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

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