DOI: https://doi.org/10.21203/rs.3.rs-1486055/v1
Background: Suicide ideation is sweeping through the older population. As COVID-19 forced nursing homes to implement the severest restrictions, nursing home residents are particularly at risk of suicide ideation due to several interrelated factors.
Methods: This qualitative study investigated the protective and risk factors for suicide among nursing home residents as well as their strategies for suicide prevention under the lockdown of COVID-19. A total of ten semi-structured interviews were carried out. Thereafter, we analyzed the interview content following a thematic approach.
Results: The experiences of ten nursing home residents with suicidal ideation were classified into three categories, nine sub-themes and twenty seven theme clusters. The three categories included: (a) protective factors for suicide prevention, (b) risk factors for suicide attempts, and (c) strategies for suicide prevention. These factors and strategies were found to be correlated with their suicide ideation and suicide attempts.
Conclusion: Factors and strategies influencing suicide ideation and attempts among nursing home residents displayed some new issues and problems under COVID-19. These factors will help both nursing home staff and other health-care providers to understand their life of nursing home residents who have suicide ideation and suicide attempts and improve intervention strategies.
Suicide is one of the priority conditions in the WHO Mental Health Gap Action Programme (mhGAP) launched in 2008[1]. Globally, more than 700 000 people die by suicide every year[2]. From 2000 to 2019, the global age-standardized suicide rate dropped by 36%[3]. In China, the overall suicide rate has also declined, however the rate has climbed among older adults[4]. The act of suicide itself is a result of multiple factors. Prior studies have identified a number of well-established risk factors. Mental disorders[5], family relationships[6], cultural context[7], suicide cluster-related social media[8], and substance consumption[9] could lead to suicide attempts among the youth. As for the older adults, negative life events[10], social isolation[11], physical diseases[12], family companionship[13], and later-life depression[14] were closely associated with suicide attempts. However, the suicide of older adults living in nursing homes is still a neglected area. As the COVID-19 pandemic swept across the world, the focus of attention has switched to the nursing home residents’ suicide prevention. Their need for social contact was largely limited due to the strict visit regulations. It was suggested that lockdown restrictions have had a far-reaching impact on the residents who might suffer from isolation[15] and loneliness[16]. Therefore, worries were mounting about their psychological and mental health. The identification of risk factors and protective factors among nursing home residents will help to better understand their experience, improve prevention strategies and save more lives. Towards this aim, this study investigated the protective factors for suicide prevention, risk factors for suicide attempts, and prevention strategies among nursing home residents who had committed suicide.
Study design
The study was conducted with qualitative data to interpret the nursing home residents’ experiences and perceptions of suicide attempts. In this study, ten participants were invited to take part in semi-structured in-depth interviews between March and November 2021. The inclusion criteria were as follows: Participants (a) were nursing home residents over 65, (b) had suicide attempts, (c) were capable of speaking Chinese. Exclusion criteria included the complication of psychotic disorder. Participants in this study included 10 nursing home residents with suicide attempts in Jinan and Zibo, Shandong, China. The aim and procedures of the study were introduced to the participants, and the decision of whether to participate or not will not affect their nursing home service. Prior to the interview, all participants were informed of the study’s procedures, the terms of confidentiality, and their right to withdraw from research without penalty.
Data collection
Each semi-structured interview lasted about 30 to 60 minutes, and the time and site of the interview were based upon the preferences of nursing home presidents. A semi-structured interview consists of a dialogue between participants and researchers,
followed by a topic guide and follow-up questions and comments. Researchers created the interview topic guide through a literature review and team discussion and then revised the guide based on two residents’ preliminary interviews. The participants made trustworthy statements when they answered questions, covering more than “Why did you want to commit suicide?”, “What factors prevent you from suicide attempts?”, “Have you ever sought help or considered seeking assistance? ”, “What kind of help-seeking strategies do you adopt or prefer to adopt?” and “What difficulties do you have when you seek help?”. During the interviews, a Ph.D. majoring in linguistics acted as the primary interviewer, and a Ph.D. majoring in geriatric nursing asked more thorough questions, which were not limited to the guide and took notes in detail. Transcripts of all recordings were converted into words, which were then analyzed several times until all sub-themes and themes were identified.
Data analysis
After the data collection, transcripts were compared with the raw recordings to improve the transcription accuracy. The study was performed with the method of qualitative content analysis with Nvivo, mainly involving the following procedures. Researcher read the ten transcripts to achieve a comprehensive understanding. The interview recordings were transcribed, and the entities and units were identified in accordance with the questions in the guide. All the researchers took part in the open coding, and the inter-coder reliability was calculated to ensure coding consistency. Once adequate consistency was achieved, these codes were then arranged into sub-themes and themes under the joint discussion.
Participant profile
Ten nursing home residents completed the interview, including eight female residents and two male residents. They ranged from 65 to 90 years old. Five female residents and two male residents were over 80 years of age, and the other three female residents were over 65 years of age. As for religious belief, three of ten residents have religious affiliation while others did not have religious beliefs. In regard to the family conditions, all residents were married. Nine residents had natural sons or daughters, while one female resident had an adopted daughter. Nine residents chatted with children or spouses every month directly, not by phone, and one resident had contact with family members once a year. Seven residents suffered from health problems, including heart disease, diabetes, cerebral venous thrombosis, and senile dementia.
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 |
Sub-themes |
Theme clusters |
|---|---|---|
|
Protective factors for suicide prevention |
Family bonds |
·Memory |
|
·Persuasion |
||
|
Relational factors |
·Help of nursing homes |
|
|
·Support and needs of loved ones in the family |
||
|
Religious belief |
·Filial piety |
|
|
·Unforgivable sin |
||
|
Risk factors for suicide attempts |
Family situation |
·Children diseases |
|
·Financial burden |
||
|
·Siblings living far away |
||
|
·Spouses diseases or death |
||
|
Physical conditions |
·Chronic conditions |
|
|
·Physical impairments |
||
|
Psychological conditions |
·COVID-19 related fear and anxiety |
|
|
·Distrust in society |
||
|
·Loneliness |
||
|
·Low self-esteem ·Pain |
||
|
Residential care |
·Delays in support providing |
|
|
·Lack of group activities |
||
|
·Personal conflict |
||
|
·Poor living settings |
||
|
Strategies for suicide prevention |
Seek outside assistance |
·Family members |
|
·Nursing home residents |
||
|
·Nursing home staff |
||
|
·Psychiatrists |
||
|
Self-care techniques |
·Prayers |
|
|
·Self reconciliation |
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)
The past few years have witnessed an increase in suicide rates during the life course among older residents in China[3]. Given the already dire condition, the findings of this study could shed light on the life experience of older residents with suicide ideation and attempts. The first category, classified as the impetus to suicide prevention, fell into three sub-themes (i.e., Family bonds, Relational Factors, Religious Belief). The first factor was the family bonds. As reported in previous studies, family cohesion and expressiveness, two aspects of family bonds, were stronger indicators of suicide ideation than family conflict[30]. However, family bonds covered more than these two indicators. In a recent study, Prabhu showed that damaged bonds led to the early occurrence of suicide[31]. Sukyung Yoon also found that family bonds were identified as one of the factors that contribute to suicide prevention[32]. Nursing home residents were living in a multi-factorial phenomenon around people with different roles. Staff in nursing homes had frequent interactions with residents, and had the experience to deal with similar circumstances. The support offered by them could save residents particularly when they felt overwhelmed in case of an emergency. In the previous studies, the beneficial effects of nursing home support against possible suicidal ideation were well documented[33, 34]. The roles of loved ones should also be given a paramount importance in the relational factors. Although family members were not able to live with them, they still remained involved in the lives of their loved ones. The early researchers assessed the quality and quantity of patient-family interactions prior to and following nursing home placement. On average, family members of 76 residents visited them 12 times per month[35]. However, some residents struggled with the absence of family visitation due to many factors, including the COVID-19 restrictions[36], transportation costs[37], family members’ beliefs and previous experiences with nursing homes[38]. The lack of visitation led to the condition that suicidal thoughts were on the rise in this study, which reached the alignment with the recent findings[39] that loved ones’ support was a significant buffer against suicidal ideation.
The changes in China over the past decades did not undermine the principle of filial piety, the pillar of Chinese ethics. Filial piety not only established the foundation of traditional Chinese society but also had a huge impact on the people life. The promotion of filial piety stretched through the individuals’ behavior. Some residents in this study said the duty of filial piety was expected to be performed by the younger generation and their children would be condemned if they make suicide attempts. As a result, some residents with such concerns, buried suicidal ideation deep in hearts or had self-adjustment of suicidal thoughts. These findings were also reflected in the MA Simon’s research that the lowest tertiles of filial piety receipt were associated with greater risk for suicidal ideation[40] and were also aligned with contemporary official Christian attitudes towards suicide that suicide was sinful[41].
According to the social reference theory, perceptions of all types (understandings, knowledge, information, judgments, etc.) were derived from some references[42]. In this theory, different references led to various perceptions[42]. The huge gap produced in this study when older adults compared themselves with others who had more achievements during the best years of life. The frequent reports of spouses’ diseases or death while mentioning the family situation often reminded them of the days that they spent together and the state of being in-adaptable to life without spouses. Exposure to the loss of beloved ones led older residents to be mired in the beautiful memories with their spouses, resulting in severe suicidal ideation[43]. Thus, it was more difficult for them to grapple with the sudden loss of intimacy and emotional connection[44] since they used to share finances. The surviving spouses often faced great financial burden because of the declining health and relevant healthcare costs, and as a result, some displayed suicidal thoughts. A parallel can be drawn with the previous research that financial hardship could be a trigger for suicidal thoughts[45]. The children’s diseases also made older residents think they had no capacity to take the role of caretakers though the diseases weren’t their faults. Parents felt helpless and even showed suicidal signs in the face of children’s serious illnesses especially when they did not have stable financial resources and support[44]. Residents in this study reported that seldom contact with siblings living away could be made because of their poor physical conditions and transportation access, which linked with their suicidal ideation and further attempts. The absence of contact with siblings living away has been associated with an increase in suicidal thoughts and behaviors[46].
Further, a number of studies have underlined the significant role of physical conditions among older residents from the public health perspective. Hassett[47] pointed out that suicide risk was elevated among individuals with chronic pain and similar findings were demonstrated by Racine[48] who suggested that chronic pain was an important risk factor for suicidality. As for the physical impairments, the relationship between physical disability and the heightened risk of suicide was examined[49]. Linda’s research[50] about suicide in older adults also supported the similar association between physical disability and suicide in this study.
In the past, physical diseases in the aspect of physical conditions mainly caused the suicidal behavior[51]. However, nowadays, the key factor leading to suicide is unbearable mental pain. It was noted that over 20% of older residents aged 60 and over suffered from psychological disorders[52]. Since the outbreak of the COVID-19 pandemic, suicide rates related to psychological disorders increased among these older residents[53]. Jenny[54] argued that the measures taken to protect residents’ health in the case of COVID-19 were short-sighted in terms of the dimension of well-being. Most nursing homes lifted strict visitation restrictions. In addition, information sources were limited to the television news, newspaper or words said by nursing staffs. The fear and anxiety associated with this serious illness emerged as a prominent trigger for suicidal ideation in this study. However, the majority of published studies did not show that fear and anxiety associated with COVID-19 led to suicidal ideation in the short term. Besides, the COVID-19 was still estimated to last for a long period of time[55]. Therefore, the nursing home staff interacted with older residents who had relevant fear and anxiety should be particularly diligent about providing health-care support. Meanwhile, visitation restrictions were implicated in a range of negative feelings, including social disconnectedness and loneliness. Based on the Interpersonal Theory of Suicide[56], social isolation was arguably the strongest predictor of suicidal ideation and suicidal desire emerges when individuals experienced perceived burdensomeness. The majority of residents in this study also stated that the suicidal ideation grew in the face of loneliness, which was in alignment with Niu’s research on the loneliness and late-life suicide[57]. For most older adults, the role transitions, including from working to retirement, from taking care of themselves to disability, had a pronounced negative effect on their psychological conditions. The large gaps between the past and the present lowered their self-esteem[58]. Self-esteem referred to the evaluations people made about themselves[59]. Research findings had indicated an inverse correlation between the self-esteem and suicidal ideation[60, 61]. Specially, the low self-esteem served as a precursor to suicidality; thus, suicidal ideation occurred when nursing home residents showed low self-esteem in this study. Apart from the low self-esteem, leading suicide studies in older adults also suggested that pain exacerbated the suicidal risk[62]. A small number of residents stated that pain conditions potentially increased their desperation and suicidal feelings especially when they worried the society was fraying and showed distrust.
China has both the world's largest total population and elderly population. According to China's seventh population census, China's 2020 population stood at 1.4118 billion in which there were 264 million people aged 60 and over or 191 million aged 65 and over[63]. However, the rapid increase in the number of Chinese elderly persons has not had a corresponding development in social and health care support system. The nurse shortages[64] became more serious as nurses were overworked. Protective equipment shortages[65] were also putting the social and health care support system at a risk from further development.
Under-staffing in aged care prevented residents from gaining timely support and participating in group activities. Sunghee[66] argued that many residents had limited opportunities and motivation for activities, which could have a negative impact on their physical, mental, and psychosocial well-being. This supports the statements, “Suicidal ideation had preyed upon me continually because there was no one to talk with” and “Staffs were nowhere to find when I wanted to end my life” in this study. The prevalence of nursing home under-staffing required nursing homes to make reasonable adjustments. New hired staffs could be offered a payout if they introduced other qualified nurses to work here. Moreover, it was also important to adjust nursing home staffing schedules, including ensuring fair compensation, providing transport to pick them up, and cancel non-necessary training.
Personal conflicts, a normal part of life in nursing homes, were also associated with different living habits[67, 68] and sudden raised voices[69]. Residents lived in their own apartments and shared common areas. Particular for some residents who were not able to take care of themselves, they also had to share nursing staff. Conflicts occurred when their needs were not met timely. When they reached a breaking point in emotion related to the unmet need, they might be verbally and even physically aggressive upon other residents, leading to suicidal thoughts[70]. In this study, some participants stated that the living setting was far from satisfied, and it was especially true with basic needs such as bathing and eating. They indicated that they were susceptible to suicidal ideation since they endured such unsanitary lockdown with no visitation under the COVID-19 pandemic. Some studies[71, 72] on equipment shortage corresponded to the above statements.
Suicide prevention requires effort from all levels of society, and effective strategies are essential. It was agreed by nursing home residents in this study that seeking outside assistance and self-care techniques helped them get rid of suicidal thoughts. As noted by Barrero, strategies aimed at older adults led to a reductions in suicide attempts following family members’ help[39]. However, the communication between residents and family members was largely limited for various reasons, and it became harder on account of the COVID-19 visitation restrictions. Therefore, nursing home residents and staff, who spent time with them every day, turned to be their major lifelines escaping from suicidal ideas. This was in accordance with the findings of Chauliac, N., et al. that trained gatekeepers could manage suicidal residents and prevention measures in an effective way[73], and the results of Schlichthorst’s study also showed that peer support translated into the suicide reduction[74]. Moreover, the essential role of psychiatry was also confirmed by participants, which correlated to the research by Rihmer, Z., Belsö, N., and Kiss, K[75]. In addition, the spiritual well-being enhancement through prayer, as one of the self-care techniques, was associated with the lower levels of suicidal ideation[76], which was consistent with those statements made by participants. According to the participants in this study, self reconciliation invited them to learn and value their strengths and become free of suicidal thoughts. Dr. Alan Wolfelt pointed out a similar viewpoint on his article called On the Journey to Healing: Seek Reconciliation, Not Resolution[77], introducing the significance of subtle changes in life.
In summary, suicide factors and prevention strategies among nursing home residents were complex problems, covering a wide variety of aspects. The findings from this study not only consisted of protective and risk factors as well as prevention strategies but also reflected some reported changes of nursing home residents based on the latest situation of COVID-19. However, the limited participants might be a barrier to the further application of prevention strategies. Besides, taking into consideration that suicidal behaviors and prevention were a multifaceted topic to the point that factors might differ upon different countries and regions, this thus suggested the direction towards future research on suicidal ideation.
Suicide-related problems are still under-represented on a global scale. Actions towards suicide among older adults, including nursing home residents, need a shared commitment. In this qualitative study, protective and risk factors of suicide, as well as nursing home residents’ strategies, were pointed out, which may be served as references in combating suicide ideation in elderly people and improving their life noticeably.
COVID 19: Coronavirus disease 2019;
Ethics approval and consent to participate
This study was approved by the Ethical Review Board of the School of Nursing and Rehabilitation, Shandong University. All participants signed informed consents in this study. All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication
Not applicable.
Availability of data and materials
The data that support the findings of this study are available from Zibo New Age Nursing Home, Happy Residential Care home and Sunflower Nursing Home in China but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the above nursing homes.
Competing interests
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding
2019 Key program of the 13th 5-year plan of Educational Science in Shandong Province (ZZ201947)
Acknowledgments
Many thanks to all participants who shared their life experiences with us. We are grateful for the support of Zibo New Age Nursing Home, Happy Residential Care home and Sunflower Nursing Home. We thank our team of research assistants who sorted out the participants’ information and recorded the interviews. We also thank the anonymous reviewers for their suggestions that guided us to improve this manuscript.
Authors Contribution
TIAN Yinong performed the interviews. ZHANG Dan and ZHANG Shuai supervised the work. TIAN Yinong processed the data, performed the analysis, drafted the manuscript. SU Yonggang aided in interpreting the results. All authors discussed the results and commented on the manuscript. The first author is TIAN Yinong, and the second author is ZHANG Dan. Both SU Yonggang and ZHANG Shuai are corresponding authors.