How can advance practice nurses make decisions based on improving the quality of patients’ lives without knowing what that really means? T
Concept Introduction
The term “quality of life” is used frequently in health care and in nursing practice.
However, this term is not very well defined and perceptions of the meaning of quality of life
often vary. Advance practice nurses work to improve the quality of a patient’s life through
health promotion, disease prevention, and disease management. Issues of quality of life are
faced by advance practice nurses when dealing with health care advances that increase the life
span. Advance practice nurses hold the goal of improving the quality of their patients’ lives, but
the vague nature of this term leads to a lack of clarity on how this should be accomplished.
Decisions for treatment and goals for care are based on the affect those will have on the quality
of a patient’s life. Differences in what is meant by quality of life can lead to different treatment
goals, choices, and outcomes.
How can advance practice nurses make decisions based on improving the quality of
patients’ lives without knowing what that really means? The purpose of this concept analysis of
the term quality of life is to bring clarity to the meaning of this term by examining the various
ways it is used in health care and other disciplines. Clarifying what is meant by quality of life
will help those in health care communicate with each other and with patients and their loved ones
about quality of life. Clarification of the concept will also help guide treatment decisions and
care goals related to improving quality of life. This clarification will be accomplished by
looking in literature at the many ways that the term has been used. From these definitions, the
critical attributes of the term will be determined followed by example cases using those
attributes. The antecedents and consequences will then be determined followed by an
operational definition of the term quality of life that includes all the critical attributes. The
empirical referents will then be identified and described.
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Comment: There should not be a heading for this first section according to APA.
Comment: Please note that starting on this page, the header should simply read QUALITY OF LIFE (“Running Head’ should only be on the title page).
Comment: Why this concept is important to you, the nurse, or to nursing in general.
Comment: Purpose or aims of the concept analysis
Comment: Description of what will be covered in the paper
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Uses of the Concept
Quality of life has been defined in a variety of ways by many different sources.
The Oxford English Dictionary (2010) defines quality of life as “the standard of living, or degree
of happiness, comfort, etc., enjoyed by an individual or group in any period or place” (para. 1).
Mosby’s Medical, Nursing, & Allied Health Dictionary (1998) defines quality of life as “a
measure of the optimum energy or force that endows a person with the power to cope
successfully with the full range of challenges encountered in the real world” (p. 1370).
From a philosophical and ethical perspective, Jennings (2002) says that “the term quality
of life seems to imply that life is not intrinsically worthy of respect, but can have greater or lesser
value according to its circumstances” (para. 3). It is an “interaction between the person and his
or her surrounding circumstances, including other people” (para. 7). He also points out that
quality of life is “sometimes used to refer to the moral worth or value of a person and his or her
life” (para. 9) and “hedonic theories identify quality of life with states of awareness,
consciousness, or experience of the individual” (para. 11). Jennings says that rational preference
theories define quality of life “in terms of the actual satisfaction or realization of a person’s
rational desires or preferences” (para. 13) and that “individuals have a good life when the
objective state of the world conforms to what they rationally desire” (para. 13).
From a religious perspective, O’Connell (2007) defines quality of life as spiritual
wellbeing, spirituality, religious issues, feelings of hope, personal beliefs, religiosity, and inner
peace.
The World Health Organization (WHO) (2004) defined quality of life as “the product of
the interplay between social, health, economic and environmental conditions which affect human
and social development. It is a broad-ranging concept, incorporating a person’s physical health,
Karen Gutierrez � 2/15/11 2:10 PM Comment: This section does NOT need to be written in paragraph form the way this student wrote it. It should start with a brief description of what this section is all about and then include either a table with the first author and year and a quote of the definition with the page number, or a list of this same information not in table form.
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psychological state, level of independence, social relationships, personal beliefs and relationship
to salient features in the environment” (p. 48). WHO (2004) also defined health related quality
of life measure as an “individual outcome measure that extends beyond traditional measures of
mortality and morbidity to include such dimensions as physiology, function, social activity,
cognition, emotion, sleep and rest, energy and vitality, health perception and general
satisfaction” (p. 31)
Haas (1999) defined it as “a multidimensional evaluation of an individual’s current life
circumstances in the context of the culture in which they live and the values they hold. [quality
of life] is primarily a subjective sense of well-being encompassing physical, psychological,
social, and spiritual dimensions. In some circumstances, objective indicators may supplement or,
in the case of individuals unable to subjectively perceive, serve as a proxy assessment of [quality
of life]” (p. 738).
Plummer (2009) discusses quality of life as being contextual and health related, defining
it as “an intangible, subjective perception of one’s lived experience” (p. 139).
Kane (2003) defines quality of life as a “summary term, connotating a multidimensional
appraisal of a variety of important aspects of life, including health outcomes” (p. 30) and health
related quality of life as “aspects of life affected by a person’s health condition and its treatment”
(p. 30). Some of the aspects of qualities of life he lists are physical health and functioning,
emotional health, cognitive functioning, role performance and work productivity, sexual
functioning, life satisfaction, ability to perform activities of daily living, psychological well-
being, and social involvement.
Xavier (2003) says that quality of life “is increasingly acknowledged as an assessment
strongly dependent on the person’s subjectivity” and “two persons with the same functional state
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or the same ‘objective’ health condition…can have very different qualities of life due to these
subjective aspects” (p. 30).
Lowey (1992) defines quality of life as short term health outcomes that are influenced by
the health state in which one resides.
Morgan (2009) says that quality of life is evaluated in cancer survivorship based on a
perception of control, aches and pains, uncertainty, satisfaction, future appearance of cancer,
fatigue, family income, valuing and living life to the fullest, and increased family closeness.
Grewal (2006) defines aspects of quality of life as being relationships with family and
others, own health, health of close others, independence, emotional or psychological health,
religion and spirituality, finances and standard of living, social and leisure activities, home and
surroundings, enjoyment, security, and control.
Johnson (1997) discusses quality of life as being personal job satisfaction, income,
neighborhood schools, status of the region’s arts and cultural amenities, air quality, and racial
tolerance. Johnson also defines non health related quality of life as the quality of the
environment, personal resources, leisure time, houses paid for, successful investments,
disposable income, opportunities to develop interests and create satisfying environments,
housing, and air quality.
Sugiyama (2009) talks about quality of life being related to neighborhood open spaces,
the pleasantness and safety of these open spaces, social interaction, social activity, and regular
physical activity.
Albert (2002) makes a distinction in discussing health related quality of life. He defines
health related quality of life as relating to functional status, mental health, emotional wellbeing,
social engagement, and symptom states. Health related quality of life refers to ambulation,
Running Head: QUALITY OF LIFE 6
mobility, body care and movement, communication, alertness behavior, emotional behavior,
social interaction, sleep and rest, eating, work, home management, and recreation.
Meeberg (1993) discusses quality of life as being subjective and individualized with the
critical attributes of a sense of well-being, happiness, conditions of living, life satisfaction, an
acceptable state of physical, mental, social, and emotional health, or an objective assessment by
some one else that the living conditions of that individual are adequate and not life threatening.
Taylor (2008) describes quality of life as subjective, multi-dimensional, and dynamic. It
is the relationships between individual circumstances and culture and an individual’s appraisal of
life and fulfilling life goals. Some of its attributes are sanctity of life, economic growth, gross
national product, and a rise in life expectancy.
Mandzuk (2005) also describes quality of life as multidimensional, subjective, dynamic,
and on a continuum with attributes of spiritual well-being, income, housing, education, social
relations, happiness, and morale.
Critical Attributes
The critical attributes are the “characteristics of the concept that appear over and over
again” (Walker & Avant, 1995, p. 41). The critical attributes of quality of life are subjective
satisfaction, multidimensional, and dynamic. It is a subjective evaluation of life satisfaction.
This subjective nature of the term quality of life is seen in the definitions of the term when
descriptive words such as perception, context, interpretation, and individualized are used. It is
unique to each individual and based on their assessment and evaluation of their situation.
However, it can be measured through objective evaluation if a subjective assessment is not
available. Satisfaction is multidimensional which means it can include a variety of physical,
psychological, spiritual, and social domains of life. The physical domains include those
Karen Gutierrez � 2/15/11 2:24 PM Comment: You will have between approximately 2 and 4 critical attributes. If you have more than this, then you probably have included information which does NOT qualify for this category. You need to analyze your concept table and look for patterns in the definitions themselves, words which are repeated from one definition to another, or several words which mean essentially the same thing, and abstract these words out of their context in order to identify the essence of the concept . By identifying the abstract (not tied to place or time) essential attributes you can define the concept in a way so it can be applied to different settings and still maintain its core meaning.
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attributes in the definitions such as activities of daily living, functional status, exercise, physical
health, cognitive function, sexual function, sleep and rest, and comfort. The psychological
domain includes those attributes from the definitions such as fulfillment, emotion, happiness,
enjoyment, security, control, independence, and satisfaction. The spiritual domain includes
attributes from the definitions such as meaning, inner peace, morale, religion or spirituality, and
sanctity. The social domain includes attributes from the definitions such as relationships with
others, work productivity, income, role performance, recreation, social engagement, personal
resources, and environment. It is also dynamic in that it is continually changing and on a
continuum depending on life circumstances, disease state, developmental state, etc.
Model Case
A model case is “a ‘real life’ example of the use of the concept that includes all the
critical attributes of the concept” (Walker & Avant, 1995, p. 42). The following is a model case
for the concept of quality of life. Mary is a 43 year old mother of two children with a loving
husband and supportive friends. She just paid off her house and has already set aside money for
her children for college and for retirement. She recently got promoted in her job, which included
a raise, so she is financially secure. In reflecting on her life Mary feels a sense of happiness and
satisfaction. She is satisfied with her health, family, friends, and financial stability. She feels
loved and supported and thinks that life in general is very good.
This case represents all the critical attributes of quality of life. Mary makes a subjective
analysis of her life situation and is satisfied with it on many dimensions including emotional
happiness, social satisfaction, financial security, and physical health. It is important to note that
those are the dimensions that are important to Mary’s life satisfaction. Not all dimensions need
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to be included, but the subjective assessment can be multidimensional or one dimensional
depending on what is important to each individual. This is dynamic since it changes. Mary is
currently satisfied with her life but these circumstances and her satisfaction may have changed
previously and may continue to change with time.
Borderline Case
Borderline cases “contain some of the critical attributes of the concept being examined
but not all of them (Walker & Avant, 1995, p. 43). The following is an example of a borderline
case for the concept of quality of life. John is 58 year old male who lost his wife to cancer one
year ago. He has three children and five grandchildren. He owns his own home and is set to
retire next year. He is an active member at his temple and is involved in social activities through
the temple. He has personally had no health problems and remains very active, walking several
miles every morning. John is happy with his life but is struggling with depression after the loss
of his wife.
This case represents most of the critical attributes of quality of life but not all of them.
John has subjectively assessed his situation and even though he is fairly happy and seems from
the outside to have a great life, he is not satisfied. It is multidimensional since he is assessing
many areas of his life but deciding that what is important to him is his relationship with his wife.
He is not completely satisfied with life because of a loss of the relationship with his wife. This is
dynamic since his satisfaction has recently changed due to the loss of his wife and might change
in the future as he adjusts to life without his wife. This scenario includes all aspects of quality of
life except for satisfaction.
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Related Case
Related cases are cases that are “related to the concept being studied but that do not
contain the critical attributes” (Walker & Avant, 1995, p. 44). Julie is watching the news and
there is a clip about an elderly gentleman who just won quite a bit of money in the lottery. She
thinks that he will always be happy in life since he is financially set for life.
It may, on the surface, seem like this man is experiencing a high quality of life, but this
scenario is missing many of the critical attributes. It does not contain a subjective analysis of
satisfaction with life but an observation by someone who does not know what is important to that
individual that he must be happy. It is not multidimensional since it is not taking into account
any other aspects of life other than financial security and is not looking at what might be
important for quality of life for that individual. It is not dynamic since it assumes that the
gentleman will always have a high quality of life because of one incidence.
Contrary Case
Contrary cases are examples of “not the concept” (Walker & Avant, 1995, p. 44). Phyllis
is an 89 year old female with terminal cancer. She has been hospitalized for almost three
months. She is confused and unable to make decisions regarding her care. She cannot feed
herself and is incontinent. She frequently moans or calls out for help and says she wants to die.
Phyllis’ son has power of attorney and insists that his mom would want everything done for her
but will not allow her to receive pain medicine since it makes her too sleepy. A feeding tube is
placed, and Phyllis is intubated and weaned off on several occasions. The son says he wants the
doctors and nurses to do whatever they need to in order to keep his mother alive.
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This case is the opposite of the critical attributes of quality of life. Phyllis has not
subjectively assessed her life situation, and there is no objective assessment of her life
satisfaction but instead only with the fact that she is alive. Care is based on keeping Phyllis alive
rather than assessing her needs or satisfaction on the many dimensions of her life and is thus not
multidimensional.
Antecedents
Antecedents are the “events or incidents that must occur prior to the occurrence of the
concept” (Walker & Avant, 1995, p. 45). The major antecedent to quality of life is having life
itself (Haas, 1999) since that life must be present before quality of life can occur. One cannot
discuss the quality of life of something without life. Several sources suggest that another
antecedent is cognitive ability (Haas, 1999) or state of consciousness (Meeberg, 2003). Taylor
(2008) suggests that an antecedent to quality of life is the ability to assess, appraise, and evaluate
life, and the ability to make decisions. Even when quality of life is evaluated by others, they
must also have cognitive ability to assess, appraise, and evaluate life. The two major antecedents
to quality of life are then life itself and a cognitive ability to assess quality of life.
Consequences
Consequences are “those events or incidents that occur as a result of the occurrence of the
concept” (Walker & Avant, 1995, p. 45). It is difficult to discuss the consequences of a quality
of life but instead the consequences of quality of life have to do with a degree of quality of life or
a change in status of quality of life, either positive or negative. It can result in increased or
decreased life satisfaction (Sugiyama, 2009), happiness, a feeling of well-being, self-esteem, and
pride (Meeberg, 1993). It can result in improved physical and psychological health (Mandzuk,
Karen Gutierrez � 2/15/11 2:19 PM Comment: It is important to note that antecedents are what MUST occur before EVERY example of the concept in ALL contexts. So, in my attachment example I used in class, the cooing of a baby CANNOT be an antecedent to attachment because attachment in the context of an animal and a person or a favorite sweater and a person would NOT be preceded by cooing. You must analyze your data and identify abstract antecedents which are NOT tied to place or time.
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2005). The change can also result in a changed perception of life and thus in decisions to make
changes to one’s circumstances (Haas, 1999) and changes in choices of daily activities (Albert,
2002). It can result in the provision for individual choices, opportunities for participation in self
care (Kane, 2003), and achieving important life functions (Grewal, 2006). Another consequence
can be disease management and changes in treatment and practice choices (Plummer, 2009). It
can also result in an increase in empowerment (Taylor, 2008) or resiliency (Xavier, 2003),
especially in the face of illness or aging (Albert, 2002). It could also result in restitution for
biopsychosocial losses (Xavier, 2003), acceptance of life’s circumstances (Taylor, 2008), or
improved coping (O’Connell, 2007). It can result in the maintenance of the dignity of the
individual and a respect for individuality and preferences (Kane, 2003). Another consequence
can be cost containment.
Operational Definition
Quality of life is a subjective assessment of an individual’s personal satisfaction with the
dynamic life circumstances that can include multidimensional domains of life including physical,
psychological, spiritual, and social aspects.
Empirical Referents
Empirical referents are “classes or categories of actual phenomena that by their existence
or presence demonstrate the occurrence of the concept itself” (Walker & Avant, 1995, p. 46).
Because the critical attributes of quality of life include a subjective component, an empirical
referent of quality of life would be an individual subjective analysis of life satisfaction (Taylor,
2008). That is truly the best case when quality of life can be determined. The best way to
determine the presence of quality of life is if patients themselves can rate their quality of life
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Comment: Please note that all of the essential attributes for this concept are included in this ONE sentence definition and all the attributes are italicized.
Comment: I have eliminated this section from the paper for this semester. So, you do NOT need to include this section.
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(Albert, 2002) or their feelings of satisfaction, happiness, or well-being (Meeberg, 1993). The
World Health Organization (WHO) developed a tool to evaluate quality of life called
“WHOQOL.” It consists of a 28 item questionnaire that taps into physical, functional,
psychological, social, and satisfaction elements (Kane 2003).
Several tools have been developed to objectively determine the occurrence of quality of
life when subjective statements are not available. Although these are not exactly empirical
referents since they do not, by their existence, demonstrate the occurrence of the concept but
instead are useful tools, and a close approximation of quality of life in the absence of an
individual’s subjective analysis of their own quality of life. Those quality of life questions can
be asked of proxy informants such as family members who are presumed to know the individual
well (Kane, 2003). Observations can also be made that can determine quality of life which
include observations of individual’s behavior and information about their physical, social, and
care environments (Kane, 2003) and ability to set and achieve goals, express feelings of
discontent, initiate and respond to change, and develop and maintain satisfactory relationships
(Taylor, 2008). An absence of quality of life can also be determined through observation of
evidence of abuse, inadequate living conditions to support life (Taylor, 2008), and intense
suffering (Haas, 1999). However, it is important to note that these things do not mean that there
is a decreased or absence of quality of life. Since quality of life is an individualized subjective
analysis of one’s own situation, individuals may not consider some of these factors to decrease
their quality of life. They may, for example, find meaning in their suffering that in fact improves
their quality of life. This is why the best determinant of quality of life is the individual’s own
subjective assessment.
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Conclusion
Quality of life is a term that is used often in health care but is not clearly defined. The
aim of this concept analysis was to bring more clarity to the term for use in clinical practice. The
literature review and analysis showed that the term is hard to pin down to one objective
definition applicable in any context. However, clarity was accomplished through the analysis of
the uses of the concept in literature, the identification of the critical attributes, and ultimately the
articulation of an operation definition based on those critical attributes.
What is most important for advanced practice nurses to take from this analysis is the
subjective nature of quality of life. In the absence of subjective assessments of quality of life,
however, objective assessments can be made by those close to the individual who may know
what they would have valued. However, it must be remembered that quality of life is
multidimensional where many of the dimension are assessed and quality of life is ultimately
determined by what is important to the individual. When deciding on care goals and treatment
plans, these must be made in collaboration with the patient so that the patient can determine what
he/she values and what would improve his/her quality of life. The practitioner needs to put aside
his/her personal opinions are on what would improve quality of life and instead listen to the
patient’s wishes and goals. Quality of life is ultimately what an individual says it is, and when
that is heard and respected, the highest and most individualized quality of care can be provided.
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References
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