6), functional independence barriers (Participant 3, 8, 10), and low mental health status (Participant 7). The discourse of Participant 7 focused on the impact of a sprained ankle on her mental health status: “I fell down on the floor, and twisted an ankle. I was unable to care for myself. As a result, I could not sleep at night because of sharp pain at the back of my head. At that time, my son and daughter-in-law were busy with the lottery business and children’s care. Over time, the suicidal ideation just hit me over the head one day.”
3.2.3 Psychological conditions
The prevalence of psychological conditions in later life, combined with its salience to the well-being of older residents, might lead to the later life suicide risk.[25] The more progressive psychological deterioration might occur when negative thoughts come up. In this study, older residents had not only shown distrust in society, loneliness, low self-esteem as well as pain, but also reported the devastating effects of COVID-19. Regarding the COVID-19 related feelings, participants were overwhelmed with fear and anxiety stemming from the news reports about the confirmed deaths. Participant 4 claimed that “I had a devoted daughter who worked two jobs. As many people died because of this scary pandemic, I began to worry about her heath.” Participant 8 became more depressed and anxious because she heard “some people still experienced tiredness, shortness of breath and other long-term symptoms after initial recovery.” Other participants believed that it was better to commit suicide than suffer these long-term effects. As Participant 3 said, “It damaged the lungs, heart and brain. I would rather take my own life before I was infected.” Participant 10 showed the distrust in society, and murmured that “I do not trust these nursing home staff, and this is an untrustworthy society.” Besides, a number of participants also spoke of their states of solitude or being alone in nursing homes. Among the ten participants, the words “alone” and “lonely” were cited eight times in a total. Although the reasons for feeling lonely in nursing homes varied, participants collectively expressed a desire to escape the loneliness through suicide attempts. Participant 6 pointed out that he felt lonely and wanted to end his life because “my wife can not talk to me now, and I can not take care of her.” According to Participant 5, she was similarly lonely and had suicidal thoughts because “I lived with four old ladies who had nothing in common.” The concern about low-esteem of residents was another factor that influenced their psychological well-being and even led to the predicted risk of suicide attempts. As living in the nursing home, they not only suffered the physical problems, but also experienced “the gap between past and present.”(Participant 10) In this way, they showed refusal to the current condition. Participants viewed themselves as “good-for-nothing” (Participant 4), and showed “the sense of unworthiness”(Participant 9, 10) and felt like “life is not worth living” (Participant 1,2,6). Participant 7 was nearly brought to tears when she looked back on her past: “I used to take care of grandchildren, but I have become a costly burden. I am more of a hindrance than a help.” Following the low-esteem, a higher risk of suicidal ideation was also connected with moderate to severe pain and relevant interference due to pain.[26] Participant 10 shook with weeping: “I can not stop obsessing over my mistakes when I was young. I am drowning in the pain of regrets.” At the same time, Participant 9 was “ashamed of her low capability for self-care,” and several factors contributed to her “unbearable pain” and “intense suicidal thoughts in her mind.” Even though they were capable of taking care of themselves in nursing homes, they still suffered a lot of pain and had suicidal ideation due to serious ailments (Participant 6, 8) and loneliness (Participant 2).
3.2.4 Residential care
Faced with the added burden of family issues, physical and psychological conditions, nursing home residents also stated experiencing suicidal thoughts as a consequence of delays in support providing. Participant 10 described his experience: “I failed to take a walk downstairs since they refused to help me. When I told them to bring a portable toilet to my bedroom, they also pretended that they had not heard my voice.” Unsatisfactory residential care was also demonstrated in the treatment for fall-related injuries (Participant 1, 9) and ineffective communication (Participant 3). For nursing home residents, engagement in activities beyond routine primary care was a significant indicator of life quality.[27] The nursing home residents were particularly limited in continuing strenuous activities under the lockdown restrictions on physical activity, and therefore group activities held by nursing homes were of vital importance. However, many participants said that the nursing home “did not plan or organize any activities” (Participant 1, 10) and “the available opportunity was to be involved in church activities” (Participant 8, 9). Besides, participants remarked that the relationship remained good despite the occasional occurrence of personal conflicts. Participant 5 mentioned: “one of my roommates came off as crazy, singing and dancing at night.” Participant 9 stated that “conflicts were definitely a part of the day-to-day business because we had different living habits.” Unavoidable conflicts arose and “suicidal feelings continued to haunt me.” (Participant 1) In addition, poor living settings also resulted in an increase in suicidal thoughts among nursing home residents. “It schedules routine showers once per week, but I can actually take a bath once a month. I can not endure that noise from people living in the same room either and just want to kill myself,” as described by both participant 1 and 10.
3.3 Strategies for suicide prevention
A substantial body of evidence demonstrated that suicide prevention strategies were indispensable for achieving the ultimate goal of suicide reduction.[28, 29] Participants interviewed in our study were eager to adopt strategies for suicide prevention when they had suicidal ideation. The preferred sources of help were as follows.
3.3.1 Seeking outside assistance
When they became trapped in the endless cycle of suicidal thoughts, they showed a marked preference to seeking external assistance. Some participants perceived that family members, including children, spouses and siblings, were the “first choice.”(Participant 10) Also, participation in the family prevented nursing home residents from attempting suicide. Participant 3 narrated: “I told my children when I was in a shitty mood, and they always tried to convince me that it was wrong to commit suicide.” Participant 9 reported,“Talking to family members served as a great comfort for me especially when suicidal thoughts started to engulf me.” Since nursing home residents lived in the shared space, they also tended to seek assistance from each other. Participant 7 mentioned, “I also made new friends, and that day, she told me about her intense suicidal thoughts. She had suffered from diabetes for many years. Therefore, I told her that many people in the hospital had worse physical conditions than us and there was always room for hope. Over time she had been relieved of suicidal feelings.” The majority of respondents indicated they were willing to offer assistance to others. Participant 8 stated, “To live is better than to die. if he was tired of living, I would persuade him to live.” Participant 2 made a similar statement that “I help myself by helping others” and “devoting time into helping others allowed me to connect with this community.” Besides, the support from staff in gatekeeper programs was also mentioned by some participants. Participant 2 highlighted that she was willing to seek help from staff because “nursing staff often instantly persuaded me to take a deep breath and be optimistic about my life when suicidal feelings hit me.” Even residents did not have any suicidal ideation anymore, some staff “continued to chat with me and made sure that I was fine ”(Participant 3) and were “always attentive to our needs and therefore I really wanted to write a letter of appreciation to the staff.” Some participants “felt better” (Participant 5) and “forget my painful suffering” (Participant 7) after talking with staff. However, in this study, only two participants showed that they knew “psychiatrists understood mental health difficulties and provided counselling” (Participant 7) and had “received relevant treatment from psychiatrists.” (Participant 10)
3.3.2 Self-care techniques
Several residents recounted examples of how divine involvement in prayer and self reconciliation led to improvements in suicide prevention. According to Participant 8, when suffering from extreme suicidal thoughts, “I always prayed for God's guidance and support.” Religious participants practiced religion in many ways, including insisting on the weekly prayer to “give me more capacities to face suicidal feelings”(Participant 9) and to “buffer the pain away and remember the love within me.” (Participant 10) Although for some participants, they had no choice but to reconcile with themselves and “persuaded myself against suicidal attempts.” (Participant 4, 8, 10) It was also reported that reconciliation was “the most useful way to turn back on the light in my heart” (Participant 1). Reconciliation could “increase inner-love to help ease my pain” (Participant 7) and “ help to understand myself and open up a space for understanding others.” (Participant 9)