Quality of life is an issue of much importance to older adults and to the professionals who work with them. Yet, the study of such an abstract construct has presented a challenge. Scientists from several disciplines - including nursing, medicine, sociology, and psychology - have struggled with defining and measuring the quality of life. There is still no single definition or method of measurement.
The research also has included attempts to identify and verify variables that relate to, affect, or even predict quality of life for the elderly. One such variable is perception of health. Several non-nursing studies have shown self-perceived health to be significantly related to quality of life for older persons and have provided support for the work of nurse researchers on this topic (Edwards, 1973; Harris, 1976; Palmore, 1972; Spreitzer, 1974).
Because perception of health has continued to appear as important to quality of life for elders, several questions have developed. Have nurse researchers recognized the relationship of these variables and designed studies that examine the subject in greater depth? The majority of the studies in the literature review were descriptive. Have nurse researchers progressed toward theory-generating or theory-testing research in relation to quality of life and perceived health? What is the link between theory and research in the current work on this topic?
The purpose of this article is to analyze the research focus, theoretical bases, research designs, statistical methods, and research findings of nursing research on the relationship between quality of life and perceived health in the elderly from 1987 through 1991. The findings from this analysis have the potential to identify nursing implications for current practice, indicate areas for future research, and build the body of nursing knowledge.
REVIEW OF LITERATURE
Lang and associates (1990) conducted a review of 476 nursing studies, from 1980 to 1990, on the quality of health care for older people in America. In their category on quality of life, life satisfaction, and health promotion, the review listed at least four studies in which perceived health was related to or predictive of quality of life for older persons.
In the first study, Laborde and Powers (1985) studied persons with osteoarthritis and examined relationships between life satisfaction and perceived health, locus of control, and illness-related factors. The authors found that life satisfaction was related to better health perception, internal locus of control, and less pain.
The second study, by Magilvy (1985), researched quality of life in hearing-impaired older women. Magilvy found that the best predictors of quality of life were social hearing handicap, functional social support, and perception of health.
Ryden (1984), in the third study, examined patterns of causal relationships among perception of situational control, health, socioeconomic status, functional dependency, length of stay, and morale in institutionalized elderly. Subjects were residents on intermediate and skilled care units. The findings indicated perception of situational control to be the key variable related to morale for the residents on both levels of care. However, functional dependency, health, and socioeconomic status also were significant variables and had direct effects on the morale of residents in the intermediate level of care.
In the fourth study, Hoeffer (1987) studied personal and social factors in older single women to evaluate whether those factors differentiated among widowed, divorced or separated, and never-married older women, and if they were predictive of life outlook for the subjects. The findings showed never-married women to be better educated, healthier, less lonely, and to have a more positive life outlook. However, only 29% of the variance in life outlook was predicted by the variables.
Such research findings can contribute some knowledge to the nursing discipline. However, if such studies were conducted without theory bases, the contributions would be fragmented. According to Fawcett (1978), the advancement of knowledge requires an integration of theory and research.
Five studies have been conducted to analyze the development of knowledge in the area of gerontological nursing. Basson (1967) reviewed and categorized the literature from the year 1955 through 1965. Of the 438 articles, 52 were classified as research studies and 34 were empirical studies; only one was identified as theory development. The author noted a paucity of research emanating from a theoretical framework.
Robinson (1981) analyzed published literature during two periods. First, she reviewed gerontological nursing research published between 1966 and 1975 and found that 36 studies were conducted by nurses. She reported that the majority of the studies were based on theories derived from behavioral and social sciences. A framework or theory from physical sciences was used in a few studies. The majority of the research was found to be reported without reference to an underlying theoretical framework. The author noted the lack of replication. Finding two studies using the same framework was rare.
In a review of gerontological nursing research published between March 1975 and November 1979, Robinson reported that more experimental designs and more sophisticated statistical analyses were used. She noted the increase of studies designed to develop and test assessment tools and guidelines. The use of theoretical frameworks was not addressed in this review.
Gunter and Miller (1977) reviewed the studies pertaining to the care of the elderly and psychosocial gerontological nursing research from 1951 to 1976. They found that, with the exception of the Rogers model used in four studies at New York University, no nursing theoretical framework was used. Theories, where used, were taken from other disciplines. The authors summarized that the researchers gave minimal attention to the integration of knowledge from biology, psychology, and sociology.
Murphy and Freston (1991) reviewed six nursing journals that consistently presented gerontological nursing studies, from the year 1983 through 1989, to examine the status of recent knowledge development and the interrelationship among theory, research, and practice. They reported that 46% of the 142 total studies identified a theory or conceptual model as the theoretical perspective that guided the research process. Fifty-nine percent of the theoretical or conceptual frameworks used came from the discipline of nursing. The authors noted that there was an attempt to link research with existing knowledge. However failure to explain the theoretical perspective was common.
The research conducted in the area of gerontological nursing has become more theory-oriented. However, there is no information about the theory-research linkage of the studies concerning quality of life and perception of health of the older adult.
For clarity and consensus among the writers, terms judged to be critical to the analysis were denned. The American Nurses' Association (ANA) (1980) definition of nursing as "the diagnosis and treatment of human responses to actual or potential health problems" was accepted. Research was defined as a process of investigation or experimentation that includes a statement of purpose, research question or hypothesis, methodology, findings, and conclusions or implications (O'Leary, 1990).
Nursing research was defined as a process of investigation or experimentation that includes a statement of purpose, research question or hypothesis, methodology, findings, and conclusions or implications, and that contributes to the body of nursing knowledge. Nursing practice research was denned as "a systematic investigation of research questions or hypotheses pertaining to assessment of the patient, interventions, or nursepatient interaction" (ANA, 1985).
Subjectively perceived quality of life is a "sense of well-being, level of satisfaction with life, and feeling of worth and self-esteem" (Institute of Medicine, 1986). Perceived health is an individual's self-appraisal of physical and mental well-being. For the purpose of this analysis, a study was considered to be gerontological nursing research if subjects were 50 years of age or older.
In-depth analysis of the research on quality of life and perception of health was viewed as an extension of a portion of the review by Lang and associates (1990). Therefore, the same journals were selected, which represented gerontological nursing research, gerontological mental health nursing research, and general nursing research. The journals selected were Advances in Nursing Science, American Journal of Nursing, Archives of Psychiatric Nursing, Geriatric Nursing, Image: Journal of Nursing Scholarship, Issues in Mental Health Nursing, Journal of Gerontological Nursing, Nursing and Health Care, Nursing Research, Quality Review Bulletin, Research in Nursing and Health, and Western Journal of Nursing Research.
In order to analyze the status of current research, the time frame was designated as 1987 through 1991. One exception was Archives of Psychiatric Nursing, which was reviewed from 1989 through 1991, due to unavailability of earlier issues. A hand search of all issues of selected journals within the designated time was conducted for articles that potentially qualified for analysis. Criteria for inclusion in the analysis were the following:
* Article identified as nursing research according to accepted definition;
* "Quality of life" and "perception of health" appeared in the research; and
* Subjects were age 50 or older.
Each potential article was read independently by two writers to determine if it met inclusion criteria. When two writers disagreed, a third writer was included.
Number of Criteria-Meeting Articles Published, 1987 to 1991*
The Nursing Practice Research Analysis Tool was used (Moody, 1990). It is a 32-item instrument that was selected due to its clarity, ease of scoring and tallying, and compatibility with the purpose of this analysis. To test interrater reliability, all four writers independently read and scored one article. Comparison of the results showed consensus on all but three items, which were related to theoretical perspectives and theoretical linkage with research design. Discussion and clarification of these areas yielded agreement on all areas. Content validity of the tool was estimated based on previously established content validity by Moody (1988).
Each article was independently read and scored by two writers and results were compared. Areas of difference were discussed by the two writers. In cases of unresolved disagreement, the article was read and scored by a third writer.
Twenty-five articles were found for potential qualification in the initial search. Seventeen articles were judged to meet the inclusion criteria. Of the eight articles that were disqualified, six omitted one of the variables, one was not research, and one included an age range under 50.
Of the 17 studies found to meet the inclusion criteria for this analysis, 14 were categorized as assessment-focused studies, and 3 were intervention-oriented. Six of the studies were published in Journal of Gerontological Nursing, which is a specialty journal. The remaining 11 studies were distributed among six journals (Figure 1). Eleven of the studies were published between 1987 and 1989.
Fourteen studies had a nurse as a primary investigator. For 10 studies, the primary investigator held a doctoral degree. Only 1 study was interdisciplinary. Eleven studies were classified as multisite. Sources of funding were stated in 6 of the studies, with 3 of these being funded by state sources. Subjects were both male and female in 13 studies; the remaining 4 studies focused on the female elderly. No study focused solely on the male elderly population.
Twelve articles provided only research purposes or aims, 3 presented research questions, and 2 had research hypotheses. The most frequent research purpose was explanatory (Figure 2). Ten studies identified theoretical perspectives, with 7 studies using a theory or framework from other disciplines, including psychologic and social sciences.
Only 3 studies used a model from the nursing discipline. One identified Riehl and Roy's model as a theoretical framework (Johnson, 1988). The other 2 studies, conducted by one investigator, used the "life span developmental view of mental health model" that was originally developed by the investigator (Reed, 1989, 1991). Of the total models or theories identified, half were descriptive; the others were explanatory models.
Findings on theory-research linkage showed that 7 studies did not discuss theoretical perspective. Four studies had minimal linkage, 4 used theory or a model as an organizing framework, and 2 tested concepts or relational statements of a model. In regard to theory-research relationship, theory fitting was found in 5 studies and only 1 study was theory testing (Figure 3).
Multivariate statistical analysis was used in almost 8 of the studies and 6 used bivariate analysis (Figure 4). Twelve of the articles addressed either current or past, or both current and past, reliability of instruments used. Nine articles reported some form of validity.
Ten of the studies were designed to build on previous study. The findings of 6 studies confirmed research hypotheses. Theory or hypothesis could be generated from 4 studies. Eleven studies suggested ideas for future research. All studies merited replication and 7 showed potential for meta-analysis. The overall assessments of the studies showed that 12 were judged to be good or excellent.
The terminology regarding quality of life and perceived health was found to be inconsistent in the literature. The actual term "quality of life" appeared in two articles. Other terms representing quality of life included "emotional well-being," "happiness" (self-transcendence), "life satisfaction" (five articles), "self-actualization," "life outlook," and "subjective well-being." In one intervention study, choice and control over daily activities was representative of quality of life (Cox, 1991). The concept of hope was considered as reflective of quality of life, and appeared in two studies (Farran, 1989, 1990).
"Perceived health" appeared as a unique term in 7 of the 17 articles. Other indicators accepted as perceived health included subjective lack of depression; mental health symptomatology; perceived physical health; activity levels and independence; measurements of activities of daily living; and subjective ratings and /or perceptions of health, both physical and mental.
Outcomes of the research related to quality of life and perceived health fell into three basic categories:
* Predictors found;
* Relationships found; and
* No relationships found.
In four articles, predictors were identified. Perceived health was a significant predictor of life satisfaction, self-actualization, or a positive outlook in three studies (Hoeffer, 1987; Huss, 1988; Speake, 1989). Another study demonstrated that hope was best predicted by mental health and that physical health was the best predictor of mental health (Farran, 1990).
Seven studies showed either a positive or inverse relationship between the variables. Self-transcendence was a significant correlate of mental health (Reed, 1991). Life satisfaction and perceived health were indicators of well-being (Stevenson, 1990). Retirement attitudes were the best predictors of perceived health status (Daly, 1989).
One study indicated a strong positive relationship between physical and mental health (Farran, 1989). Another study showed that with the intervention of humor, a moderate positive correlation was obtained between perceived health and life satisfaction (Simon, 1990). An inverse relationship was shown between developmental resource levels, which were related to quality of life, and depression (Reed, 1989). Self-esteem and depression had a significant negative relationship, but religious participation and social support related positively to quality of life in the same study (Nelson, 1989).
Theory-Research Relationships of Articles
In six articles analyzed, no relationship was found between quality of life and perception of health. One descriptive study implied a positive relationship between physical and mental health and life satisfaction, but no significant relationship was demonstrated (Terpstra, 1989). Another study characterized resilient older women, but did not relate the two variables in question (Wagnild, 1990). Quality of life and mental health were influenced by ethnicity, but no relationship was demonstrated between quality of life and perceived health (Johnson, 1988). In an intervention study, increased choice and control in the experimental group increased general wellbeing, even with diminished health status (Cox, 1991). Meditation/ relaxation skills increased quality of life while perceived health remained the same, and subjects dressed in street clothes rated higher in selfesteem than those in bedclothes, although no relationship to quality of life was demonstrated (Pensiero, 1987; Thomas, 1988).
Quality of life is an issue of importance and frustration in gerontological nursing. Researchers continue to struggle with the variety of definitions and measurements for this abstract construct. This analysis has identified a body of current nursing research that indicates a strong positive relationship between perception of health and quality of life in the elderly. Based on these findings, nurses must recognize the importance of self-perceived health in older adult patients and reflect this knowledge in practice.
Despite continued identification of the problem in past reviews and analyses, there is still a lack of nursing theory used as framework to guide nursing research. In this analysis, only one nursing theory, Riehl and Roy, was identified (Johnson, 1988). Two studies included a researcher developed model (Reed, 1989, 1991). Clearly, nurse researchers must use nursing theory as a framework for the research process.
Major Analytical Focus of Articles
The level of analysis in the majority of the studies was descriptive or explanatory. More experimental research is necessary to develop and test interventions. Also, more replication of research is recommended with more attention to sample size and randomization, in order to yield more generalizable outcomes. Additionally, research on older males is necessary to learn whether this population has special needs in relation to quality of life and perceived health.
Quality of Life
This analysis did not include nonnursing research; however, the contributions of other disciplines to this body of knowledge is not to be ignored. O'Leary and colleagues (1990) judged nearly 50% of multidisciplinary gerontological research articles surveyed to be useful to nursing practice. Nurses are encouraged to read multidisciplinary research and apply the findings when appropriate and applicable to nursing. Also, nurse researchers should be open to and take advantage of opportunities to participate in interdisciplinary research. Quality of life and perception of health for older adults has implications for all service disciplines, and for the professional providers of those services.
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