The Q-population for this study was developed and refined through an integrated literature review and interviews. The authors conducted in-depth interviews with eight NH practitioners including two nurses, two social workers, two physical therapists, and two care workers, all of whom had experience caring for residents with dementia in NHs. Interviews lasted between 60 and 90 minutes and continued until data saturation was achieved. The researchers recorded the interviews using an audio device and took field notes. Semi-structured questions were as follows:

• What do you think are primary discomforts experienced by residents of nursing homes?”

• Which aspects of managing resident discomfort do you consider most important? Can you explain why?”

• Can you share your personal experiences in managing resident discomfort?”

A review of previous studies on discomfort and discomfort assessment and intervention was also conducted. A literature search was conducted using keyword “discomfort” alone and combined with search terms such as “nursing home,” “assessment,” and “intervention.” The literature was later integrated and developed into a Q-population along with analysis of interview data.

In this study, the Q-population was reconstructed by categorizing similar statements. Statements containing multiple ideas were separated. Those with repetitive viewpoints were eliminated. A total of 70 statements were derived and organized into four categories: 17 statements on assessment of discomfort, 19 statements on strategies for assessment, 17 statements on intervention of discomfort, and 17 statements on strategies for intervention. After evaluating the clarity and distinctiveness of these statements, a total of 34 Q-samples were finally selected to represent the concourse (Table 1).

The convenience P-sample consisted of nurses, care workers, and others involved in the management of discomfort in residents with dementia in NHs. P-sample refers to participants who perform Q-sorting, a task of classifying Q-samples [22]. A total of 34 participants were recruited through purposive sampling. Finally, 10 nurses, eight care workers, eight physical therapists, and eight social workers were selected as P-sample.

Before conducting Q-sorting, information about the purpose of this study and instructions on how to do the Q-sorting were provided. Thirty-four Q-statements were printed on cards. Numbers were randomly placed on the back of cards. All participants were given a Q-sort table containing 34 Q-statement cards and 34 blank spaces with a forced quasi-normal distribution. Each column of the Q-sort table was numbered from “Strongly disagree” (-4) on the far left to “Strongly agree” (+4) on the far right. Participants ranked and ordered their level of agreement with each Q-statement card according to their subjective perception of discomfort care of their resident with dementia and placed cards in a pyramid shape on the Q-sort table. After sorting, researchers collected additional information for further interpretation of the Q-factor by asking participants why they sorted cards into two extremes. All participants’ responses were recorded.

Principal component factor analysis and varimax rotation were performed to analyze Q-sorts using the PQMethod 2.35 program [23]. As a result of statistical analysis, four discrete Q-factors representing perspectives shared by included participants were extracted. For each discrete factor, a distinct set of statements and their mean ranking from “Strongly disagree” (-4) to “Strongly agree” (+4) were reported. The nature of these factors was interpreted using the factor that produced Q-statements that most strongly agreed or disagreed (p<0.05). Finally, each factor was assigned a descriptive naming to represent interpreted characteristics.

Q-Factor I had an eigenvalue of 9.1 and an explanatory power of 27%. Eleven subjects were found to be significant in this factor. All participants of Q-Factor I were females. Their ages ranged from 24 to 65 years. Their NH experience ranged from 2 to 17 years. Regarding their occupation, there were five social workers, two physical therapists, and four care workers.

The P-sample belonging to Q-Factor I consisted of physical therapists, nursing assistants, and social workers, excluding nurses. Sources of residents’ discomfort were focused on emotional, personality, and reactive aspects rather than only physical aspects. Since the discomfort of residents with dementia is more complex than what practitioners can judge arbitrarily, Q-Factor I intends to take a cooperative stance among practitioners.

For example, “I think the most important thing is to regularly observe discomfort of the dementia resident. Given the nature of dementia residents, they are often unable to fully express their thoughts and needs. Therefore, we should focus more on their nonverbal expressions… When talking about dementia in residents, there is no common behavioral pattern that always appears with dementia, and there is no hypothesis that ‘if the elderly person remembers this, that will happen’.” (P-sample 5, P-5, Social worker)

Instead, Q-Factor I instinctively finds it more important to comprehensively capture their movements, facial expressions, or general mood. In fact, Q-Factor I believes that experienced professionals in dementia care often know that they can tell when the resident needs care just by looking at their facial expressions or eyes. They think that they have a kind of sensitivity and intuition.

Q-Factor II had an Eigenvalue of 4.8 and an explanatory power of 14%. There were eight participants. Statements most agreed upon by samples of Q-Factor II were statements 1 and 28. Six were females and two were males, with age ranging from 28 to 62 years. Their experience in NH varied from 1 to 15 years. Regarding their occupation, there were four nurses, three physical therapists, and one care worker.

This factor focused on assessing discomfort based on observation and information from various sources. It seeks to find various hypotheses about causes of discomfort in dementia residents through observation of various aspects of residents as well as situations based on vital signs. Q-Factor II focuses more on situations where practitioners themselves assess residents rather than collaboration between practitioners. It is similar to Q-Factor IV. However, it differs from Q-Factor IV in that it attempts to approach residents first and provide care before residents complain of discomfort.

“Most residents are in dementia. Because they can’t express their self, practitioners have to first figure out what expression residents are most uncomfortable with, groaning, or what part residents are most uncomfortable with right now, so I think practitioners should be able to do this well. Also, we need to be aware of individual patterns of how residents sometimes feel. I don’t think we should apply the same rules to all residents.” (P-31, Nurse)

“The biggest problem is the lack of communication due to dementia. I try to assess how much food a person with dementia is eating and the emotional environment they are trying to express. If a person with dementia seems uncomfortable somewhere, I try to wait until the situation becomes clear and check in.” (P-9, Nurse)

Q-Factor III had an eigenvalue of 3.6 and an explanatory power of 11%. Seven participants were significant in this type. The most agreed statements in this factor were statements 1 and 2. They were all females. Their ages ranged from 28 to 61 years. Their NH experience ranged from 2 to 12 years. Regarding their occupation, there were two social workers, three physical therapists, and two nursing assistants.

The P-sample of Q-Factor III consisted of social workers, physical therapists, and nursing assistants, excluding nurses. Q-Factor III was thought to promote emotional stability of residents and encourage them to express their discomfort in comfortable ways. Practitioners should observe discomfort patterns they express in a comfortable state and identify the cause of the discomfort. This is because, in terms of characteristics of their occupation, it is important to have emotional stability with residents through rapport in managing the discomfort of residents. It is believed that an attitude of trying to make residents as stable as possible can allow residents to accept management of the practitioner rather than reject it, which affects alleviation of discomfort of residents.

For example, “First, in order for residents to express what they want to express, they must feel comfortable themselves. Therefore, rapport between the practitioner and the resident is important. In a relationship of mutual trust, it is possible to find out whether what the resident wants to express is true. If residents are uncomfortable with the relationship with practitioners, residents will not express their difficulties well.” (P-3, Physical therapist)

“It is challenging to accurately understand the behavior and psychology of residents with dementia. These behaviors can vary slightly from one resident to another, and I have observed that a resident’s attitude can change significantly depending on which practitioner is interacting with them. This is why I believe the attitude of the practitioners and the trust established with residents are crucial.” (P-6, Care worker)

Q-Factor IV had an eigenvalue of 2.8 and an explanatory power of 8%. Seven subjects were significant in this type. Statements that most agreed with the sample of Q-Factor IV were statements 5 and 21. All P-samples belonging to Q-Factor IV were females aged from 40 to 65 years. The duration of experience in NHs ranged from 2 to 15 years. There were six nurses and one care worker. Q-Factor IV showed characteristic of recognizing discomfort of residents, obtaining objective data by measuring vital signs, and synthesizing all data obtained by asking practitioners or family members of other professions about past information of the resident with dementia to determine direction of the care plan. Q-Factor IV recognized that physical discomfort such as pain was more important than emotional or environmental discomfort. Since situations and behaviors that caused discomfort were all different due to various characteristics of residents with dementia, it was recognized that it would be more important to first secure physical and objective data and provide care based on this.

For example, “Anyway, if a resident with dementia feels uncomfortable with something, the easiest thing to do is to objectively measure vital signs. At the same time, it is good to look at the resident’s complexion, observe something naturally, talk about it, observe the atmosphere and speech, and understand the resident’s discomfort comprehensively. Is there a fever or is it because the resident’s blood pressure is low?” (P-20, Nurse)

“After all, clinical work is most directly related to life. So for people with health problems or who cannot speak, I think physical changes are the most important, and then cognitive and emotional aspects are considered. Anyway, residents with dementia have difficulty expressing themselves verbally, so we have to observe them carefully. So I think characteristics of each profession that manages the discomfort of residents with dementia are very important, and I think it’s important to build trust with the resident.” (P-16, Nurse)