Geriatric Nursing 34 (2013) 289e294
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Geriatric Nursing
journal homepage: www.gnjournal.com
Feature Article
Health despite frailty: Exploring influences on frail older adults’ experiences
of health
Zahra Ebrahimi, RN, PhD(C) a, b, *, Katarina Wilhelmson, MD, PhD a, b, Kajsa Eklund, OTR, PhD b, c,
Crystal Dea Moore, MSW, MA, PhD d, Annika Jakobsson, RN, PhD a
a
Sahlgrenska Academy, Institute of Medicine, Unit of Social Medicine, Department of Public Health and Community Medicine, University of Gothenburg, Sweden
The Swedish Institute for Health Sciences, Sweden
c
Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
d
Skidmore College, Saratoga Springs, NY, USA
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 4 June 2012
Received in revised form
9 April 2013
Accepted 15 April 2013
Available online 10 May 2013
The aim of this study was to explore and identify influences on frail older adults’ experience of health. A
sample of older adults, 11 men and 11 women aged 67e92, with diverse ratings of self-perceived health
ranging from poor to excellent were selected through a purposeful strategic sampling of frail older adults
taken from a broader sample from a quantitative study on health. In total, 22 individual qualitative
interviews were analyzed using qualitative content analysis in which themes were developed from raw
data through a systematic reading, categorization of selected text, theme development and interpretation. To feel assured and capable was the main theme, which consisted of five subthemes: managing the
unpredictable body, reinforcing a positive outlook, remaining in familiar surroundings, managing
everyday life, and having a sense of belonging and connection to the whole. The importance of supporting frail older adults in subjective resilience in their context is emphasized.
Ó 2013 Mosby, Inc. All rights reserved.
Keywords:
Frail older adults
Perceptions of health
Feel assured
Promoting health and well-being
1. Introduction
Maintenance of health in old age is both a challenge and goal of
the health care system. The proportion of people aged 65 and older is
expected to increase worldwide in the coming decades.1 Reserve
capacity decreases, and the risk of morbidity and frailty increases by
aging.2 There is a close link between ill health and frailty in older
adults; a combination of multimorbidity, impairment of reserve and
functional capacity, and dependency on others in daily activities is
associated with frailty.3e5 Although there is no strong consensus as
to its definition, frailty as a multi-factorial syndrome is a concept
often used to understand aging and health among older adults.3
Distinct from aging,6 frailty is preventable.7 Knowledge of frail
older adults’ descriptions and perceptions of their health and how
they experience health despite frailty is scarce. To fully understand
Declaration of conflicting interests: The authors declared no conflicts of interest
with respect to authorship and/or publication of this article.
Funding: The authors disclosed receipt of following financial support for the
research and/or authorship of this article: Vårdalinstitutet, The Swedish Institute
for Health Sciences.
* Corresponding author. Department of Public Health and Community Medicine,
Unit of Social Medicine, Institute of Medicine, Sahlgrenska Academy, University of
Gothenburg, Box 453, 405 30 Gothenburg, Sweden.
E-mail address: [email protected] (Z. Ebrahimi).
0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2013.04.008
frailty, individuals’ subjective perceptions of health in their unique
context should be taken into account.8 Eriksson9 links health to
suffering and posits “health is endurable suffering.” Unendurable
suffering hinders human development, and therefore care is intended to alleviate it. Eriksson defines health as physical and mental
soundness and feelings of well-being and wholeness. This definition
of health is holistic and multidimensional, relative, and subjective.10
Healthy and successful aging have been associated with the
older adults’ ability to constantly modify, reassess, and redefine
oneself.11 Older people perceive healthy and active aging as maintaining physical health and function, leisure and social activity, and
social relationships and contacts.12 This has been conceptualized as
a balance among life habits and activities in order to bring harmony
and well-being.13 There are different theories on successful aging
but no consensus on definition. Successful aging from a public
health perspective is defined as an optimal state of overall functioning and well-being (objective perspective), while older adults
define successful aging as a process of adaptation within a specific
context,14 as a social experience, a coping strategy and a way to
have fun to achieve and maintain a subjective feeling of wellbeing.15 Older adults, who were independent in activities of daily
living and rated their health as good to excellent, defined successful
aging as multidimensional phenomenon encompassing physical,
functional, psychological and social health.16
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Z. Ebrahimi et al. / Geriatric Nursing 34 (2013) 289e294
Does successful and healthy aging mean a lack of frailty? As the
healthy aging and successful aging perspectives do not consider the
frail older adults’ perspectives, it is possible that labeling frail older
adults as “unsuccessful” could produce feelings of guilt or inferiority. Richardson et al. view both successful aging and frailty as
social constructs of western culture. Frailty does not preclude
successful aging if it encompasses a sense of well-being and social
acceptance which may not necessarily mean being free from
disease or disability.17 Previous studies point out that older adults
with somatic health problems strive to maintain control and
balance in their lives through constant calibration and adjustment
of expectations to adapt to reduced energy levels, aging and health
problems.14 Frail older adults have described health as being and
becoming harmonious with and balanced in everyday life. Maintaining harmony and balance despite frailty is a result of changing
perceptions and expectations of one’s health status and its essential
structures.18 Therefore, when considering older adults’ own
perspectives, “successful” aging transcends physical realities of
aging.
Resilience is another relevant concept that defines aging as
a dynamic process involving many stepwise and gradual iterations
toward a reconstituted sense of wellness; ultimately, it gives people
the capacity to live a meaningful life despite adversity.19 Charney20
explains resilience and vulnerability in a model of psychobiological
factors involving neural mechanisms of reward and motivation, fear
responsiveness and adaptive social behavior.20 Resilience in aging
is not avoidance of disease and ill health but is a positive adaptation
to hardship, through a process of “person-environment interaction”.21 However, empirical studies about the influences on older
adults’ experiences of health despite frailty from older adults own
point of view still is scarce. In this study, we use Fried and
colleagues’ definition of frailty: a “biological geriatric syndrome” of
reductions in physiological reserve capacity and impairment of
defense mechanisms against stress and disease which implies a risk
of multimorbidity.3 We assume frail older adults can experience
health. Eriksson’s10 definition of health, i.e., “health is endurable
suffering,” was the crucial guiding framework for this qualitative
study. The aim of this study was to explore and identify what
influences frail older adults’ subjective experiences of good health.
2. Method
Qualitative methods that provide access to the interviewees’
lifeworld were used. Interviews were characterized by an open and
flexible conversation, with the interviewee controlling the direction and content of the conversation.22 The interviewer adapted an
attitude of active listening and flexibility to allow unexpected
experiences and life stories to emerge.23,24 In the first analysis of
this qualitative study, we focused on frail older adults’ health with
a phenomenological approach,18 and the present study examines
influencing factors on older adults’ experience of health. Qualitative
content analysis was utilized.25,26
2.1. Sampling and participants
The sample was selected from161 participants in the ongoing
project, “Continuum of Care for Frail Elderly Persons” with followups at 3, 6, and 12 months, a multi-professional intervention for
frail older adults living in a community in western Sweden. The
main study included older adults living in the community who
sought emergency treatment in a hospital, and who were either
80 years or older or persons aged 65 years or older with one or
more chronic diseases who were dependent on help in at least one
activity of daily living. People receiving palliative care, suffering
from dementia or cognitive impairment or in need of immediate
emergency care were excluded.27
Through a strategic purposive sampling from the main project,
21 frail older adults (11 men and 10 women) with varied ratings of
self-perceived health were selected at the 3 month follow-up. The
goal of this strategic sampling was to choose a group of frail older
adults, who varied in their assessment of their self-perceived
general health as assessed by one statement from the SF-36 questionnaire: “In general, you would say your health is” followed by
responses on a 5-point Likert-type scale: poor, fair, good, very good
and excellent.28 The first 2 older adults in each health and sex
category who agreed to be interviewed were included. All participants but one woman were recruited from the 161 participants in
the main project. The intention was to capture a wide variation in
sex and self-estimated health by choosing at least two men and two
women from each category. In the category of “excellent,” there
was only one person (a man) who chose this rating at the 3 month
follow-up. To include adequate representation for the “excellent”
category, an additional participant was recruited from outside the
main project; an 83 year-old woman who was married to one of the
participants fulfilled the criteria for inclusion and estimated her
health as excellent. To compensate for the lower number of
participants in the “excellent” category, additional people in the
category of “very good” were selected to be interviewed. This
sampling method was employed to provide rich, relevant, and
diverse data.29 See Table 1 for a description of the participants.
2.2. Ethical considerations
Kvale’s22 suggestions for ethical conduct of interview studies
guided us in study design and implementation. The interviewees
received information about the purpose and procedure of the study
Table 1
Characteristics of participants.
Total
Age (years)
65e74
75e84
85e92
Self-estimated health
Excellent
Very good
Good
Fair
Poor
Marital status
Married/cohabiting
Widow/single
Educational status
Elementary school
High school graduate
University education
ADLa (at least one dependent)
Instrumental
Personal
Frailtyb
At least tree frailty indicators
At least two frailty indicators
N ¼ 22
2
15
5
2
6
5
5
4
11
11
10
8
4
16
9
15
22
a
Activities of daily living (ADL) scale includes instrumental and personal activities. Personal ADLs consist of bathing, dressing, toileting, transferring, feeding.
Instrumental ADLs consist of cleaning, shopping, mode of transportation, cooking
(Åsberg-Hulter, 1990).30
b
Frailty indicators consist of weakness, fatigue, weight loss, reduced physical
activity, impaired balance, reduced gait speed, visual impairment, and impaired
cognition. A more detailed definitions/cut off levels of frailty indicators are given in
the study protocol of the main project (Wilhelmson et al27). The participant who
was recruited from outside the main project was assessed as frail according the
interviewer’s clinical judgment.
Z. Ebrahimi et al. / Geriatric Nursing 34 (2013) 289e294
via telephone, and then orally and in writing on the day of the
interview. They were informed that participation was voluntary;
they could stop the interview and withdraw at any time, their
interview content was confidential, and any information reported
would not allow for individual identification of interviewees. Given
the health status of the interviewees and consideration of possible
interviewee fatigue, participants determined the interview length.
The study was approved by the Ethics Committee of Gothenburg
080812, dnr 413-08. The participants signed an additional consent
for this qualitative study.
2.3. Data collection
Data were collected through 22 individual qualitative interviews
via an interview guide22 which was tested in two pilot interviews.
The first author (ZE) conducted all interviews in the interviewees’
homes. The interviews began with general conversation about
health and information about the study. Participants were asked:
Can you describe a day/situation, where you experience health? What
gives you a feeling of being in good health? Can you describe a day/
situation where you don’t experience good health or where you
experience poor health? What gives you a feeling of poor health? What
do you presently lack in order to experience good health? In addition,
the interviewer used probes to gain a deeper understanding of the
interviewee’s everyday life situation by using such phrases as,
please tell me more about your experience, thoughts, and emotions,
please give me some examples from your everyday life. Background
information about the study and the informed consent process was
not recorded. On average, each visit lasted one and a half hours. The
audio-recorded conversations that directly addressed the interview
guide questions lasted between 18 and 63 min and were transcribed verbatim. A total of more than 11 h of audio-recorded data
was collected. The visits ended with general and spontaneous
reflections and questions.
2.4. Data analysis
A conventional content analysis was conducted whereby categories and themes emerge from the data based on participants’
unique perspective31 about what influences their experiences of
health. This analysis has a focus on the “latent content” which
consists of the researchers’ interpretation of the underlying
meaning of the text; i.e., the “latent content” is an abstraction of the
291
“manifest content.” The manifest content was summarized under
categories, while the latent content was described under themes.26
All interviews were transcribed verbatim and read several times to
understand the entirety and overall perception of the informants’
description of what influences their experiences of health through
searching for what enable older adult to endure suffering, frailty
and adversities.21,22 Four of the authors [ZE, KW, KE and AJ] listened
and read all interviews. The first author [ZE], a registered nurse
specialized in elderly care, worked most closely with data along
with three of the coauthors with diverse professional credentials:
a geriatrician [KW], an occupational therapist [KE] and another
registered nurse [AJ]. A continuous discussion and peer debriefing
between four of the authors [ZE, KW, KE and AJ] during all five steps
of the data analysis process and modifying of categories and themes
performed until consensus was reached. The fourth author, a social
worker [CM], assisted during the last phases of data analysis to
provide a fresh perspective. See Table 2 for a summary of the steps
in the analysis and an example of how the meaning units were
connected to the main theme.
2.5. Findings
Ten categories emerged from the manifest content which
resulted in five subthemes and one main theme. The main theme
was identified as feeling assured and capable. The five subthemes
related to feeling assured and capable consisted of: managing the
unpredictable body, reinforcing a positive outlook, remaining in
familiar surroundings, managing everyday life, and having a sense
of belonging and connection to the whole. The maintenance of
a life-routine to which the older adults were accustomed provided
assurance to their everyday lives. The frail older adults’ experiences
of health were strengthened when they felt a sense of assurance
and control over everyday life, whereas an unpredictable body and
experiencing symptoms and ailments that affected their everyday
lives produced a sense of anxiety and insecurity, which weakened
their experience of health.
2.6. Managing the unpredictable body
The incomprehensible symptoms and ailments that affected
older adults’ daily lives decreased their experiences of good health.
When the body was experienced as unpredictable and untrustworthy, this was perceived as a hindrance, and they felt imprisoned
Table 2
Analysis step by step and one example of the process from some meaning units to one of subtheme and thereby to the main theme.
Meaning unit
Condensed meaning unit
Categories
Subtheme
Main theme
1.Each interview was read lineby-line to divide the
interview text into “meaning
units,” i.e., words, sentences
or paragraphs, which contain
aspects related to each other
in their content and context.
2. All meaning units were
condensed without doing
interpretation. The aim was to
reduce the text and rewrite the
text as close as possible to the
original text.
3.All condensed meaning units
that have internal homogeneity
and external heterogeneity
were sorted into categories and
were interpreted through
continuous discussion in the
research group until consensus
was reached.
4.Through a constant repetitive
reading, interpretation and
validation of the interviews in
their entirety and comparisons
to the categories five
subthemes emerged.
5. One theme representing the
latent meaning of the content
emerged comprising five
subthemes.
Missing lost friends he used to
see
Social relations
The sense of belonging and
connection to the whole.
To feel assured and capable
Meeting and talking to others
To have something to do
Example:
- I miss friends., we were
some friends that met. They
are gone.
- When I meet people and talk
to them.
- It’s very good that I always
have something to do.
- To perform a specific activity,
such as gardening.
- I can’t go out in nature, I miss
nature.
Good to have something to do
Be active, like gardening
Missing nature
To be a part of the whole
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Z. Ebrahimi et al. / Geriatric Nursing 34 (2013) 289e294
in an unknown body. The symptoms that restricted their mobility
and ability to conduct everyday activities were experienced as
obstacles. Ongoing and persistent symptoms and unpredictable
ailments produced disappointment; their bodies were described as
no longer able to bear their ailments. These bodily changes
disturbed the rhythm of everyday life and weakened their experience of health. A 76 year-old man, who estimated his health as
excellent said: “My body plays tricks on me,. it does not function as
usual. it limits me, I cannot go out now and take even the simplest
walk as I have done before. my body is inflexible, it is not as
controllable as it was.”
Troublesome symptoms included ones that limited mobility,
such as poor balance, pain, vision loss, fatigue, and lack of energy.
These frail older adults experienced their bodies as a barrier to
being healthy, as an unpredictable entity that deceived and was no
longer able to serve them. The older adults with manageable
symptoms and disorders were more likely to experience safety and
control, thereby experiencing good health.
going to have it so much better, it is close to everything, close to the sea
and so on, there are so many opportunities.” Thinking about the risk
of being forced to leave one’s home to be institutionalized raised
anxiety. An 84 year-old woman, who estimated her health as very
good said: “I have mobility, can participate and still experience things
around me; I think it is extremely important. I am afraid of ending up
in an elderly home and just sitting there.” A 67 year-old man, who
estimated his health as poor said: “I understand that I cannot live at
home any longer and this makes me very depressed.” The desire to
remain at home was a motive to successfully adapt after changes in
health status and life circumstances, which gave them strength to
continue to struggle and move on. To stay in their own home
strengthened the older adults’ experiences of safety and control,
thereby promoting health. An 82 year-old man, who estimated his
health as good said: “to remain in own home and not end up in
a nursing home is an advantage for the experience of health.” Another
92 year-old man, who estimated his health as fair said: “I really
want to remain living here; I am deeply rooted and have my belongings here as well. I’m trying to do the best I can.”
2.7. Reinforcing a positive outlook
2.9. Managing everyday life
Positive thinking and willingness to go on facing further challenges were dependent on awareness of age- and disease-related
changes. Good mood and willingness to carry on and live despite
consistent body hindrances were important driving forces, and
enabled these older adults to directly face the future and its
concomitant changes in their lives. An 84 year-old woman, who
estimated her health as fair said: “I have so much trouble with my
heart; I have my good disposition and feel pretty good anyway. I
know that today is my day, I must enjoy the day as it is.” She also
pointed that “good mood hides my handicap.”
Knowledge and information about resources such as assistive
devices to compensate for loss of function helped to prepare these
older adults to meet the future. Insight, acceptance and adaption
shaped willingness and strength to carry on and provided the
foundation for a sense of meaning. An 81 year-old man, who estimated his health as good said: “I solve crossword puzzles and things
like this to keep my brain active, it may not make you better, but
perhaps it prevents or slows down degeneration. Of course it was
a slight uphill battle after surgery. It takes time to recover stamina; and
age affected recovery. I am aware that I will soon be 82, feel satisfied
with life as it is.”
Positive thinking and hope facilitated the ability to cope with
increasing frailty, and those with a positive outlook were more
likely to feel assured and capable, particularly when the older
adults could understand the ongoing changes in their lives. An 83
year-old woman, who estimated her health as excellent said: “My
heart is not really well and sometimes I don’t feel so good, and I just
hope that tomorrow it will pass; and then the next day you feel better;
then I’m happy, when you’ve gotten through it one more time.”
To continue to manage and maintain control over one’s life gave
a sense of assurance and health. Frail older adults experienced good
health when they were able to manage their daily activities independently, control their own lives in spite of dependency, remain
occupied and engaged in useful activities, and not be a burden on
others. A 78 year-old woman, who estimated her health as good
said: “Health is to a great extent being able to look after yourself,” and
another 79 year-old man, who estimated his health as poor
remarked: “It feels very tough. I was used to taking care of myself,
but now need help with just about everything.”
Managing and steering the activities of one’s everyday life was
a reflection of the older adults’ self-determination, a quality that
strengthened the experience of good health. Adapting and
continuing with previously enjoyed hobbies and interests, keeping
up with the rapid developments in society, and mastering the
details of everyday life enhanced the experience of good health
despite frailty and promoted a sense of independence. When able
to successfully manage everyday, these older adults experienced
themselves as independent. Having meaningful daily activities,
being able to continue with their previous life style, and maintaining daily routines not only gave them a sense of usefulness and
filled their days, it also created a sense of independence and
autonomy; an 83 year-old woman, who estimated her health as
very good summarized this feeling: “To be able to do what I want to
do.” These older adults were grateful for the help they received and
wanted to give something in return. Doing something useful and
not being a burden to others enhanced their feelings of autonomy.
Independence and self-determination contributed to a sense of
security and control and reinforced the feeling of good health.
2.8. Remaining in familiar surroundings
2.10. A sense of belonging and connection to the whole
These older adults were deeply rooted in their homes and
endeavored to stay there as long as possible. The home had much
more meaning than just a residence; it brought about feelings of
remaining in a pleasant place with familiar and important objects
and shared norms, history and values. Although many of these
older adults preferred to adapt the home environment in order to
stay in familiar surroundings, some moved from their homes to
accommodate their health conditions so they could continue to
manage their everyday lives. An 84 year-old man, who estimated
his health as good pointed out: “I would like to have a chance to go
out and walk. we are going to sell this house, because we are so old
and shall not have a garden, we have bought an apartment . We are
Social interaction validated a sense of connection to others and
the rest of the world, which evolved through contact with others
and having someone in their lives that cared about them. Having
social connections of any kind reinforced experiences of good
health. An 85 year-old man, who estimated his health as fair said: “I
read the daily newspaper and monthly magazines to keep me up-todate with what is happening in the world.” A well-adapted home
environment, ambulatory aids and supported access to the
outdoors facilitated older adults’ mobility and social participation.
Participation in activities with peers assuaged loneliness and
provided a sense of belonging. Meaningful, positive contact and
Z. Ebrahimi et al. / Geriatric Nursing 34 (2013) 289e294
regular interaction with friends, neighbors, and relatives promoted
happiness and a sense of security. Being able to move freely among
other people and spending time in nature enhanced security and
belonging. An 84 year-old woman, who estimated her health as fair
said: “Nature is health in that I am able to come out and take pleasure
in nature. I cannot go out by myself, I miss nature.”
Lack of social interaction in combination with physical disabilities was related to the experience of loneliness and isolation.
Participation in social contexts and a sense of belonging led to
increased feelings of security which reinforced the experience of
good health. A 67 year-old man, who estimated his health as poor
said: “A sign of health to me is that I avidly follow developments in
society, I meet and talk and spend time with other people. Keeping in
touch with my children, grandchildren.”
3. Discussion and implications
The main factor that reinforced older adults’ experiences of good
health was feeling assured and capable, which was dependent on
predictability and perceived control over one’s body and psychosocial context. A positive outlook was associated with having the
resources to remain in familiar surroundings, managing and
controlling everyday life, and a sense of belonging and connection
to the whole. These factors reinforced the experience of good health
and enabled the older adults to better cope with their vulnerability
and frailty.
The findings that older adults were able to better manage frailty
through an understanding of symptoms and bodily changes are
consistent with Antonovskys’ sense of coherence.32 Comprehensibility shapes security in frail older adults’ lives, increasing a sense of
control and the predictability of one’s body and life in general. The
capacity of having a positive outlook facilitates one’s willingness to
face further challenges and calls on inner strength and the ability to
create insight and accept changes in one’s health situation. Insight
and knowledge of aging, disease, and its effect on their lives made it
easier to accept and facilitate adaption to age-related changes and
frailty. Findings from this study emphasized the role of inner
strength in creating well-being despite frailty, indicated as
a component of resilience or “internal hardiness” in another
study.33 The findings from this study are in line with Lundman
et al’s research.34 They identified four core and interacting
dimensions of inner strength: connectedness, firmness, flexibility,
and creativity. Inner strength meant believing in one’s own possibilities, making choices and having control over life’s trajectory in
a meaningful way.34 Our study emphasizes the value of health and
social care staffs’ attitudes, positive interactions, and confirmation
of older adults’ courage, and how insight into facing the changes
and challenges in life facilitated older adults’ experiences of good
health despite frailty.
Aging in place was the other factor that gave a sense of safety
and confidence in life and strengthened older adults’ experience of
health. Two other Swedish studies emphasized that the home has
a central place in older adults’ lives and is equated with security and
freedom.35 Another study described resilience in aging as a positive
adaptation to hardship through a process of “personeenvironment
interaction”.21 Older adults reported they cannot imagine living
anywhere else; while they were aware they might be forced to
leave, they chose not to think about it.36 Being sensitive to older
adults’ real and everyday needs, desires and challenges are among
the key issues in planning a responsive health care system. In
addition, present findings corroborate other studies which highlight self-determination and autonomy as enhancing factors in
older adults’ control and satisfaction,37 and the role of having
control over one’s own life and its beneficial effects on quality of life
and well-being.38 A well-adapted life based on individual needs
293
and resources, well-planned health and care efforts, the staff’s good
attitude and sensitive treatment enhances older adults’ autonomy
and strengthens their experience of good health.
A sense of belonging and being connected to the whole were
other factors in creating safety and control in frail older adults’
everyday lives. Lack of social interaction and activities gave older
adults a sense of loneliness and isolation, while being with others,
being in nature, and participating in activities were validating. This
study focused on the factors which strengthen frail older adults’
experiences of health. The findings from this study emphasize the
importance of feeling assured in everyday life, which promotes an
experience of good health despite frailty. Helvik et al focused on
older adults’ salient problems and illuminated facilitating strategies
such as: utilizing a network of important others, enjoying one’s
cultural heritage, being occupied by interests, having a mission to
fulfill, improving one’s situation by limiting boundaries and
creating meaning in everyday life.39 The findings from these studies
are complementary and provide some basis for developing frail
elder-specific interventions aimed at preventing vulnerability and
promoting health. The key issue is that maintaining health despite
frailty is possible through focusing on older adults’ everyday lives
and providing opportunities to feel assured in one’s daily life. The
threshold for experiencing health is in constant flux depending on
an individual’s reconceptualization of its barriers and resources to
maintain control in everyday life.
The contribution of this study is its description of factors that
generate good health and subjective resilience to adversity from
frail older adults’ own point of view. Further evidence about this
has been requested by several authors.20,21,33 We advocate ongoing
assessment and dynamic treatment plans implemented by multiprofessional teams that support older adults’ assuredness in their
everyday lives. A multi-professional team is more likely to attend to
the whole person in context, facilitate the managing of the
unpredictable body, provide opportunities to remain in familiar
surroundings so that older adults can manage their everyday lives
and have a sense of belonging and connection to the whole.
4. Strengths and limitations of the method
The qualitative content analysis involved systematic categorization, interpretation, and validation of manifest content into
a latent context-dependent social reality.25 Only including
community-dwelling individuals and excludes a large group of frail
older adults, i.e., institutionalized older adults, which limits transferability of the findings to this latter group. Despite this limitation,
we conducted a strategic purposeful sampling to capture diversity
of experiences and developed a valid description of what influenced the frail older adults’ views of health. This approach was
implemented to increase trustworthiness and transferability of the
findings.40 We are also aware that interpretations in all qualitative
studies and the results are located in a particular context and
setting,41 but we think that results from this analysis have an
adequate degree of transferability. We believe that the results can
be applied beyond the study setting, for example in other situations
where older adults are cared for due to using purposeful sampling,
good information about participants and a well-described analysis
method.41,42
To ensure the relevance and validity of the questions of the
interview guide, two pilot interviews were conducted and adjustments made. Researcher triangulation was conducted to increase
credibility and validity of the findings, i.e., an interdisciplinary
perspective throughout the analysis process reduced research bias,
and reached the maximum critical approach and reflexivity crucial
for the trustworthiness of the findings.40,43 As five researchers with
diverse backgrounds involved in ongoing data analysis and
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Z. Ebrahimi et al. / Geriatric Nursing 34 (2013) 289e294
interpretation from different professional perspectives, we ensured
the themes covered a holistic and relevant view on healthstrengthening factors.
Interviewing this group of older adults who suffered from
several diseases and fatigue was an ethical dilemma and limited the
ability to go more in-depth during some interviews. Interviewerobserved signs of fatigue led to the challenge of not burdening
the participants. Still, we cannot guarantee that our understanding
of the older adults’ statements completely captured what was
intended by the study participants but we believe that even shorter
stories had a qualitatively rich content.
5. Conclusion
The findings from this study reveal frail older adults’ subjective
resilience to adversity from their own point of view and further
demonstrate an association between their experiences of health
and feeling assured in their day-to-day lives. They emphasized the
importance of maintaining consistency and predictability in biopsychosocial contexts; having a manageable everyday life creates
a sense of assurance and strengthens the older adults’ experience of
health. The findings have two clear clinical implications. One is the
importance of supporting frail older adults in stimulating their
experience of health and well-being despite frailty by focusing on
the individual’s resources, requirements and conditions in the life
context to which they are accustomed. Secondly, the necessity of
multi-professional teams in working with frail older adults is
underscored by this study’s findings. The challenge for health and
medical personnel is to focus on the factors that strengthen older
adults’ health. In summary, we emphasize the importance of
subjective potential for resilience in the individual context. In
addition creating health despite frailty will be possible through
enabling older adults to feel assured, and to provide opportunities
for managing their everyday lives and endure suffering, which
requires on-going coping and support.
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