The term “quality of life” is a commonly used concept within healthcare and nursing practice. However, it lacks a precise and universally accepted definition, leading to varying perceptions of its meaning. Advanced practice nurses are pivotal in enhancing a patient’s quality of life by focusing on health promotion, disease prevention, and disease management. As healthcare advances extend lifespans, advanced practice nurses grapple with issues concerning the quality of life.
While advanced practice nurses share the overarching goal of improving their patient’s quality of life, the ambiguity surrounding this term has resulted in a lack of clarity regarding achieving this objective. Decisions about treatment and care goals are rooted in their potential impact on a patient’s quality of life. Discrepancies in interpreting “quality of life” can lead to divergent treatment goals, choices, and outcomes.
The question arises: How can advanced practice nurses make decisions to enhance the quality of their patients’ lives without a clear understanding of what “quality of life” truly entails? This concept analysis seeks to clarify the definition of “quality of life” by exploring the diverse ways it is employed in healthcare and other disciplines. By elucidating the concept, it becomes possible for healthcare professionals to communicate effectively among themselves and with patients and their families about quality of life. This conceptual clarification also offers valuable guidance for treatment decisions and care goals, focusing on improving the quality of life.
This clarification process entails examining existing literature to uncover the various interpretations of the term. It will entail identifying the core attributes of the term, providing illustrative cases that exemplify these attributes, and subsequently determining the antecedents and consequences associated with “quality of life.” The outcome of this analysis will be an operational definition of “quality of life” that incorporates all the critical attributes. Lastly, empirical referents associated with the concept will be identified and described.
Uses of the Concept
The term “quality of life” has received a multitude of definitions from various sources. The Oxford English Dictionary (2010) characterizes 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). According to Mosby’s Medical, Nursing, & Allied Health Dictionary (1998), it denotes “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 standpoint, Jennings (2002) posits 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). He asserts that it is an “interaction between the person and their surrounding circumstances, including other people” (para. 7). Furthermore, Jennings points out that quality of life is “sometimes used to refer to the moral worth or value of a person and their life” (para. 9), and “hedonic theories identify quality of life with states of awareness, consciousness, or experience of the individual” (para. 11). Rational preference theories, according to Jennings, define quality of life “in terms of the actual satisfaction or realization of a person’s rational desires or preferences” (para. 13), asserting 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) characterizes the quality of life as encompassing spiritual well-being, spirituality, religious issues, feelings of hope, personal beliefs, religiosity, and inner peace.
The World Health Organization (WHO) (2004) characterizes 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, psychological state, level of independence, social relationships, personal beliefs, and relationship to salient features in the environment” (p. 48). WHO (2004) further defines health-related quality of life 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) offers a multidimensional perspective, defining quality of life as “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) emphasizes the contextual and health-related nature of quality of life, defining it as “an intangible, subjective perception of one’s lived experience” (p. 139).
Kane (2003) characterizes quality of life as a “summary term, connotating a multidimensional appraisal of a variety of important aspects of life, including health outcomes” (p. 30). Health-related quality of life, according to Kane, encompasses “aspects of life affected by a person’s health condition and its treatment” (p. 30). He identifies several aspects, including 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) underscores the subjectivity of quality of life, noting that “two persons with the same functional state, 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 influenced by one’s health.
Morgan (2009) evaluates the quality of life in cancer survivorship, considering factors such as a perception of control, aches and pains, uncertainty, satisfaction, the 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 encompassing relationships with family and others, personal health, the 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 the quality of life in the context of personal job satisfaction, income, neighbourhood schools, the status of the region’s arts and cultural amenities, air quality, and racial tolerance. Non-health-related quality of life, according to Johnson, includes factors like 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) links quality of life to neighbourhood open spaces, considering the pleasantness and safety of these open spaces, social interaction, social activity, and regular physical activity.
Albert (2002) defines health-related quality of life as relating to functional status, mental health, emotional well-being, social engagement, and symptom states. Health-related quality of life encompasses ambulation mobility, body care and movement, communication, alertness behaviour, emotional behaviour, social interaction, sleep and rest, eating, work, home management, and recreation.
Meeberg (1993) provides insight into the quality of life, highlighting subjectivity and individualization. Critical attributes of this concept include a sense of well-being, happiness, living conditions, life satisfaction, an acceptable state of physical, mental, social, and emotional health, or an objective assessment by someone else that an individual’s living conditions are adequate and not life-threatening.
Taylor (2008) describes quality of life as a subjective, multi-dimensional, and dynamic construct. It involves the interplay between individual circumstances and culture, along with an individual’s assessment of life and the pursuit of life goals. Its attributes include sanctity of life, economic growth, gross national product, and increased life expectancy.
Mandzuk (2005) also characterizes quality of life as a multidimensional, subjective, dynamic concept situated on a continuum. It encompasses spiritual well-being, income, housing, education, social relations, happiness, and morale.
Critical attributes are those recurring characteristics that consistently define a concept (Walker & Avant, 1995, p. 41). In the context of quality of life, these critical attributes encompass subjectivity, multidimensionality, and dynamism. At its core, quality of life entails a subjective assessment of life satisfaction. The subjective nature of the term is evident in its various definitions, which frequently employ descriptive words like perception, context, interpretation, and individualization. Quality of life is inherently individualized, shaped by each person’s assessment and evaluation of their unique circumstances. However, when a subjective evaluation is unattainable, it can be quantified through objective assessment.
Multidimensionality is another critical attribute, signifying that quality of life encompasses a range of physical, psychological, spiritual, and social domains. The physical domain encompasses attributes found in definitions, such as activities of daily living, functional status, exercise, physical health, cognitive function, sexual function, sleep and rest, and comfort. The psychological domain incorporates attributes from definitions, such as fulfilment, emotion, happiness, enjoyment, security, control, independence, and satisfaction. As noted in definitions, the spiritual dimension involves attributes such as meaning, inner peace, morale, religion or spirituality, and sanctity. The social aspect includes attributes from definitions like relationships with others, work productivity, income, role performance, recreation, social engagement, personal resources, and the environment.
Quality of life is also dynamic, continuously evolving, contingent on life circumstances, disease state, developmental stage, and other factors.
A model case, as defined by Walker and Avant (1995, p. 42), serves as a “real-life” example that encompasses all the critical attributes of the concept. The following scenario illustrates a model case for the concept of quality of life:
Meet Mary, a 43-year-old mother of two, happily married with a robust support system of friends. Mary recently achieved a significant milestone in her life – she paid off her home, secured funds for her children’s education, and made sound financial preparations for her retirement. Adding to her contentment, she received a job promotion, complete with a raise, further enhancing her financial security. When Mary reflects on her life, she experiences profound happiness and satisfaction. Her contentment extends across various dimensions of her life, encompassing her emotional well-being, harmonious social relationships, financial stability, and physical health. Mary feels not only loved and supported but also believes that life, in general, is exceptionally good.
This case represents an exemplary instance that encompasses all the critical quality of life attributes. Mary conducts a subjective assessment of her life situation, finding satisfaction across multiple dimensions essential to her overall life satisfaction – emotional happiness, social contentment, financial security, and physical health. Not all dimensions need to be included, and the subjective evaluation can be multidimensional or one-dimensional, depending on an individual’s priorities and values. The concept’s dynamic nature is evident here, as Mary’s present satisfaction may differ from her past experiences, and it may continue to evolve as time progresses.
Borderline cases, according to Walker and Avant (1995, p. 43), include some, but not all, of the critical attributes of the concept under examination. The following illustrates a borderline case for the concept of quality of life:
Meet John, a 58-year-old male who tragically lost his wife to cancer a year ago. He is the father of three children and the proud grandfather of five. John is a homeowner and is preparing for retirement next year. He actively participates in his temple’s community and engages in various social activities through his involvement. Remarkably, he has experienced no significant health issues and maintains an active lifestyle, routinely walking several miles every morning. John appears content with his life, yet he grapples with depression after his wife’s passing.
This case encompasses most of the critical attributes of quality of life but not all of them. John conducts a subjective assessment of his life situation and despite experiencing a degree of happiness and appearing to have a fulfilling life externally, he does not find complete satisfaction. His evaluation is multidimensional as he assesses various aspects of his life but emphasizes that his relationship with his wife is paramount to his well-being. While he is not entirely satisfied with life due to the loss of his wife, the dynamic nature of the concept is evident as his satisfaction has recently changed following this loss. It may continue to evolve as he adapts to life without his wife. This scenario encapsulates all aspects of quality of life except for complete satisfaction.
Related cases, as defined by Walker and Avant (1995, p. 44), are cases that are “related to the concept being studied but that do not contain the critical attributes.” Consider the case of Julie, who is watching a news clip about an elderly gentleman who has just won a significant sum of money in the lottery. Julie assumes that this man will experience perpetual happiness since he is now financially secure.
At first glance, it may appear that this man is enjoying a high quality of life. However, this scenario lacks many of the critical attributes. It does not involve a subjective evaluation of life satisfaction but is rather an observation made by someone who lacks insight into what truly matters to that individual. It is not multidimensional because it exclusively considers financial security, overlooking other aspects of life that contribute to quality of life. Furthermore, it is not dynamic as it assumes that the gentleman will always have a high quality of life solely based on this occurrence.
Contrary cases, as described by Walker and Avant (1995, p. 44), represent “not the concept.” In this instance, let’s consider Phyllis, an 89-year-old woman diagnosed with terminal cancer. She has been hospitalized for nearly three months and has deteriorated significantly. Phyllis is in a state of confusion, rendering her incapable of making decisions about her care. She has lost the ability to feed herself and is incontinent. Phyllis frequently moans and calls for help, expressing her desire to end her suffering.
Phyllis’s son holds power of attorney and is adamant that everything possible should be done for his mother, as he believes it aligns with her wishes. However, he refuses to allow her to receive pain medication due to its sedative effects. A feeding tube is inserted to provide sustenance, and Phyllis is subjected to intubation and subsequent weaning on several occasions. The son insists that the medical team should take any necessary measures to prolong his mother’s life.
This scenario serves as a contrary case, representing a stark departure from the concept of quality of life. Phyllis’s situation is marked by profound suffering, confusion, and her inability to make decisions regarding her care. It is a poignant example of the challenges and ethical dilemmas often encountered in healthcare when addressing end-of-life care and quality-of-life concerns.
This case starkly contrasts the critical attributes of quality of life. Phyllis has not conducted a subjective assessment of her life situation, and there is no objective evaluation of her life satisfaction. Instead, the focus is solely on preserving her life without considering her needs or satisfaction across the various dimensions of her existence. Thus, this approach is not multi-dimensional.
Phyllis’s situation underscores the profound ethical and practical complexities often encountered in healthcare, where the pursuit of life preservation takes precedence over holistic assessments of an individual’s quality of life.
As defined by Walker and Avant (1995, p. 45), antecedents are the events or incidents that must precede the occurrence of the concept. The primary antecedent to quality of life is simply having life itself, as life must exist before assessing its quality (Haas, 1999). Discussing the quality of life of something that lacks life is impossible. Several sources also propose that cognitive ability (Haas, 1999) or a state of consciousness (Meeberg, 2003) serves as another antecedent. Taylor (2008) suggests that an antecedent to quality of life is the capacity to assess, appraise, and evaluate life and make decisions. Even when others assess the quality of life, they too must possess the cognitive ability to appraise and evaluate life. Therefore, the two significant antecedents to quality of life are the presence of life itself and the cognitive ability to assess its quality.
Consequences, in accordance with Walker and Avant (1995, p. 45), are the events or incidents that occur as a result of the concept’s occurrence. While it is challenging to discuss the direct consequences of quality of life, the consequences are related to a change in the degree of quality of life or the status of quality of life, whether positive or negative.
Quality of life can lead to increased or decreased life satisfaction (Sugiyama, 2009), heightened happiness, well-being, self-esteem, and pride (Meeberg, 1993). It can improve physical and psychological health (Mandzuk, 2005). Such changes may also alter one’s perception of life, prompting decisions to modify one’s circumstances (Haas, 1999) and choices in daily activities (Albert, 2002).
Consequences of quality of life can manifest as an increased provision for individual choices and opportunities for self-care (Kane, 2003) or the achievement of essential life functions (Grewal, 2006). This concept can also influence disease management and change treatment and practice choices (Plummer, 2009). Additionally, quality of life can result in an increase in empowerment (Taylor, 2008) or resilience (Xavier, 2003), especially in the face of illness or ageing (Albert, 2002). It may lead to restitution for biopsychosocial losses (Xavier, 2003), an acceptance of life’s circumstances (Taylor, 2008), or improved coping (O’Connell, 2007). These consequences are also associated with maintaining the individual’s dignity and respecting their individuality and preferences (Kane, 2003). Another consequence can be cost containment.
Quality of life can be defined as a subjective evaluation of an individual’s satisfaction with the dynamic circumstances of life. This assessment encompasses multidimensional physical, psychological, spiritual, and social domains.
According to Walker and Avant (1995, p. 46), empirical referents are classes or categories of actual phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself. Given the subjective nature of quality of life, a primary empirical referent for this concept is an individual’s subjective analysis of their life satisfaction (Taylor, 2008). The most accurate means of determining the presence of quality of life is through patients’ self-assessment, where they rate their quality of life, feelings of satisfaction, happiness, or well-being (Albert, 2002) – this is the gold standard.
The World Health Organization (WHO) has developed the “WHOQOL” tool, a 28-item questionnaire designed to assess the quality of life, encompassing physical, functional, psychological, social, and satisfaction aspects (Kane, 2003).
In cases where subjective statements are unavailable, various tools have been created to determine the presence of quality of life objectively. While not true empirical referents, these tools are useful proxies for assessing quality of life when individuals cannot provide their subjective analysis. These methods include:
Proxy Informants: Questions related to quality of life can be posed to family members or individuals presumed to be knowledgeable about the person’s life (Kane, 2003).
Observations: Quality of life can be observed through the individual’s behaviour and physical, social, and care environments (Kane, 2003). This may involve assessing their ability to set and achieve goals, express discontent, initiate and respond to change, and develop and maintain satisfactory relationships (Taylor, 2008).
Negative Indicators: An absence of quality of life may be inferred through observations of evidence of abuse, inadequate living conditions to support life, and intense suffering (Haas, 1999). However, it’s crucial to recognize that these factors do not necessarily indicate a decreased or absent quality of life, as individual perspectives vary. Some individuals may derive meaning from suffering that enhances their quality of life.
It’s important to note that the most reliable indicator of quality of life remains an individual’s subjective assessment.
The term “quality of life” is frequently used in healthcare, yet it lacks a clear and universally applicable definition. This concept analysis aimed to provide greater clarity to this term for its practical application in clinical settings. The review of the literature and subsequent analysis revealed the challenge of pinpointing a single, objective definition of the concept that is universally applicable. However, clarity was achieved by analysing how the concept is utilized in various contexts, identifying its critical attributes, and, ultimately, articulating an operational definition based on these critical attributes.
What advanced practice nurses should primarily glean from this analysis is the inherently subjective nature of quality of life. In cases where subjective assessments of quality of life are not feasible, objective assessments can be made by those close to the individual. They may have insights into what the individual values. Nonetheless, it is imperative to recognize that quality of life is multidimensional, with various dimensions being assessed, and it is ultimately determined by what holds importance for the individual. Therefore, collaboration with the patient is vital when determining care goals and treatment plans. The patient should have the agency to articulate their values and what would enhance their quality of life. In this context, the practitioner must set aside their personal opinions regarding what would improve quality of life and instead listen to the patient’s wishes and goals. At its core, quality of life is defined by the individuals themselves. When this individual perspective is acknowledged and respected, care provision becomes highly personalized and aligned with the patient’s values and aspirations.