A Humanbecoming Qualitative Descriptive Study on Quality of Life with Older Adults

Nursing Literature

Nursing literature is filled with references to quality of life. Indeed, a great wealth of nursing literature has been written on quality of life. According to Parse’s (1994) humanbecoming theory, quality of life is the “whatness” that makes life what it is for persons. The whatness is expressed and symbolized in the meaning a person gives to situations. From Parse’s perspective, quality is the human’s “view on living moment to moment as the changing patterns of shifting perspectives weave the fabric of life through the human-universe interconnectedness” (Parse, 1994, p. 17). Therefore, even though nursing literature has added to the understanding of quality of life, they have not fully captured this researcher’s conceptualisation of quality of life as everchanging, indivisible, unpredictable existent. Moreover, quality of life research should be theory-driven and theory-based.

There are only four published humanbecoming-guided studies that used a qualitative descriptive research method to study the lived experiences of quality of life. Fisher and Mitchell’s (1998) question for the study was What is the experience of quality of life for people admitted for inpatient psychiatric care? It started with the theoretical belief that quality of life means different things to different people, and how one person’s views of his or her life were intimately linked to personal priorities, relationships, and hopes in day-to-day living. It was the process of clarifying, choosing, imaging, and moving on that shaped one’s quality of life. In the second study, Parse (1996) ascertained the meaning of quality of life for persons living with Alzheimer’s disease. The research question was What is the meaning of the experience of quality of life? The findings consisted of four themes: contentment with the remembered and now affiliations arises amidst the tedium of the commonplace; the easy-uneasy flow of transfiguring surfaces with liberating possibilities and confining constraints; desiring cherished intimacies yields with inevitable distancing in the vicissitudes of life; and contemplating the ambiguity of the possible emerges with yearning for successes in the moment. According to Parse (1996), the first, third, and fourth themes were not identified in the general literature on quality of life for persons with cognitive impairment. Parse (1996) concluded that the themes and paradoxical rhythms provided the world of science with new knowledge about quality of life for persons living with Alzheimer’s disease and about quality of life in general. The third study was conducted by Pilkington (1999) and illuminated quality of life through the exploration of stroke survivors’ perceptions of their quality of life. The guiding theoretical perspective of the study was Parse’s (1981, 1992, 1998) humanbecoming theory because of its emphasis on health as lived experience. The specific objectives of the study were to: “describe the meaning of quality of life, describe patterns of relating and daily routines related to quality of life, describe concerns, hopes, and dreams related to quality of life, and explore changes in quality of life over the first three months after stroke” (Pilkington, 1999, p. 337). The study has shed light on the knowledge and understanding about quality of life after a stroke from the perspective of persons living with stroke. In the fourth study, Pilkington and Mitchell (2004) examined quality of life from the perspective of women living with a gynecologic cancer. The research question was What is life like for women living with a gynecologic cancer? According to the authors, findings from the study consisted of four broad themes and they were “quality of life is treasuring loving expressions, affirming personal worth, consoling immersions amid torment, and expanding fortitude for enduring” (Pilkington & Mitchell, 2004, p. 149).

Findings from the nursing research literatures have enriched the understanding of the concepts in the context of personal experience. It also enhanced the knowledge and understanding about quality of life from the perspective of people, which is consistent with the researcher’s perspective.

Purposes of the Study

The purposes of this study were to: (a) explicate the experience of quality of life for older adults, (b) contribute to the understanding of quality of life for older adults, and (c) contribute to nursing’s extant body of knowledge by enhancing the humanbecoming.

Research Question and Objectives

The research question guiding this qualitative descriptive study was: What is the meaning of quality of life for older adults? According to Parse (2001), in a qualitative descriptive study, “data may be gathered through interview, observation, or questionnaire. The interview is a face-to-face discussion between the researcher and participant during which the researcher asks open-ended questions derived from the objectives of the study” (p. 59). The three objectives with interview questions for this study were:

Nursing Perspective

Parse’s (1981, 1992, 1995, 1998, 2007b, 2013) humanbecoming paradigm is rooted in the human sciences. It is grounded in the belief that humans coauthor their health with humanuniverse (Parse, 2007b), cocreate distinguishable patterns, which specify the uniqueness.(Parse, 1998). According to Parse (1981, 1987, 2013), three paradigms exist in nursing, the totality, simultaneity paradigms, and the humanbecoming paradigm, humanuniverse is indivisible, unpredictable, everychanging . The person’s experience is paramount (Parse, 1981, 1992, 1987, 1992, 1994, 1995, 1998, 2001, 2005, 2007b, 2013).

Parse (1994) associates quality with “whatness” (p. 17) and locates quality with the individual’s living experiences, and in doing so, claims that quality of life is “what the person there living the life says it is” (p. 17). According to Parse (1994), quality of life is also “the indivisible human’s view on living moment to moment as the changing patterns of shifting perspectives weave the fabric of life through the human-universe interconnectedness” (p. 17). Quality of life, in essence, is a global perception of meaning of the totality of life experiences. It continually changes from moment to moment in cocreation with the universe and therefore, the personal nuances of the nurse with person enhance quality of life (Parse, 1994).

Arguably, the most appropriate description of quality of life must come from people themselves and not from any outsiders looking in and thinking what it is. Therefore, quality of life for older adults must be based on how they structure their own situation and the personal meaning they give to changing pattern preferences. People choose value priorities with intentions that constitute quality of life. Quality of life is personal and based on lived experiences.

Methodology

“Appropriate conceptualisation of the research project is crucial, since it frames the entire study and lays the foundation for sound sciencing” (Parse, 2001, pp. 114-115). One of the approaches is the qualitative descriptive exploratory method. By utilising this method, this researcher’s phenomenon of interest, quality of life is synthesized with an extant discipline-specific theory. This method has been chosen by the researcher to answer the research question: What is the meaning of quality of life for older adults?

Findings

Themes surfaced from dwelling with the participants’ descriptions relative to the questions from the three objectives. The themes are stated in the language of the participant and the language of the researcher according to the objectives. Examples of the participants’ descriptions of the themes are presented below.

Discussion of Findings

Theme 1, fortifying tranquillity amid potential turbulence can be connected directly to the first principle of humanbecoming (Parse, 1981, 1998, 2007a). The first principle of humanbecoming is, “Structuring meaning is the imaging and valuing of languaging.” (Parse, 2007b, p. 309). According to Parse (1981, 1998, 2007b), humans structure personal meaning through the languaging of imaging and valuing. “Humans, in structuring meaning, have illimitable options from which to choose in the context of what is known explicitly-tacitly and confirmed-not confirmed with speaking-being silent and moving-being still” (Parse, 2007b, p. 309). These are the paradoxes of Parse’s first principle. In this study, the participants’ knowings and values regarding the meaning of quality of life have been created from all that they know, and from their sense of circumstances and conditions. While talking about the meaning of quality of life, they illuminated personal meanings. The participants were able to envisage the past, present, and future of their lives and the different meanings they have structured. They were fully aware that they live and continue to live their cherished beliefs. This is reflected in the first postulate of the humanbecoming school of thought which is: “Illimitability is the indivisible unbounded knowing extended to infinity, the all-at-once remembering-prospecting with the emerging now” (Parse, 2010, p. 258).

Other than in Parse method studies, the theme of objective one, fortifying tranquillity amid potential turbulence was not apparent in the extant literature on quality of life in general, nor in the research literature on quality of life for older adults.

Theme 2, gratifying engagements of diverse affiliations can be further articulated in connection with the second principle of humanbecoming which is “Configuring rhythmical patterns is the revealing-concealing and enabling-limiting of connecting-separating” (Parse, 2010, p. 258). According to Parse (2007b) “Humans configure rhythmical patterns of relating in cocreating reality illimitably with paradoxical rhythms: the disclosing-not disclosing of revealing-concealing, the potentiating-restricting of enabling-limiting, and the attending-distancing of connecting-separating” (p. 309). All participants talked about how their lives used to be as compared to now, and disclosed details about the paradoxical, rhythmical patterns they lived with others. The participants spoke of how they decided to move with the nursing home routines, at the same time revealing and concealing their involvements with the changing day-to-day rhythmical patterns of interrelationships. Most participants also described the importance of a spiritual life, religion, and their trust in God for moving with changing day-to-day relationships. The rhythm of connecting-separating was demonstrated as the participants spoke of being with and being away from family, friends, and other residents. The discourse reflected a reverence for family, old and new friends, and the changing routines. The theme gratifying engagements of diverse affiliations, when connected with Parse’s theory also relates clearly to the theoretical concept of enabling-limiting. Enabling-limiting is living the opportunities-restrictions present in all choosings all-at-once (Parse, 1981, 1998). Participants’ conversations illuminated the enablements and limitations of being an older person. The enabling aspects were related to moving with the changes in the nursing home environment, new relationships, involvement in activities, spiritual and religious activities, attitudes toward helping others, and peace of mind. As the participants chose certain patterns and gave up others, the consequences of the choices were not all known.

There were no studies that provided information consistent with the theme of objective 2, gratifying engagements of diverse affiliations. However, the spiritual and religious comments can be connected to some theoretical and extant literature. Apart from those that have been mentioned in the two excerpts, one participant spoke about when she was independent, she would go to church and stay there from 11am to 8pm. She would talk to Jesus and she was happy. Another participant said, “God is very important, sometimes, when I’m in trouble, I’ll pray to God for help.” Another participant in describing his feeling about God said,

If I need help, I will pray to God. Of course, not at once, God will help you. Sometimes, it takes a lot of patience to wait for God to help. Sometimes, when I am in a very bad way, I have to pray to God. There is no other way.

Layard (2005) has written about a source of comfort called “divine.” He suggested that different people have different ways of disciplining their minds and their moods, and these generally include some form of system relying on the deep positive part of one. Therefore, he declared that “people who believe in God are happier” (Layard, 2005, p. 72). Eckersley (2007) identified that in terms of correlation between religion and well-being, it seems that religion provides things that are good for health and well-being. Stenner, Cooper, and Skevington (2003) found that a deep-rooted and highly valued sense of faith was important to one’s health and quality of life.

Theme 3, envisioning possibilities with discordant constraints can be further clarified with the third principle of the humanbecoming, “Cotranscending with possibles is the powering and originating of transforming” (Parse, 2007b, p. 309).This principle suggests that “Humans cotranscend with unbounded possibles in risking being-nonbeing with the certainty-uncertainty of conformity nonconformity in pushing-resisting the affirming-not affirming of the familiar-unfamiliar” (Parse, 2007b, p. 309). Participants in this study expressed their hopes and dreams while pushing-resisting in creating new ways of viewing the familiar-unfamiliar (Parse, 1992). Parse’s concepts of powering, originating, and transforming are related in this principle (Parse, 2007b). Powering was illuminated when participants spoke about what they hoped for in the future. They imagined possibilities to go on, dreamed about things being better, hoped for improvement, and also feared for tomorrow, which were evidence of the theme, envisioning possibilities with discordant constraints. Originating is “inventing new ways of conforming-not conforming in the certainty-uncertainty of living. It is creating ways of distinguishing personal uniqueness” (Parse, 1998, p. 49). Participants thought about living and made choices about what to hope for, how to be in relationships, how to live with losses, and how to make the best of life on a day-to-day basis. However, when the participants made different choices to fulfill their hopes and dreams, there was always a degree of certainty and uncertainty about what was the now moment, and what would actually happen. Transforming is “shifting the view of the familiar-unfamiliar, the changing of change in coconstituting anew in a deliberate way” (Parse, 1998, p. 51). All participants spoke of losses and shifting relationships, recognizing their limitations, envisioning new ways to fulfill their hopes and dreams, figuring new ways to spend their time, and discovering new understandings of what life was like for them.

Apart from Parse method studies, the theme of objective 3, envisioning possibilities with discordant constraints did not surface in the general literature on quality of life nor in the research literature on quality of life.

Connection with Humanbecoming Literature

There were four published humanbecoming guided studies that used the qualitative descriptive research method to study the lived experiences of quality of life (Fisher & Mitchell, 1998; Parse, 1996; Pilkington, 1999; Pilkington & Mitchell, 2004). All of these studies were previously discussed in the review of literature. The study by Fisher and Mitchell (1998) investigated the experience of quality of life for people admitted for inpatient psychiatric care. The participants were 24 people over 20 years of age. In this study, the participants were men and women aged 65 and above with physical challenges residing in a long-term residential care facility for over a year. The participants in the study by Fisher and Mitchell (1998) described a sense of discomfort in and the struggles with relationships. One participant stated:

I’ll have to be a bit less sensitive, like some of them are quite busy and probably don’t have time to phone me, so I shouldn’t worry so much about whether they phone me or whether I phone them, as long as they have time to talk when I do get them on the phone. And uh, I think, I think I do need to get out to some place in the community and make more friends…I’m isolated from people.

In this study, one participant described quality of life as being able to go shopping with a family member and meeting other people in the coffee shop. Another participant expressed that her son was too busy to visit her in the nursing home. For others, it was about being close to others, but keeping a distance because of past experiences. One of the themes of Fisher and Mitchell’s (1998) study was distant hopes fuel the relentless struggle to carry on, which signified a tenacious persisted struggle to carry on with just a ray of hope that someday their situations might improve. In the present study, all participants had hopes and dreams related to quality of life, which included living with their families and love ones, being healthy, and hoping that things would change for the better.

Another study was Parse’s (Parse, 1996) study about quality of life for persons living with Alzheimer’s disease. In this humanbecoming qualitative descriptive exploratory study, 5 men and 20 women who had been medically diagnosed with early to moderate Alzheimer’s disease were asked to describe their quality of life. The majority of the participants resided in a multi-level care facility and the themes that emerged from the study were: The easy-uneasy flow of transfiguring surfaces with liberating possibilities and confining constraints (p. 130); desiring cherished intimacies yields with inevitable distancing in the vicissitudes of life (p. 130); and contemplating the ambiguity of the possibles emerges with yearning for successes in the moment (p. 130). The participants spoke about “the smooth and troublesome struggles of change [that] arise with opportunities and limitations”(p. 128), and “an appreciation of family and old and new friends resides along with living the humdrum routine day-to-day” (p. 128). In the present study, all the participants were also residing in a long term residential care facility. They expressed their hopes, wishes, tribulations, and thoughts of being healthy and perfect again. Participants spoke about wanting to live with their family members and missing their friends. They had also reflected on their day-to-day changing relationships with others, reminisced about the past and explored all possibilities for the present and the future.

Another study that connects this study on quality of life with humanbecoming literature is the study by Pilkington (1999) on quality of life with 9 men and 4 women who were stroke survivors between the ages of 40 and 91. The post-stroke participants spoke of having ups and downs. For example, “each participant spoke about feeling pleased with his or her progress or with life in general, as well as feeling down, sad, frustrated, and so forth.” (Pilkington, 1999, p. 345). Conversely, despite the challenges, the second theme hopes for endurance mingle with dreams of new possibilities (p. 344) illuminated “the participants persevered toward recovery and new possibilities in life” (p. 344). In the present study, instead of talking about restrictions in the future, participants envisioned new ways to view the certainty-uncertainty, and the familiar-unfamiliar in the now and in the future. For example, one participant expressed that she was worried about the numbness of her hands, but she would pray to Jesus to heal her, and to get better so that she could do things for herself such as walking, cooking, and shopping. The hope showed here emerged with the third theme envisioning possibilities with discordant constraints.

The last example is a study by Pilkington and Mitchell (2004). The focus of the study was an examination of quality of life from the perspective of 14 women living with gynaecologic cancer. They described the paradoxical rhythm of enabling-limiting of connecting-separating by stating the ups and downs of their everyday lives, which was also found in the present study. For example, one participant spoke of wanting to talk to other residents, but was unable to because of different dialects. Another participant expressed that she did not want to trouble others to help with her activities of daily living, but she was unable to do them all herself. While participants were connecting and separating with “diverse affiliations,” all participants also disclosed details about the paradoxical, rhythmical patterns they lived with others. Revealing and concealing their involvements, and the changing of day-to-day rhythmical patterns of interrelationships.

Connection to the Humanbecoming Community Change Mode

Each human is community (Parse, 2003). “Each human is a humanuniverse cocreation, the individual is community, and the group is community. This means that each human is a unique history cocreated with all of the experiences of that human’s becoming” (Parse, 2012, p. 44). According to Bunkers (2003), “Community lives health in choosing what is important for quality of life…is defined by community, and the meaning of health depicts quality of life” (p. 82). Parse (1994) said, “Quality of life is not what those outside the life looking in think it is, but rather it is what the person there living the life says it is” (p. 17). Therefore, “quality of life is defined by community and is not evaluated by any set of societal norms, but by community itself [the individual]. Quality of life is the meaning community constituents give to multidimensional lived experiences of health” (Bunkers, 2003, p. 82).

There are three change concepts in the humanbecoming community model, and they are moving-initiating, anchoring-shifting, and pondering-shaping (Parse, 2003, 2012). The concepts are “rhythms [that] arise in all day-to-day relationships as new meanings unfold with shifting patterns in cocreating what is possibles” (Parse, 2003, p. 23), which is reflected in the findings of the present study: Quality of life is fortifying tranquillity amid potential turbulence with the gratifying engagements of diverse affiliations as envisioning possibilities arise with discordant constraints. For many of the participants in this present study, living in a long-term residential care facility may not be their choosing, but it did not hold them back from their hopes, dreams, and wishes to change the quality of their lives. The participants clearly cocreated personal meaning through their experiences and were guided by personal value priorities in order to move on. As mentioned earlier, quality of life from the person’s perspective is the goal of the humanbecoming school of thought (Parse, 1994, 1998, 2007a). Therefore, “quality is the ‘whatness’ of a life and that whatness can be described only by the person living the life – yet the person’s description is a reflection of community cocreation” (Parse, 1999, p. 120).

Moving-Initiating is discarding-creating with the emerging now and a cocreated paradoxical rhythm of community change. It is the discarding and creating all-at-once with meanings of the moment. Meanings shift and change with personal expectations and a shifting of value priorities is cocreated with each unfolding situation (Parse, 1999, 2003, 2012). According to Parse, “Individuals’ different ways of being call for vigilance…The different ways of being arising from individuals’ diverse histories cocreate calm-turbulent moments that surface as conflict.” (Parse, 2012, pp. 45-46). The theme of the present study, Fortifying tranquillity amid potential turbulence described the conflicting feelings and expectations of the participants. As community, the individual participants in the long-term residential care facility have to consider keeping what they cherish and all-at-once giving up their independence to engage with the new environment and routines of the residential care facility.

Anchoring-Shifting is persisting-diversifying with the emerging now, savouring-sacrificing, and revering-liberating. It is a cocreated paradoxical rhythm of community change (Parse, 2012). “Individuals and groups are anchoring-shifting community change with the becoming visible-invisible of the emerging now in all day-to-day engagements.” (Parse, 2012, p. 47). The research findings from Pilkington’s (2000) study on persisting while wanting to change, shed light on anchoring-shifting community change. The structure is “The lived experience of persisting while wanting to change is wavering in abiding with the burdensome-cherished as engaging-distancing with ameliorating intentions arises with anticipating the possibilities of the new” (p. 510). Another theme of the present study, gratifying engagements of diverse affiliations is reflective of persisting-diversifying, savouring–sacrificing and revering-liberating. Participants spoke of the certainty-uncertainty of their involvements with others, as issues of conforming-not conforming to the routines and rituals of the long-term residential care facility arose with questions of what they desire and what is possible. Participants also expressed their wish to relish their relationships with others, while distancing from others at the same time.

Pondering-Shaping is contemplating while configuring with the emerging now. It is a cocreated paradoxical rhythm of community change (Parse, 2003, 2012). “It is contemplating reflectively and prereflectively the familiar-unfamiliar possibilities that all-at-once reveal and conceal the opportunities and restrictions” (Parse, 2003, p. 39). Another theme of the present study envisioning possibilities with discordant constraints exhibits the participants’ hopes and dreams of the possibilities while all-at-once shaping what will be in light of the constraints of what might happen. In pondering-shaping the possibilities, participants imagine the cherished such as living with families, being healthy, and breaking the monotony of the daily routine, while at once engaging with the on-going struggle of limitations.

New Knowledge

This study is the first to investigate the meaning of quality of life as described by 10 older adults living in residential care in Singapore. The unique findings of this study are:

Findings from this study extend the scientific base of nursing and enhance understanding about the meanings, relationships, dreams, hopes, and values that link to the experience of quality of life for older adults residing in a long-term residential care facility. It also generates new knowledge and expands the humanbecoming paradigm.

Recommendations for Research, Practice, and Teaching-Learning

Quality of life is a universal experience, and therefore, study of the same phenomenon with different populations may lead to different themes that further extend knowledge and enhance understanding about this human experience. The meanings of quality of life that emerged from this study were interpreted in light of Parse’s theory, and new knowledge about humanbecoming was illuminated. Quality of life experiences should also be explored with older adults from different communities in order to unearth the differences and similarities for different groups of older adults.

The first theme stated in the language of the researcher is: fortifying tranquillity arises amid potential turbulence. Studies from this theme might be, being resilient when facing difficult times, feeling calm, feeling unsettled, and others. The second theme of this study is: gratifying engagements surface with diverse affiliations. Studies from this theme might be feeling safe with others, feeling grateful, and others. The third theme is: envisioning possibilities arise with discordant constraints. It might yield studies such as feeling restricted, feeling annoyed, considering tomorrow, and others. These research phenomena have the potential to benefit people and contribute to nursing knowledge related to the humanbecoming school of thought. The findings of this research study also have implications for practice.

Findings of this study can guide nurses who practice with older adults and families in different communities. According to Parse (1999), community “is a oneness of human connectedness that is configured with unique beliefs and values” (p.119). The perspective is grounded in the philosophical assumptions and principles of humanbecoming (Parse, 1981, 1992, 1995, 1997b, 1998, 2001, 2003, 2012). The nurse in true presence (Parse, 1998) with persons, focuses on meanings from the perspective of the person, explores ideas and options, is present without judgement, and bears witness to the person’s own value priorities. The findings of this study provide understanding of each person’s unfolding and changing patterns of meanings, values, beliefs, and choices for living. Thus, enhancing the nurse-person relationship, the goal of which is quality of life from the person’s perspective (Parse, 1998). The findings of this study also have implications for the teaching-learning.

During the 2009 Singapore National Day Rally speech (Khalik, 2009), Prime Minister Lee Hsien Loong announced that acute hospitals should be for the critically ill, and fast-track medicine such as surgery, intensive care, and high-end diagnostic services. He explained that long-term care facilities are for older patients who need care over a longer period of time, and this separation would help to keep costs down. This plan would also make sure that patients are at the right place for the right type of treatment and care. A total of 20 to 25 nursing homes will be built by 2020 in order to provide care for older people (Khalik, 2012). With such shifting emphasis for shorter hospitalization for older adults in Singapore, it means that there will be a reduction in placement for nurses and nursing students within the healthcare setting for gerontology and geriatric experiences. However, with the growing numbers of individuals over the age of 65, it is essential to educate nurses in caring for older adults with multifaceted issues that require specialized knowledge. Long-term residential care facilities will be an alternative placement for teaching-learning in educational programs. The findings of this study enhance understanding of quality of life for older adults and the knowledge should be included in courses in nursing programs.

Conclusion

This study is the first to investigate the meaning of quality of life as described by 10 older adults living in residential care in Singapore. The themes were weaved together and the answer to the research question, What is the meaning of quality of life for elders? Quality of life is fortifying tranquillity amid potential turbulence with the gratifying engagements of diverse affiliations, as envisioning possibilities arise with discordant constraints. This conceptualisation extends the scientific base of nursing, and enhances the understanding about the meanings, relationships, dreams, hopes, and values that link to the experience of quality of life for older adults residing in a long-term residential care facility. It also generates new knowledge and expands the humanbecoming school of thought. The challenge for future research is to continue to unleash the knowledge of the phenomenon of quality of life as experienced by older adults, as well as to reach beyond in the spirit of discovery.