Although the term quality of life has become a recent buzzword in health care literature, only a few research studies describing factors which enhance quality of life have been reported (Walker, 1988; Mukherjee, 1989; Szalai, 1980). Furthermore, quality of life has been described only in abstract terms. Such abstractness is inevitable because the quality or value attached to even 1 day of life is very subjective and, under the best of circumstances, will differ from one person to another (Szalai, 1980; Walker, 1988). It is important, however, to be cognizant of all factors that can potentially increase a resident's quality of life; thus, nurses may identify which factors are most important for a particular resident and develop interventions to promote these factors.
Though literature regarding the concept of quality of life in long-term care has been especially limited, examination of that which exists is necessary. Such literature has identified the physical environment, recreational activities, and the social environment as the three major factors that affect a resident's quality of life (Clark, 1990; Cox, 1991; Huss, 1988; Kahana, 1982; Kayser-Jones, 1990; Koncelik, 1976; Moos, 1980; Paunonen, 1990; Ross, 1990; Walker, 1988). The physical environment has been examined by looking at both the physical properties and the organizational structure. Physical aspects include such areas as architectural features, color, lighting, space, and privacy. The organizational structure considers facility policies, staffing, financing, and the presence or absence of residents' and grievance council meetings. Moos (1980) has developed a conceptual framework that describes the physical and architectural settings, as well as the policy and program resources, as they affect resident well-being. He suggests the examination of the physical and architectural features of a facility, as well as the policy and programmatic resources, as reported by the administrator of that facility. The environmental system proposed by Moos (1980) has a direct impact on the residents' stability, morale, health, and well-being.
Clark and Bowling (1990) also examined both the physical properties and organizational structure as components of quality of life for elderly persons in long-term care. They reported that in their qualitative study in the physical settings of two nursing homes - a long-stay geriatric hospital ward and a hospital patients' club - there was no evidence that the physical structure had a direct impact on quality of life. Regarding organizational structure, Clark and Bowling (1990) reported that the philosophy of the nursing homes was that a smaller environment would lead to flexibility in care practices and, subsequently, a better quality of life. Findings revealed that the philosophy was evident in the actions of the staff, and the observational data supported the conclusion that a different quality of life was apparent between settings.
Individualized recreational activities, such as music, reading, and engaging in personal hobbies, have been identified as factors influencing quality of life, as have group activities, such as sing-a-longs, exercise sessions, and current-events readings (Clark, 1990; Ross, 1990). Ross (1990) explored the activities chosen and the use of time in later life and its relation to health and well-being. She emphasized the need to individualize recreation for the elderly and that the frequency, duration, location, and social context of activities are important determinants of perceived satisfaction.
While the physical and recreational environments have been shown to be important, the human relationships and social contact with others have been described as being far more crucial in determining quality of life (Kayser-Jones, 1990; Ross, 1990; Walker, 1988). Although both the physical properties and organizational structure of the environment are important, nothing is more vital than the characteristics of the nursing staff. The interaction between resident and nurse, and the subsequent bond that develops, is where the resident places importance, rather than the color of the room or the administrative philosophy of the facility (Kayser-Jones, 1990).
Huss, Buckwalter, and Stolley (1988) conducted a study designed to explore the relationship between residents of long-term care facilities and the nursing staff, as it was associated with their life satisfaction. Thirty subjects were interviewed from two intermediate care facilities. Researchers found that, although the nurse /resident relationship did not correlate significantly with life satisfaction, nurses did have an effect on residents' perceived life satisfaction when they assumed the role of a confidant. Those residents who reported having a confidant exhibited higher levels of life satisfaction (Huss, 1988).
Although the above research suggests three factors that affect quality of life, further study was warranted both to confirm that these three factors did influence quality of life and to determine whether other factors that have not yet been identified also contribute to a person's quality of life, and, hence, should be incorporated into the research and practice protocols.
Much of the research that has been done in this area has been quantitative and based on surveys. Findings indicate a limited number of factors affecting quality of life and are largely atheoretical. In accordance with Weick's description of and in recognition of the value of qualitative research, these researchers intended to identify new factors and attempted to lead to a theoretical basis to explain both the previously and the newly identified aspects of quality of life (Weick, 1983). The purpose of this study, therefore, was to allow the residents living in a long-term care facility to explain what quality of life meant to them by describing those activities and events that contributed to the quality of their life.
Common Content Areas Identified Upon Initial Analysis
To identify what contributed to the quality of life of long-term care residents, a semistructured, open-ended format was used. This openness encouraged the expression of residents' true thoughts and feelings as they were encouraged to describe what, for them, constituted quality of life, rather than asking them concrete, structured questions which would have limited free expression and potentially masked emergent themes.
A convenience sample of eight subjects who were permanently residing in a 150-bed, long-term care facility in northeastern Ohio was utilized. West, Bondy, and Hutchinson (1991) noted the difficulty of finding good informants among institutionalized elderly. Hence, the social worker and the director of nursing compiled a list of subjects who met the criteria as described by Dobbert (1982) of sources who are likely to provide valid data. Those individuals who met these criteria:
* were comfortable and unstrained in interactions;
* were generally open and truthful;
* provided solid answers with good detail;
* stayed on the topic or related important issues; and
* were thoughtful and willing to reflect on what they said.
Potential subjects who were legally incompetent or seen by the social worker and director of nursing as being unable to participate in a 20to 30-minute interview were not considered as candidates. Out of 142 residents, only 12 met the criteria. The range in length of stay was 8 months to 7 years, with primary diagnoses including paraplegia, cerebrovascular accident, brain injury, and lowerextremity amputation. The actual sample included six females and two males between the ages of 44 to 90.
After obtaining consent from both the facility and the residents, the interviewer conducted 20- to 30minute taped interviews with each subject. The sessions were conducted in the subjects' rooms with no one else in the rooms and the doors dosed. Staff were given a brief description of the research study and were asked not to interrupt. The researcher began with open-ended questions such as, "What does quality of life mean to you?" and "What gives your life quality or meaning?" At times, the terms life satisfaction and meaning were substituted for quality of life if the researcher found that the subjects did not appear to understand the meaning of the original term. Although the researcher had some semistructured questions on topics previous researchers had found to be components of the concept of quality of life (namely environment, recreation, and social interaction), those questions were only asked if prompts were necessary to continue the conversation. Because seven of the eight residents alluded to the importance of helping others, either through direct descriptions or as evidenced by the enthusiasm in which they spoke, it was determined that there was considerable redundancy among the factors explained as contributing to the residents' quality of life. The researcher, therefore, decided to halt data collection upon completion of eight interviews to allow a full analysis, which would then direct the next stage of the research program.
Each interview was reviewed, and direct quotations were transcribed. These transcripts were analyzed using traditional content-analysis procedures, as outlined by Krippendorff (1980), in an attempt to identify common themes. Initially, nine content areas were identified (Figure 1). Client responses were then placed categorically into nine columns to allow the data to be analyzed comparatively between subjects. While looking for commonalities among content areas, three themes emerged that identified abilities important to the residents. Minor areas of disagreement were discussed and resolved, and both researchers collaboratively identified the three common themes after the nine content areas were developed and analyzed separately.
Ability to Communicate With Others
Ability to Core tor Self
Ability to Help Others
The first theme identified when the subjects were asked about the meaning of the term quality of life was the subjects' ability to communicate with other residents and staff within the facility. The second theme that gave the participants a sense of their life quality was the ability to care for themselves. The last, and strongest, theme identified was the subjects' ability to care for or help others who were in more need than themselves.
The importance of being able to interact with other residents was identified as shown in Figure 2. The second emergent theme was that of the subjects' ability to care for themselves. Although they did not identify complaints concerning the care provided by the staff, the majority of the respondents felt that the ability to perform self-care activities provided them with a feeling of satisfaction and gave their lives a sense of quality. Expressions of this theme are outlined in Figure 3.
The final theme was the strongest element affecting the quality of life for these residents. The determination that this was the strongest area was based on the number of times the theme was repeated, the verbal emphasis given to that particular comment, and facial expressions exhibited during the discussion. As residents described the importance of their ability to care for others (Figure 4), they elaborated openly and spoke with more conviction than they had in any other area of the interview.
Of the three components previously identified in the literature (physical environment, recreational activities, and social environment), participants in this study discussed only the importance of social interaction with others as giving their lives quality when asked to describe quality of life in an open-ended manner. This finding supports the need for therapeutic relationships as described by Huss, Buckwalter, and Stolley (1988).
Residents suggested that, although the environment (primarily physical) was "nice," it was not a determining factor in their quality of life. Likewise, residents noted the importance of recreational activities and hobbies, but described them as being more "to pass the time" than a meaningful part of their lives. Perhaps physical facilities and recreation would be more readily noted if these needs are not being met; if they are, other concerns are discussed. Social interaction was identified by previous researchers as a factor affecting quality of life. The respondents in this study reinforced this belief.
However, this study did identify two new findings as contributing to quality of life - the importance of caring for oneself, and the importance of helping others. These components were not previously identified in the literature. Yet, in this study, the subjects' ability to help others who were in more need than themselves emerged as the strongest theme.
RECOMMENDATIONS FOR FUTURE RESEARCH
As noted above, the first goal of this study was to begin to identify factors that improved the quality of life for cognitively intact residente in a long-term care facility. This small sample did elicit, quite convincingly, the importance of caring for self and others. Repetition of this study with a larger sample size is certainly recommended.
This study is best viewed as the first stage of a research program to investigate the impact of a new factor, namely the importance of caring for others, on quality of life. The next step in this program is to use a larger sample and a more highly controlled method to clarify the relative importance of mis factor, the type of residente for whom this factor is especially relevant, and the most effective manner of promoting this factor for those residents to which it is highly valued. Such extended research should be done using a variety of methodologies, such as listening to stories, videotaping and observing behaviors which subjects confirm or refute, and the use of structured questionnaires. Considering that the second goal of this study was to identify a theoretical basis that would connect the various factors affecting quality of life in the long-term care setting, Orem's theory of self-care may achieve that goal.
IMPLICATIONS FOR PRACTICE
Although further research is needed in this area, the findings of this study are decisive enough to begin to incorporate them into daily nursing care. Encouraging self-care and promoting independent decision making has been shown, both in previous research as well as this study (Faucett, 1990), to be beneficial in enhancing the well-being of nursing home residents. Failure to accurately assess a resident's ability to provide selfcare may lead to a phenomenon known as excess disability, a situation in which a resident may become more functionally disabled, due, in part, to staff's performing more care for the resident than is actually needed (Dawson, 1986; Salisbury, 1991).
Health care providers in longterm care institutions need to understand the factors identified as important to the quality of life of their residents. Creative means of incorporating residents' needs for selfcare, as well as care for others, must be recognized. Maintaining a philosophy of promoting the highest level of independence through such programs as restorative ambulation, dining/feeding, and activities of daily living will help decrease the potential for excess disability. In addition, residente should be permitted, if they so desire, to participate in resident volunteer programs; such programs allow residente help others by reading mail and current évente to those who may not be able to read for themselves, writing letters for those who have suffered strokes, or becoming involved in a birthday club, in which they sing and /or give balloons to other residents on their birthdays.
Innovation on the part of professionals working in long-term care is needed when addressing quality of life. Re-evaluating traditional programs and creating new, diverse ones will be a challenge requiring interdisciplinary cooperation. The potential for improving quality of life for residente of these institutions would be well worth the effort.
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