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Response to Letter to the Editor
In response to the much welcome feedback from M. J. Hammer, we are in the process of developing a quality-of-life (QOL) instrument that focuses on connectedness, which is the unifying theme in Register's Generative Quality of Life for the Elderly model.1 We believe connectedness is QOL. Therefore, instruments researchers currently use, which seek to determine factors that diminish or influence QOL proxies, are not sufficient. Instead, our instrument will measure connectedness to the forces and processes (people and systems) that older adults encounter on a daily basis, which is QOL.
We believe ontological and conceptual congruence is essential in QOL research. As Hammer and a number of experts rightly indicate, QOL measurement must be multidimensional (holistic) and allow for subjective appraisal that accounts for individual preferences2-7 among the various types of connections. Although experts generally recognize the multidimensionality and subjective imperative related to QOL, no QOL instrument can demonstrate ontological and conceptual congruence regarding the essence of QOL, which is connectedness. Hammer adeptly underscores the importance of subjectively quantifying the connections that are most salient to each patient, without diluting or distorting the overall QOL measure, regardless of patient setting or circumstance.
Researchers have recognized, and we acknowledge, that people perceive events or situations in different ways.8 We also acknowledge that perceived connections are dynamic and subject to change over time.1 In research related to stress and coping, Lazarus9 contends a person's perception greatly determines the impact of stressful encounters. We believe the same holds true for connectedness. The variability in perceptions is especially applicable to older adults who are displaced to residential centers, assisted living facilities, or other institutional settings, either by choice or by necessity. We plan to purposefully examine individual perceptions and subjective appraisal of the various types of connections by using the strategies germane to Lazarus and Folkman's10 Daily Hassles scale. Lazarus and Folkman's instrument measures the frequency and perceived severity of stressful encounters. However, the instrument examines frequency and severity separately. Severity scores offer insight into the saliency of events. Frequency scores offer additional insight in terms of the most common daily hassles. Our instrument will examine the frequency and relevance of the various dimensions of connectedness. Relevance scores will inform us about the saliency of the connections and frequency scores will help us identify the types of connections typically employed by the individual. We believe this strategy can address Hammer's concerns about the appropriateness of traditional paper-and-pencil instruments and ensure ontological and conceptual congruence in QOL measurement. Furthermore, relevance and frequency information can help researchers design a new class of nursing interventions that target connections perceived as most important to the individual. Interventions grounded in the patient's unique perceptions and personal appraisal can leverage optimal patient outcomes and offer a more constructive alternative to the current problem-oriented deficit-based approach to QOL among older adults.
M. Elizabeth Register, RN, MSN, MPH, CCM
JoAnne Herman, PhD, RN, CSME
College of Nursing, University of South Carolina, Charleston
1. Register ME, Herman J. A middle range theory for generative quality of life for the elderly. Adv Nurs Sci. 2006;29(4):340-350. [Context Link]
2. Moore M, Hofer S, McGee H, Ring L. Can the concepts of depression and quality of life be integrated using a time perspective? Health Qual Life Outcomes. 2005;3(1):1. [Context Link]
3. Rapkin BD, Schwartz CE. Toward a theoretical model of quality-of-life appraisal: implications of findings from studies of response shift. Health Qual Life Outcomes. 2004;2:14. [Context Link]
4. Jonker C, Gerritsen DL, Bosboom PR, Van Der Steen JT. A model for quality of life measures in patients with dementia: Lawton's next step. Dement Geriatr Cogn Disord. 2004;18(2):159-164. [Context Link]
5. Gerritsen DL, Steverink N, Ooms ME, Ribbe MW. Finding a useful conceptual basis for enhancing the quality of life of nursing home residents. Qual Life Res. 2004;13(3):611-624. [Context Link]
6. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA. 1995;273(1):59-65. [Context Link]
7. Whitney CM. Maintaining the square. How older adults with Parkinson's disease sustain quality in their lives. J Gerontol Nurs. 2004;30(1):28-35. [Context Link]
8. Speisman JC, Lazarus RS, Davison L, Mordkoff AM. Experimental analysis of a film used as a threatening stimulus. J Consult Psychol. 1964;28:23-33. [Context Link]
9. Lazarus RS. Psychological Stress and the Coping Process. New York: McGraw-Hill; 1966. [Context Link]
10. Lazarus RS, Folkman S. Manual: Hassles and Uplifts Scales. Research ed. Redwood City, Calif: Mind Garden; 1989. [Context Link]
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