Nursing focuses on changing or modifying human behaviors and responses in order to positively impact the quality of life. Nursing’s role in acute and

chronic disorders and in the organization of nursing care

within health care agencies and systems is directed toward preventing illness and disability and promoting

health in physical, psychological, and social realms. Not

only are such actions done on behalf of individuals, but

the profession recognizes that positive outcomes for

groups, such as families and communities, are also important if the state of the nation’s health is to be optimally affected.

The ultimate proof of the effectiveness of any

nursing intervention or program is the nature of the outcomes that result. However, a major challenge that confronts nursing (as in other health professions) is demonstration of the worth of its interventions and programs

through research with clear and tangible evidence of the

effectiveness of its clinical practice. But, one cannot

study well what cannot be measured well. Although

much work has been done to refine the measurement of

nursing outcomes, unfortunately, there are still several

measurement issues that need to be addressed for the

assessment of the impact of nursing practice outcomes

(Strickland & Waltz, 1986; Waltz & Strickland, 1989).

Various concepts have been selected for measurement of nursing outcomes, however, nurses as well

as other health care providers have most often focused

on the measurement of health status, functional status,

patient satisfaction, and quality of life to determine the

effectiveness of their care. The consideration of these

concepts for the evaluation of practice outcomes make

sense because they reflect the overall health goals of

improving health status, functional ability, life satisfaction, and ultimately the quality of one’s life. Although

the focus on these concepts are intuitively appropriate,

there are a number of conceptual, methodological, and

practical issues associated with their use for the assessment of of nursing practice outcomes. The primary focus of this paper is to provide an overview of measures

and instruments used to measure quality of life, functional status and health status; and to address the major

measurement issues that need to be dealt with if clear

and unequivocal evidence of these outcomes of nursing

practice is to be generated.

Conceptual Issues

 Lack of clarity regarding the definitions of

health status, functional status, patient satisfaction, and

quality of life is a major problem in outcomes measurement. The theoretical definitions of these concepts are

very important because they provide the fundamental

basis upon which their approach to operationalization

or measurement should be derived. Although some authors use these terms interchangeably as if they have a

common meaning, and therefore, a common basis for

measurement, these concepts are not construed as the

Measures and Instruments

Ora L. Strickland, Ph.D., R.N., F.A.A.N.
same by all authors. In general, health status and functional status tend to be used interchangeably, however,

quality of life and patient satisfaction are usually conceptualized differently. Whereas health status and functional status conceptualizations tend to focus on patient

limitations and capabilities, quality of life is a much

broader concept that may include spiritual, social, economic and family dimensions as well as health and physical functioning dimensions. Functional and health status conceptualizations are considered among the many

dimensions of quality of life and are often referred to as

“health-related quality of life.” Patient satisfaction measures are used to assess quality of life in multiple domains with a focus on the patient’s perceptions.

Table 1 presents examples of the variety of dimension of quality of life. However, one caveat should

be noted regarding conceptualizations of quality of life.

Some researchers have broadened their conceptualization

of quality of life to include concepts that may well be

covariates of quality of life rather than dimensions of

quality of life (Molzahn, 1991). For instance, coping

ability, self-esteem, and lifestyle changes have been included among the dimension of quality of life (Jalowiec,

1990). These may be highly correlated with one’s quality of life, but are necessarily dimensions of the concept.

Health Status and Functional Status

Health status and functional status are often conceptualized with three dimensions: (a) physical, (b) psychological, and (c) social functioning. Hence, functional

status and health status measures may be general or generic, disease specific, system specific or organ specific.

Generic or general instruments were developed

to reflect the health status and functional ability of people

in a wide variety of populations. They often focus on

function, disability, and distress. General functional or

health status instruments often provide health profiles.

As such, these single instruments measure different aspects of functioning and are used in a wide variety of

conditions. A major limitation of general instruments

are that they may be insensitive to disease specific, clinically important change (Bell et al, 1990). Commonly

used health profiles include the Rand Health Insurance

Study Questionnaire (Brook et al, 1979), and the Sickness Impact Profile (Bergner, Babbitt & Pollard, 1976).

Activities of daily living (ADL) scales are used

by some researchers and clinicians to assess general

health and functional status. However, activities of daily

living is not completely synonymous with function.

ADL scales usually measure ones’ basic human functioning (such as eating and brushing teeth), and range

hierarchically upward to higher functions (such as dressing and talking). In actuality, ADL scales measure basic capacity for self-care and hence assess a narrower

range of performance than most general health and functional status measures (Applegate, Blass & Williams,

1990). Some ADL scales, however, assess somewhat

high levels of performance, such as the person’s ability

to drive a car, perform household chores, or go shopping (Lawton, Moss, Fulcomer & Kleban, 1982; Lawton

& Brody, 1969.

Disease specific instruments measure variables

or dimensions that are particularly called into question

by specific diseases or health conditions. For example

the Arthritis Impact Measurement Scale (Meenan,

Gertman & Mason, 1980) includes a physical disability

dimension that addresses mobility, physical activity,

dexterity, activities of daily living, and household activities in a manner of particular concern to those with

arthritis. It also has a pain dimension because this is a

common problem experienced by persons with arthritis.

System specific instruments measure the functional status of identified body systems. For example, a

neurologic examination may be done to measure the

functional status of the neurologic system. One’s psychological functioning may be assessed through the use
of personality tests, such a the Million Multiaxial Clinical Inventory (Millon, 1987). Given ones’s purposes, a

single instrument may be appropriate for the assessment

of a system or several instruments may be needed. For

example, in addition to a personality test it may be appropriate to also use a depression or anxiety measure to

determine a person’s psychological status.

Organ specific functional or health status measures assess the capacity of an identified organ such as

the heart, liver, or brain. Careful monitoring for jaundice and for excessive bilirubin in the blood, and dye

recreation tests may be used as approaches for determining the functional status of the liver. For example

quantitative electroencephalography (QEEG) may be

used to determine the functional capacity of the brain.

Given the variety of approaches that are possible for

measuring the functional status of specific systems or

organs, a large number of instruments and approaches

have already been developed and used for these types

of assessments. Such approaches and measures include

physical assessments or examinations, biochemical laboratory tests, pathological evidence, clinical diagnoses,

or use of bioinstrumentation.

A major limitation in the conceptualization of

most health status and functional status measures is that

they have focused primarily on the negative aspects of

health, such as disability, dysfunction and the like. Since

nursing interventions are designed to prevent illness and

to promote health and well-being, more measures are

needed to address positive as well as negative health

status variables. With the focus on health promotion

and preventive interventions, instruments are desirable

that measure enhanced health status and functioning,

such as increasing energy and strength, resilience or

physiologic reserve, productivity and stamina (Patrick

& Bergner, 1990).

The definition and measurement of health and

functional status also need to clearly distinguish between

state and trait aspects of positive health status variables.

Fitness, hardiness, and resilience, for example, may characterize a personality trait as well as transitory behaviors that are the focus of health status measures. When

assessment of health status is the focus, instruments that

are selected to measure such variables should be state

measures because health and functional status are transitory in nature and are amenable to change over time.

Researchers and clinicians who seek to measure health and functional status need to be consciously

aware of whether they desire to measure current or potential functional capacity or performance (Applegate

et al, 1990). These are quite different since measures of

current functioning seek to determine what is the functional or performance ability at the time of measurement,

whereas potential capacity or performance measures aim

to determine what the future ability of the person could

be if proper care and therapeutics are implemented.

Quality of Life

While health status and functional status measures tend to focus on health problems and what a patient can and cannot do, quality of life measures may

also include patient perceptions of their satisfaction with

various aspects of their life including health and functioning. Grant, Padilla, Ferrell and Rhiner (1990, p. 261)

noted that “quality of life can be defined as a personal

statement of the positivity or negativity of attributes that

characterize one’s life.” Ferrans (1990) concurred with

this view and indicated that definitions of quality of life

can be grouped into the following categories:

(1) normal life which focus on client perceptions of the ability to live a normal life similar to healthy

persons or typical persons in the same age category, as

espoused by the Karnofsky Performance Status Scale

(Karnofsky, Abelmann, Craver et al, 1948);
(2) happiness/satisfaction which consider patient contentment, happiness and satisfaction with various aspects of their life (Hornquist, 1982; Ferrans, 1990);

(3) achievement of personal goals which focus

specifically on the clients perception of success or failure in goal achievement, examples of which include

definitions by Gerson (1976) and Calman (1989);

(4) natural capacity which focuses on a person’s

actual or potential physical and/or mental capabilities

(McCormick, 1974; Shaw, 1988); and

(5) social utility which focuses on one’s ability

to live a socially “useful” life.

Ferrans (1990) also carefully notes that the various definitions have certain limitations and that instruments based on a particular definition may fit some situations but not others. A concern with normal life definitions is that it is not consistently clear whose criteria

for “normal” should be used. When using happiness/

satisfaction definitions one needs to understand happiness has been found to decrease with age, whereas satisfaction tends to increase with age and they are not necessarily synonymous (Campbell, 1976). Natural capacity definitions are used primarily for assisting with clinical decision making, such as whether to try to prolong a

person’s life or to allow him/her to die.

Since social utility conceptualizations of quality of life focus on whether the patient can satisfactorily

fulfill valued roles in society (such as parent, teacher,

citizen, employee), data important to planners and policy

makers are generated by such measures to allow for a

cost-utility analysis and decisions regarding allocation

of resources for health care. The Quality of Well-Being

(Lang et al, 1986), also known as the Index of WellBeing, uses this approach. For example, the Quality of

Well-Being instrument has been shown to be useful for

measuring the change in rheumatoid arthritis patient status and the cost-utility of total joint replacement (Bell,

Bombardier & Tugwell, 1990).

Specifying Variables to be Measured

As noted previously, there are a variety of dimensions of quality of life and a large number of potential outcome variables exist that could be used as indicators of quality of life, functionsl status, and health status. The first step that must be taken to build evidence

of the impact of nursing practice is to specifically identify the outcome variable(s) to be measured that are the

best indicators given one’s purposes and focus. Clearly,

this is an extremely important task and one that must be

done carefully and seriously because these concepts are

multidimensional and can be measured with a single instrument or a variety of multiple measures. So how does

one know which are the correct or most important quality of life or health status variables to measure in a given

particular situation, and when should these measurements be made? In order to address this question there

needs to be a full understanding of the following: (a)

the problems or potential problems that are the focus of

the specified nursing interventions or strategies, (b) the

components of the nursing interventions and their anticipated effects, (c) the consistency of the conceptual

and practical links between the problems and interventions, and (d) the adequacy of specific variables and

measures for monitoring desired outcomes. In essence,

one cannot select the most sensitive quality of life and

health status outcome variables to measure if health problems are not clearly identified and understood. Understanding of the problem helps the nurse to know what

needs to be changed. The components of nursing interventions or strategies reflect the actions that are taken to

bring about planned change or desired outcomes. The

nature and temporality of these actions are relevant not

only for the selection of specific variables and instruments, but also and the proper time to assess or measure

such outcomes. It should be noted that in a particular

situation a wide array of variables may be appropriate

and that outcomes can be measured at various times
during and after nursing interventions have been implemented (Waltz, Strickland & Lenz, 1991). The conceptual and practical links between the health problem and

implementation of various components of nursing interventions dictate the nature of the outcomes that would

be best to measure at a particular point in time. Some

quality of life and health and functional status outcomes

would be expected to be rather immediate, while others

would be intermediate, and still others long-term. The

variables selected for measurement should clearly reflect the changes or outcomes that are intended by nursing actions at specified points in time, and measurement

approaches must be properly timed and sensitive enough

to monitor changes in variables. Therefore, quality of

life and health and functional status outcome variables

should be selected that reflect desired changes associated with specified problems, that are affected by nursing actions designed to address those problems, that can

be practically measured at times when resultant changes

would be expected to occur, and for which measuring

instruments have been developed that a reliable, valid

and responsive to variations in the variables under study.

When appropriate measures are not available, qualitative approaches may be used to help document outcomes.

Issues in Selecting Health Status, Functional Status and

Quality of Life Instruments

Whenever a researcher or clinician selects instruments to measure nursing outcome variables sveral

issues should be given priority for consideration. These

include conceptual and practical issues, which if ignored,

could lead to compromised results and conclusions.

Conceptual Compatibility

Given the conceptual issues discussed above,

several guiding principles should be followed when selecting functional status, health status, and quality of life

instruments. First, the researcher should be fully aware

of the concept, i.e. health status, functional status or quality of life, that he/she wants to measure as well as its

appropriate breadth given the focus and purpose of the

study. The selected concept needs to be theoretically

defined to clarify the dimensions that comprise the concept for the study at hand and the most appropriate approaches to measurement. There should also be consistency between the conceptual definition of the outcome

variable and the way that it is measured. For example,

if the conceptual definition of health status indicates that

there are physical, psychological, and social dimensions

then the measurement approach should address each of

these dimensions. It may be necessary to use more than

one instrument in some instances to bring about conceptual and operational congruency. This idea is particularly relevant when measuring quality of life because

it can be defined so broadly with multiple dimensions.

Care also should be taken that there is consistency between the conceptual background of the study, the conceptual framework of the instrument(s) selected, and the

items or measurement approaches employed by the

instrument(s).

Consistency of Purpose

When selecting an instrument one must be clear

about its purpose and focus, and its match with one’s

own purposes. There is no quality of life, patient satisfaction, or functional status instrument that can be used

to assess patient outcomes in every situation. Careful

consideration should be given to the population for which

the instrument was designed to assess, the setting for

which it was developed, and the instrument’s time perspective.

The population for whom an instrument is designed needs to be clearly specified and consistent with

the population with whom the researcher intends to use

it. If the focus of measurement is on disease specific,

clinically important change, then a disease specific measurement approach for the assessment of health or functional status must be employed. Generic instruments

such as health profiles would not be able to provide the
discrete information required. Careful consideration

should also be given to whether the mode of administration and the nature of the items or tasks on the instrument are appropriate for the proposed sample. Self-report questionnaires assume that the population can read

and respond to items or tasks on the instrument. In situations where reading ability is of concern then interviewer scoring or observations may be better administration approaches. Cognitive impairment, educational

level, age, gender and cultural differences could bias

results, particularly for self-administered instruments.

Marshall’s (1990) article on perceived quality

of life is enlightening regarding cultural issues that could

impact upon the measurement of patient perceptions of

quality of life. Cultural experience and ethnic background influence the meaning associated with illness,

responses to pain, what is considered appropriate and

acceptable health behaviors, and appropriate health care.

For example, although obesity is socially stigmatized in

most U.S. subcultures, in many countries fatness is associated with health, prosperity and a “good” quality of

life (Lock, 1984). Also, some dimensions of quality of

life, such as satisfaction with relationships with extended

family members, may be more or less relevant for some

subcultures than others (Marshall, 1990).

In a society that is becoming increasing culturally diversified, researchers often find a need to translate quality of life instruments for populations in which

subjects speak a variety languages. Translation should

be done carefully since literal translations do not necessarily communicate “underlying semantic structures,

idiomatic expressions, and cultural interpretation of response categories (Marshall, 1990, p. 280).” Even

among English speaking societies from different parts

of the world, the meaning and nuances attributed to some

concepts can vary considerably. Also, differences between an interviewer and respondent’s cultural background can result in misconceptions and bias results.

An instrument designed for one setting may not

be practical for another. A patient satisfaction or quality of life instrument designed for an acute care setting

is not likely to be appropriate for a long-term care or

community setting because indicators that are important to patient contentment and happiness often vary from

setting to setting. Likewise, dimensions of quality of

life that are highly influenced by societal norms and

mores that change over time, such as social roles, should

be reviewed carefully for consistency of items with current societal viewpoints. For example, an instrument

designed to assess one’s satisfaction with paternal role

function in the 1970’s may not be appropriate for use in

the 1990’s. When assessing whether there might be setting or time perspective influences that affect the usefulness of a quality of life instrument, a careful review

of the items can help determine if they are appropriate

for the purposes intended.

Sensitivity/Responsiveness to Change

A key question that any investigator or clinician who is interested in measuring patient outcomes

should ask is: “Is the instrument or measure I intend to

use capable of eliciting small changes or different

amounts of the outcome variable?” This is a crucial

question because it is desirable to determine even the

smallest amount of change in a patient outcome. Regretfully, however, this is one of the most serious problems that face clinicians and investigators who wish to

measure changes in functional status, health status, and

quality of life. Most global health-related quality of life

measures lack the sensitivity or responsiveness to detect subtle change. Although some measures may record

changes in scores in the expected direction, this does

not indicate the ability to distinguish between patients

who improve and those who do not (Deyo, 1988). Instruments that are coarsely scaled with limited gradations for noting change are not likely to have a high level

of sensitivity to variations (Applegate et al, 1990). Also,
when an instrument has too few items or very large inter-item correlations it will not be sensitive enough to

detect true score variance.

Approaches to Data Collection

The method of administration of an instrument

or measure can affect the quality of data collected. Consider the nature of the measure and who is administering the instrument—nurses, therapists, patient, or physician and who is being assessed. It is not uncommon

for some patients to consult family members when completing self-administered instruments. This can result

in consensus responses that do not accurately reflect the

patient’s own views (Applegate, et al., 1990). Item formats that respondents find difficult can affect the quality of the data obtained, as well as poor reading ability,

and cognitive impairment. Observational measures more

accurately assess a patient’s level of performance, particularly when patients are confused, very young, or

unconscious (Guralnik, Branch, Cummings & Curb,

1989). Lack of motivation, clinical depression, and temporary illness create disparity between performance and

actual capacity. Nurses and other therapists who make

trained clinical judgments can influence data by introducing bias arising from their clinical interactions and

impressions of the patient. Self-administered and interviewer administered instruments tend to confound capacity with performance (Applegate, et al, 1990).

Few studies have been conducted regarding the

efficiency and accuracy of different modes of administration approaches. However, Rubenstein and colleagues

(1984) found that patients tended to rate their own function higher than nurses, and family members rated patients function lower than nurses. Elam and colleagues

(1989) found that patient self-assessments were reasonably accurate when compared to actual timed measures

of physical performance. Family member assessments

were intermediate in accuracy, and physicians were the

least accurate. In terms of quality of life, there is growing consensus that the individual is the only proper judge.

As suggested by Ferrans (1990, p. 252) “a disability that

makes life not worth living to one person may only be a

nuisance to another.”

Approaches to Scoring

The way in which scores will be interpreted and

used will determine the measurement framework that

should be employed by an instrument. In addition, the

measurement framework of an instrument needs to be

commensurate with the study’s purposes and hypotheses. A criterion-referenced instrument should be used

if the intent is to classify individual patients or research

subjects based on some criterion of health status, functional status, or level of quality of life. Health and functional status inherently imply that a criterion-referenced

framework should be used. Such instruments should be

able to indicate what a patient can and cannot do, and in

what areas of life they have achieved satisfaction. For

example, if it is important to interpret individual scores

on a health status measure as “normal” or “abnormal”

or as “poor,” “good,” or “excellent health” then an instrument that uses a criterion-referenced approach is required. This point is particularly cogent for studies of

functional and health status with an emphasis on the

determination or documentation of limitations, disability or morbidity. However, if the conceptual framework

and study purposes and hypotheses do not require interpretation of individual scores, and the focus is directed

toward comparison of scores within the sample through

statistical analysis, then a norm-referenced measurement

approach would be appropriate.

When scores provide summaries of individual

items or variables, they may conceal important specific

information regarding function or health status (Deyo

& Inui, 1984). When multiple variables or instruments

with subscales are used to assess health-related quality

of life, care should be taken to examine all measures

and dimensions within a measure to detect changes. It
is possible that a change in one variable or subscale

within an instrument could provide important information regarding a key patient outcome (Applegate, et al.,

1990).

When scoring quality of life instruments, a related concern is whether all dimensions that are measured should be weighted equally. Different areas of

life may predominate or be given more preference, depending upon the individual concerned (Flanagan, 1982).

Currently, there is some controversy regarding whether

preference weighted or non-preference weighted scores

should be derived for health status and quality of life

measures. In preference weighting states of health and

quality of life scores are weighted according to different rules and procedures such as paired comparisons,

magnitude estimation, and category scaling for example.

Theses approaches allow the respondent’s preferences

regarding areas of life and functioning that is most important to them to be more highly weighted in the scoring procedure. In non-preference weighting the investigator assigns weights to items, often using Likert-type

items that are summated (Patrick & Bergner, 1990). Few

empirical studies have investigated the contribution of

preference-weighting to reliability and validity, however.

Metric Properties of the Instrument

The reliability and validity of a measure or instrument is paramount in determining whether it will be

useful for one’s purposes. The literature should be carefully checked to determine if the instrument measures

quality of life, and physical, emotional, cognitive, or

social health and functioning consistently and validly,

particularly with a population similar to the one for which

the clinician or researcher intends to use it. The researcher should question how well the instrument has

performed with populations with similar age, gender,

socioeconomic and cultural backgrounds as those for

which it will be used. The results of prior studies that

have employed the instrument should be evaluated in

order to further assess its utility. The type of reliability

and validity evidence available should be examined including the methods or approaches used and coefficients

and other statistical or information obtained.

Feasibility and Practicality

The ultimate value of any instrument is determined by whether it is likely to work well in the situation desired. The issues of feasibility and practicality

deal with whether the subject and researcher costs associated with using an instrument or measure are reasonable given the data that will be obtained. Will the instrument overburden the researcher or respondents?

When the instrument or measure is used in combination

with other instruments will the demands be too much

for subjects? Instruments that are too long and cumbersome may be reliable and valid, but not useful for collecting data in a frail or severely ill clinical population.

Even in a healthy population long demanding instruments can result in patient fatigue that can compromise

scores. Does the researcher have adequate resources to

use the instrument? This question refers to skill as well

as financial resources and staff. Highly sophisticated

laboratory and technological instruments can be very

expensive. Many observational measures require skill

and training to implement reliably and validly.

Future Needs

Although several concerns have been identified

related to quality of life, health status and functional status instruments and measures, several advancements

have been made in the area over the past three decades.

While the development of new instruments should be

encouraged where indicated, it is important to build upon

what already exists. A variety of useful quality of life

instruments are already available for some purposes.

Where possible these should be used, modified and further developed as indicated. However, there are some

areas where a great deal of work still needs to be done.

These are as follows:
1. Better definitions and measures of community health

status are required (Patrick & Bergner, 1990). A major

focus of nursing is to assess community health status.

This is done to monitor local populations to assist with

health planning, priority setting, analyses of care delivery needs and patterns of utilization. There needs to be

clear indicators of quality of life for residents in defined

geographical regions.

2. Better approaches for measuring organizations and

their outcomes are needed. Since most measures are

designed to measure outcomes at the individual level, it

is difficult to ascertain system or organizational change.

Approaches to measuring and statistically handling organizational data to reflect organizational outcomes

rather than changes in individuals alone are indicated.

3. There is a need to develop child health status profiles

that reflect dimensions of importance to childhood quality of life. Few measures are designed to provide a generic profile or index of child health status. Most tools

now assess specific domains, diagnostic groups, or stages

of development. Well-developed child health status profiles could provide information that could help identify

the impact of nursing care and services on children’s

health and quality of life.

In conclusion, there are many issues that must

be considered when quality of life, functional status, and

health status are the focus of outcome measurement. No

instrument will be useful for all situations. Variables

and instruments for the measurement of these concepts

must be selected carefully and be compatible with the

purposes, situations, interventions, and populations for

which they will be used. Although generic or global

health status and quality of life instruments can be useful in many situations, during the 1980’s much attention

has been given to improving the sensitivity and applicability of measures to reflect clinically important changes

in specific organs, systems, and diseases as well as across

health conditions. Many instruments and approaches

used to measure various dimensions of quality of life,

functional status and health status have been in use for

other purposes for quite some time. Although reliable a

valid instruments already exist that measure dimensions

of quality of life, functional status, and health status,

further development in this area will enhance the ability

to monitor changes in patient status in response to nursing interventions.

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