The aim of the study was to explore thoughts about death, dying and experiences of end-of-life care among older persons living in nursing homes. The results emphasize that dying caused worry among older persons. Their worries were especially related to a fear of pain and a long, protracted death. The finding on the fear of dying among older persons is supported by the findings of several other studies [6, 16, 17]. The results in this study also highlight wishes among older persons at the end stage of life, i.e., dying quickly without pain or suffering quick was expressed as the ideal way of dying. The results indicate that older persons were not afraid of death, which is supported by earlier studies [3, 4, 8, 16]. In the present study, death was considered a natural and inevitable part of life. Österlind et al.  suggested that older persons’ lack of concerns regarding death could be explained by their view of death as a natural end to a long life.
The results in the present study showed that older persons, with a few exceptions, worried about dying but not about death. Rahm Hallberg  found in her literature overview that older persons tended to plan their own death, for example, their funeral arrangements. However, preparing for dying seemed to be more uncommon, even though dying was seemingly what the older persons were most worried about. A potential explanation is that older persons avoid preparation or planning because it may cause anxiety and worries. Rahm Hallberg’s  results are in line with the results of the present study, which show that some of the older persons had made funeral arrangements, while dying was not something the older persons were prepared for.
The purpose of this study was not to explore older persons’ opportunities to discuss death and death-related questions at the nursing home. Nevertheless, the results indicate that older persons have fears and worries about dying. These fears and worries need to be adequately addressed by caregivers. A possible explanation for why older persons worry about dying is that they are not often given the opportunity to discuss such questions . Previous research [7, 9] has found that caregivers rarely open up for a discussion about death and dying, despite several studies supporting the idea that older persons have a need for conversations about this topic [8, 11, 18]. Earlier research has suggested that caregivers’ unwillingness to discuss death and dying can be caused by a lack of knowledge and/or confidence among caregivers [7, 8]. There exists a need to offer caregivers at nursing homes suitable support and education about how they should discuss death- and dying-related questions with older persons. The importance of giving older persons the opportunity to discuss these questions cannot be stressed enough – these conversations offer an opportunity to collect knowledge about the older person’s individual preferences in the end stage of life, and upholding these preferences should be considered an essential part of adequate end-of-life care.
The results revealed that life at the nursing home, to some extent, was characterized by negative experiences. The older persons shared stories related to the difficulties of living at a place with other residents who demanded more care than they did. The results suggest that the co-residence of mentally healthy older persons with older persons suffering from cognitive failure in the same nursing home has a negative impact on mentally healthy older persons. The older persons participating in this study were mentally healthy and expressed difficulties finding a social context at the nursing home. Previous research comparing cognitively healthy residents at nursing homes with residents suffering from dementia revealed that the former group experienced social difficulties, resulting in feelings of frustration and loneliness [22, 23]. A systematic overview by Bradshaw et al.  showed that mentally healthy residents avoided contact with residents with cognitive failure, which resulted in loneliness and social isolation. However, the same overview also indicated that older persons who managed to find a social context at the nursing home felt a sense of belonging that had a positive impact on their wellbeing.
Earlier studies [24, 25] have indicated that social isolation is common among older persons, and there is also research  suggesting that loneliness and isolation can be connected to symptoms of depression among older persons. As previous research has shown [25, 26], social isolation can have a negative impact on older persons’ wellbeing, which emphasizes the significance of optimizing older persons’ opportunities to find a social context at the nursing home. Riis Iden et al.  proposed dividing older persons into different wards/homes based on their mental health to improve the social aspects and quality of life of older persons in nursing homes.
In qualitative research, trustworthiness includes credibility, dependability, confirmability, and transferability [21, 27] and is important for the assessment of the study quality. Credibility concerns the extent to which the content of the data and the analysis process address the purpose of the study . One way to increase reliability is to collect data on a variety of experiences from participants to highlight several different perspectives of the phenomenon studied. This study included 20 women and 16 men aged 67 to 102 living at various nursing homes, which contributed to variation in age, gender and nursing home type. A limitation of this study is that only cognitively healthy older persons who could participate during a one-hour interview were included, which might have contributed to a biased view of the final stage of life in nursing homes. Thus, it is important to highlight that the use of this sample might have prevented the results from reflecting the thoughts and experiences of the frailest, oldest persons. Credibility also concerns the questions of whether the data collection method is the most appropriate in relation to the study focus and whether the amount of data collected is large enough to achieve the purpose of the study . The data collection was conducted through structured interviews, which encouraged the older persons to respond mainly in short statements, which can be considered a limitation. It is possible that semi-structured interviews with open-ended questions would encourage more detailed and comprehensive responses. However, the older people chose to talk spontaneously about their thoughts about death and dying and their experiences of end-of-life care. It seems that the older persons had a need to talk about these issues. Thus, it can be considered that the responses, based on spontaneous thoughts that the older persons decided to share, are a strength in terms of the study credibility. To further strengthen the credibility of the study and to facilitate the reader's assessment of the reliability of the results, quotes in each category and sub-category were presented, as well as examples of how the analysis process was performed are presented reported in Table 2.
Dependability is another important part of a study's trustworthiness and is related to the stability of the data material over time . To strengthen the dependability of this study, all older persons responded to the same questionnaires, all interviews were conducted by the same experienced interviewers, and the data collection period was relatively short (nine months).
Confirmability is related the extent to which data are objective or neutral, for example, through consistency between two or more researchers regarding the accuracy, relevance or meaning of data . Confirmability also concerns whether the results reflect what the study participants expressed and not the perspectives, interests, or preconceptions of the researchers. The participation of both authors in the analysis process reduced the risk of misinterpretation. The authors had continuous discussions during the analysis, which strengthened the confirmability of the study.
Transferability refers to the extent to which the results can be transferred or applied to other contexts or groups [21, 27]. Suggestions can be given about whether a study's results are transferable, but it is ultimately the reader's decision that determines the transferability. This decision can be facilitated through the provision of a clear description of the selection of participants and the context of the study for the reader . This study included cognitively healthy older persons aged 65 or older from both larger and smaller nursing homes located in both urban and rural areas . Thus, the results can be applied to other older persons living in nursing homes, provided that they are cognitively healthy. However, the results are unlikely to be transferable to older persons suffering from cognitive impairment or who are not residents of nursing homes.