Nursing Strategies and Quality of Life Outcomes: A Systematic Review

Sykepleievitenskap . Omvårdnadsforskning . Nursing Science

Nursing Strategies and Quality of Life Outcomes: A Systematic Review Carol S. Burckhardt School of Nursing Oregon Health Sciences University, Portland, Oregon 97201 USA Berit R. Hanestad Section of Nursing Science Department of Public Health and Primary Health care University of Bergen Bergen, Norway

ABSTRACT This study evaluated the impact of nursing interventions on the quality of life of patients. After an extensive literature review that yielded 46 studies, research synthesis techniques were applied. Overall, strategies such as counseling, patient education, cognitive-behavioral techniques, and exercise were successful in increasing the quality of life of treated groups. Despite this finding, there are few studies that target quality of life as a major outcome measure of nursing care. KEY WORDS: quality of life, nursing, nursing interventions, research synthesis

4

Introduction

Quality of life (QOL) is a valued outcome of nursing and medical care. A growing literature provides evidence of its increased importance to clinicians, researchers, policy makers, government agencies, and funding institutions (1-3). Much of the research effort by nurses has focused on conceptual definitions of QOL, instrument development, descriptions of QOL in patient groups, and studies of the impact of physical and psychosocial variables on QOL. Both Haas (4) and Padilla et al (5) have reviewed this literature. Their reports, as well as those of researchers in specialty areas, have concluded that nursing has a primary interest in QOL issues and that the focus of some nursing research efforts should be on determining effective strategies that enhance the QOL of patients (6,7). If QOL is to be a valid evidence-based outcome of nursing care, the research focus must move from descriptive studies to testing specific strategies through clinical trials or program evaluation. Nursing and health care must demonstrate changes in QOL in a positive direction, or in some populations, such as those at end of life, a decrease in the deterioration of QOL. A number of research syntheses of nursing interventions are available in the literature (8-16). None of them focused on QOL as an outcome measure. The only review in the nursing literature that did focus on QOL contained mainly drug trials (17). Thus, the work to date does not provide nursing practice with direction for producing positive QOL changes or preventing deterioration of QOL in patients. The purposes of this study were to: (1) describe and summarize the use of QOL as an outcome measure in nursing intervention research, and (2) analyze the effects of specific nursing

VÅRD I NORDEN 1/2003. PUBL. NO. 67 VOL. 23 NO. 1 PP 4–9

interventions on the QOL of patients. Integrative review techniques as described by Cooper (18) were used to answer four questions: (1) How was QOL measured in the studies? (2) What types of nursing interventions were used in studies where QOL was an outcome variable? (3) What was the effect of these interventions on patients’ QOL? (4) What was the impact of age, gender, setting, diagnosis, duration of treatment, sample size, type of design, and study quality on QOL outcomes?

ons began to cluster into broad categories of patient education, counseling, cognitive-behavioral strategies, and special types of nursing care.

Sample MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsychLit computerized databases were searched for the years 1983 through 1998 using the key words, quality of life, well-being, life satisfaction, and happiness meshed with nursing, nursing research, nursing intervention, Study methods and nursing care. Several specific Definitions therapies (patient education, psyBecause QOL is defined in multi- choeducation, relaxation, guided ple ways in the literature, we did imagery, exercise, home visiting, not begin with an a priori definireminiscence, therapeutic touch, tion but rather began a search of case management), specific disthe literature to determine how eases (diabetes, cancer, cardiac QOL had been defined in nursing disease, rheumatic disease, renal theoretical and research studies. disease), and the words elderly Several nurse researchers have adult or aged were meshed with summarized nursing conceptual QOL, life satisfaction, well-being and operational definitions of and nursing. Twenty nursing jourQOL as having multiple dimensi- nals containing relevant articles ons of well-being that encompass, found by the computer searches physical, psychological/spiritual, and representing a broad range of social and interpersonal, and nursing specialities were searched financial or material aspects that manually for the years 1990 may be measured on scales of through 1998. Reference lists of satisfaction, importance, or disreview articles that focused on tress (19-21). nursing, nursing interventions, We chose to use this wellpatient education, and psychoebeing definition of QOL, not only ducation, along with QOL bibliobecause it is well-accepted within graphies and indexes, were also nursing, but also because it searched. Due to resource limitaallows for a range of domains and tions, attempts to locate unpublispersonal subjective expression. hed work were limited to DisserAs such, it is a generic definition, tation Abstracts International not disease specific and can be which was searched for the years applied across a range of illnesses 1961 to 1997. All Scandinavian and developmental stages. For the nursing journals were examined. purposes of this study, variables Since no articles were found in such as health status, functional these journals, only English langstatus, psychological distress, and uage articles and dissertations symptoms were seen as predicwere obtained. tors of positive or negative QOL Inclusion criteria to determine and not defining QOL itself (22). whether a study would be retaiInterventions were defined as ned for analysis included: (1) a any type of care over which nurQOL outcome measure that met ses could exert primary control the above definition; (2) an interand responsibility. As the literavention that was administered or ture was searched, the interventi- conducted by nurses or a program

in which nurses were the key personell; (3) subjects who were patients, or from a group that was expected to benefit from the intervention, such as elderly persons, and not simply healthy volunteers; and (4) sufficient data to determine direction of the treatment effect. Descriptive and correlational studies, methodological studies of QOL instruments, and case studies were excluded. Coding Coding included the study citation, educational level and discipline of the first author, study design, treatment description, number and description of subjects, setting, outcome variables, instrument used to measure the variables, attrition rate, direction of effect, and overall study quality. The two authors independently coded five studies during the initial data collection. Agreement on the coded variables was 95%. All disagreements were discussed and consensus reached. The remaining studies were coded initially by the first author. Any variables on which there was uncertainty were discussed with the second author. Decisions were made jointly as to how to code and whether to keep the study in the analysis. In order to ensure coding accuracy and to provide a measure of study quality, a third person, a doctorally prepared nurse researcher with extensive experience in research methods and critique, independently coded, rated all the studies and came to consensus with the first author. For each coded study, only one QOL outcome measure was used in the analysis. Where more than one measurement of QOL was evident, the most well-known, reliable, and valid measure was retained. In studies with multiple treatments, if each treatment group was compared to a control group, the group that got a combination of treatments was used to represent the study. If there

was no control group, then each treatment was considered a separate study since there was no overlap of subjects. Analytic Procedures The primary analysis was to determine, from the verbal and quantitative data contained in each study, the direction of the treatment effect. The study was coded as positive direction, negative direction, or no change based on the means for treated group compared to the control group at posttest or the pretest versus posttest means in the single group treatment program studies. If means were not available, we relied on the verbal conclusion presented by the author(s) of the paper. All variables were analyzed using descriptive and one-way analysis of variance statistics. Results

Characteristics of the Studies Although several thousand titles were found through the searches, when the abstracts were read, only 130 appeared to be experimental or program evaluation studies and contain the necessary variables. When the entire article was scanned, more than 50% were rejected for one of three reasons: (1) The outcome measure did not meet the definition of QOL. The most common measures to be called QOL were physical functioning, anxiety, and depression. (2) Nurses were not involved in the research. (3) The article described an intervention and appropriate QOL outcome but did not present data that would allow any assessment of the effect of the intervention. After this screening, 44 articles and 2 dissertations were retained for analysis. Table I summarizes the descriptive characteristics of the studies. The majority (74%) of the studies were carried out by a nurse with a doctoral degree. Eighty-nine percent were recent

5 Table I. Study Characteristics

N

%

PUBLICATION FORM Journal Dissertation

44 2

96 4

FIRST AUTHOR Nurse Other

39 7

85 15

ACADEMIC QUALIFICATIONS Nurse with Doctorate Non-Nurse Doctorate Nurse with Masters Medical Doctor

34 4 5 3

74 9 11 6

PUBLICATION DATE 1980-89 1990-99

5 41

11 89

RESEARCH DESIGN Randomized Controlled Trial (RCT) 23 Non-randomized Controlled Trial (NRCT) 9 Pre-Post Test Program Evaluation 14

50 20 30

CONTROL No treatment Usual treatment or attention Not applicable

14 18 14

31 38 31

STUDY SETTING Outpatient clinic Community/Home Nursing Home Hospital Hospice

18 15 7 3 3

39 32 15 7 7

QUALITY OF LIFE MEASURE Life Satisfaction Index (24) Visual Analog QOL Scale Quality of Life Index (20) Quality of Life Index (27) Philadelphia Geriatric Morale (23) Quality of Life Scale (26) Faces Scale Hospice Quality of Life Index (60) Other Scales

11 6 5 4 3 3 2 2 10

24 13 11 8 7 7 4 4 22

studies. Fifty percent of the studies used an randomized controlled trial (RCT) design while 20% were non-randomized controlled trials (NRCT). The remainder were program evaluations with only one group that was prete-

sted, treated, and then posttested. Of the 32 RCTs and NRCTs, 44% used a no-treatment control and 56% had a usual treatment or attention control group. Mean duration of the experimental treatment for all studies was 16 sesCAROL BURCKHARDT OG BERIT R. HANESTAD


sions. These sessions were usually weekly although in some studies the intervention was in place at all times for a defined period of time, such as case management or hospice care. Settings in which the studies were carried out were varied with a majority in outpatient or community settings. A wide variety of QOL measures were used across the studies ranging from simple visual analog scales to scales developed specifically for the elderly (23,24) to multidimensional instruments (25-27). A majority of measures were published instruments with evidence of psychometric work during development and sufficient reliability and validity for group testing. Overall quality of the study was rated as high if it used an RCT design and had low attrition (37% of the studies), medium if it used a NRCT or program evaluation design and had low attrition (30% of the studies) and low quality if it had high attrition (33% of the studies). High attrition was defined as the loss of more than 20% of the subjects during the study. Subject characteristics are summarized in Table II. The average age of the subjects was 61 years. Sixty-five percent of the studies included both men and women. A medical diagnosis was given for subjects in 65% of the studies. In the other 35%, the subjects were described only as elderly. All studies included the sample size which ranged from 9 to 531 with a mean size of 78 and a median size of 51. A total of 3607 subjects participated in the studies.

6

Table II. Characteristics of Study Samples

N

%

AGE (mean in years) 31–40 41–50 51–60 61–70 71–80 81+

6 5 14 8 9 4

13 11 30 17 20 9

GENDER Men only Women only Both

4 12 30

9 26 65

DIAGNOSES Elderly Cancer Cardiovascular Pulmonary Rheumatic HIV/AIDS Mental Illness Drug Addiction Chronic Pain

16 12 5 4 3 2 2 1 1

35 26 11 9 7 4 4 2 2

relaxation, and guided imagery), counseling techniques (reminiscence, life review, insight), exercise, and combination strategies (combined education, cognitivebehavioral techniques and exercise). A positive treatment effect was evident in 33 studies. In 4 studies the treatment resulted in negative effects while in the remaining 9 studies, no treatment effect could be discerned. Patient education and special nursing care had the lowest percentage of positive effects on QOL while counseling and exercise had the highest percentage of positive effect. Cross tabulations with the chisquare statistic were analyzed Impact of Interventions on QOL between the three nominal types As shown in Tables III and IV, the of effect (negative, none, posiintervention strategies were grou- tive) and gender, setting, type of ped into six categories: special design, diagnosis, type of internursing care (case management, vention, and study quality. There hospice care, visiting nurse care were no significant associations in the home), patient education between type of effect and any of (information focused), cognitive- these variables. One-way analysis behavioral training (restructuring, of variance revealed no signifiVÅRD I NORDEN 1/2003. PUBL. NO. 67 VOL. 23 NO. 1 PP 4–9

cant differences between type of effect and age, sample size, or duration of treatment. Discussion

The major finding of this study was that nursing interventions had a positive effect on the QOL of patients. Most subjects in the experimental groups had higher QOL at the end of the experiments when compared with either no-treatment or usual-treatment controls. Most of the program evaluations yielded positive results. Negative effects of treatment were small and limited to one very elderly sample (mean age 84), one hospice sample, one elderly COPD group, and one very ill lung transplant group. One could speculate that without nursing treatment, the QOL of these groups might have deteriorated more rapidly especially in the hospice and lung transplant samples. All of the studies that were coded as no effect were stu-

dies in which the means for QOL were not given and we had to rely on the conclusion of the authors. It is possible that in those studies, the actual mean effect on QOL may have been weakly positive or negative. It was not surprising that counseling techniques such as reminiscence had positive effects on QOL. The major purpose of reminiscence or life review is to help older persons feel better about their lives and increase life satisfaction. Special nursing care techniques, which did not have as great an affect on QOL, may have had other purposes such as increasing independence or meeting other patient needs more effectively. Many studies, while including a QOL measure, did not have QOL as a major outcome, but rather measured it as part of a large battery of outcomes. Nevertheless, whether measured as a global assessment by a VAS scale, Life Satisfaction Index (24), or by multidimensional instruments developed by nurses (25-27), a large majority of the QOL scales were sensitive to change and indicated change in the desired direction. Use of standardized QOL measures across patient groups and interventions could enable nursing science to better target measures for nursing practice, to more clearly articulate which nursing interventions improve the QOL for which patients groups, and enable nursing to compare results of interventions with those of other disciplines. Despite the extensive nature of the literature search, the number of studies that met criteria was small. On the one hand, the small number was in part due to the stringent definition of QOL that was imposed on the data. On the other hand, to have broadened the definition to include any measure that the researchers labeled QOL would have been to abandon any coherent definition of the concept and foster the lack of clarity in

Table III. Summary Characteristics of the Studies

Citation Special Nursing Allen (29) Cox (38) Ferrell (41) Hawthorne (51) Heslop (52) Holloway (53) McEwan (59) McMillan (60) McMillan (61) McMillan (62) Mirolo(63) Nickel (65) Únden (72) Patient Education Braden (33) Ferrell (42) Gillis (45) Grant (47) Lefort (56) Reele (66) Ruffling (68) Rustøen (69) Scherer (70) Zauszniewski (73) Cognitive-Behavioral Abraham (28) Erickson (40) Fürst (44) Larsson (55) McCain (58) Moody (64) Richardson (67) Counseling Anderson (31) Burnside (35) Cook (36) Cook (37) Haight (48) Haight (49) Haight (50) Combination Programs Alt-White (30) Bennett (32) Burckhardt (34) Fridlund (43) Kay (54) Manzetti (57) Exercise Dungan (39) Goldberg (46) Stevenson (71)

Diagnosis

Mean Age

Sample Size

Design

Effect Size

Elderly Elderly Cancer Cardiac Pulmonary Mental Illness Elderly Cancer Cancer Cancer Cancer AIDS Cardiac

80 65 60 56 70 35 75 71 58 61 58 35 58

19 39 83 21 75 64 296 62 28 67 25 57 103

Program Experimental Experimental Experimental Experimental Experimental Experimental Program Program Program Program Experimental Experimental

0 1.08 .32 0 0 .52 .04 .07 -.13 .04 + + 0

Lupus Cancer Cardiac Cancer Chronic pain Cancer Elderly Cancer Pulmonary Elderly

46 68 59 56 39 55 77 53 70 75

234 66 156 41 110 32 28 96 24 37

Program Program Experimental Experimental Experimental Quasi-Experiment Quasi-Experiment Experimental Program Quasi-Experiment

.41 0 0 .31 .58 0 1.20 .57 -.14 .98

Elderly Hypertension Cancer Cancer HIV Pulmonary Cancer

84 44 59 60 40 60 46

42 20 82 64 26 19 31

Quasi-Experiment Quasi-Experiment Quasi-Experiment Experimental Quasi-Experiment Program Experimental

-.07 .94 .44 .43 2.07 + 0

Drug Abuse Elderly Elderly Elderly Elderly Elderly Elderly

35 65 81 82 76 78 76

531 67 41 36 35 188 51

Program Program Experimental Experimental Experimental Program Experimental

.72 0 + + 1.52 + 1.19

Elderly Fibromyalgia Fibromyalgia Cardiac Elderly Pulmonary

65 42 42 56 60 40

54 104 86 110 132 9

Program Program Experimental Experimental Experimental Quasi-Experiment

+ .22 .29 .51 + -.06

Elderly Elderly Elderly

74 83 64

44 30 72

Program Experimental Experimental

.76 .79 .15

definition that has so long plagued the QOL literature (22). Although researchers often label symptom severity, health status, and psychological distress as health-related QOL, each of these categories can also be seen as influences on the patient’s perception of overall life quality. To consider them the same as QOL is to set people with chronic illness apart from the rest of the population making the erroneous assumption that QOL means something different to them than it does to their healthy compatriots. QOL research, in general, could benefit from further dialogue and consensus regarding definitions of QOL. In conclusion, because the number of studies within each nursing intervention category was small and many of the individual studies used small samples, the results of this review should be viewed as preliminary and interpreted with caution. At this point no generalizations should be made from these findings. They should rather be viewed as hypothesis-generating. Had there been more studies and more means and standard deviations reported in each intervention category, metaanalysis techniques to compare effect sizes could have been used. Also, the roles that the descriptor variables may have played in determining the intervention effects on QOL could have been determined with greater precision. The fact that many of the studies were successful in increasing the QOL of elderly patients and patients with terminal cancer has implications for future research. Further work could focus attention on the strategies that are most likely to enhance QOL in these patients. Patients with terminal cancer, for example, might benefit from life review strategies. The three studies of exercise strategies were all successful in raising elderly patients’ perception of QOL. QOL is not usually CAROL BURCKHARDT OG BERIT R. HANESTAD

7


Table IV. Effects of interventions on quality of life outcomes

Intervention*

No. Studies

Special Nursing Care

13

Direction of Effect Positive

Negative

None

8

1

4

29,38,41,51-53, 59-63,65,72 Patient Education 33,42,45,47,56,66, 68-70,73

10

6

1

3

Cognitive-Behavioral 28,40,44,55,58,64,67

7

5

1

1

Counseling 31,35-37,48-50

7

6

0

1

Combination Programs 30,32,34,43,54,57

6

5

1

0

Exercise 39,46,71

3

3

0

0

*Numbers refer to the citations in the reference list.

thought of as an outcome of exercise. Yet, as these studies indicate, the benefits of exercise may be far beyond physical fitness. This review study has shown the potential for research synthesis techniques to add to our knowledge of treatment effects on QOL. Nurse researchers should be encouraged to include a measure of QOL in their future intervention studies and further work on integrating these studies should be done.

Accepted for publication 07.05.2002

8

Carol S. Burckhardt School of Nursing Oregon Health Sciences University Portland, Oregon 97201 USA

reform in the USA and the future of public health. Quality Life Res 1993; 2: 357-361. 4. Haas, BK. Clarification and integration of slimilar quality of life concepts. Image: Journal Nursing Scholarship, 1999; 31: 215-220. 5. Padilla GV, Grant MM, Ferrell B. Nursing research into quality of life. Quality Life Res 1992; 1: 341-348. 6. Gulick EE. Research priorities for nurses caring for persons with multiple sclerosis. J Neurosci Nurs 1996; 28: 314-321. 7. Rudy, SF, Wilkinson MA, Dropkin MJ, Stevens G. Otohinolaryngology nursing research priorities: results of the 1996/1997 SOHN Delphi survey. ORL – Head Neck Nurs 1998: 16: 14-20. 8. Andersen BL. Psychological interventions for cancer patients to enhance the quality of life. J Consult Clin Psychol 1992; 60: 552-568. 9. Brown SA. Studies of educational interventions and outcomes in diabetic adults: A meta-analysis revisited. Patient Educ Counsel 1990; 16: 189-215. 10. Burckhardt CS. The effect of therapy on the mental health of the elderly. Res Nurs Health 1987; 10: 277-285.

Correspondence to Berit Rokne Hanestad Deptartment of Public Health and Primary Health Care Section of Nursing Science Ulriksdal 8c NO-5009 Bergen, Norway Telephone: +47 55586166 Fax: +47 55586130 Email: [email protected] References 1. Bech P. Issues of concern in the standardization and harmonization of drug trials in Europe: health-related quality of life, ESCT meeting, Strasbourg, 23-24 May 1991. Quality Life Res 1992; 1: 143-145. 2. Berzon RA, Donnelly MA, Simpson Jr RL, Simeon GP, Tillson HH. Quality of life bibliography and indexes: 1994 update. Quality Life Res 1995; 4: 547569. 3. Gellert GA. The importance of quality of life research for health care

VÅRD I NORDEN 1/2003. PUBL. NO. 67 VOL. 23 NO. 1 PP 4–9

11. Devine EC. Effects of psychoeducational care for adult surgical patients: A meta-analysis of 191 studies. Patient Educ Counsel 1992; 19: 129-142. 12. Devine EC, Reifschneider E. A meta-analysis of the effects of psychoeducational care in adults with hypertension. Nurs Res 1995; 44: 237-245. 13. Dickson, R. Psycho-educational care for adults with cancer. Nurs Standard 1997; 11(9): 32-34. 14. Mullen PD, Mains DA, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Counsel 1992; 19: 143-162. 15. Heater BS, Becker AM, Olson RK. Nursing interventions and patient outcomes: A meta-analysis of studies. Nurs Res 1988; 37: 303-307. 16. Smith MC, Stullenbarger E. An integrative review and meta-analysis of oncology nursing research: 1981-1990.

Cancer Nurs 1995; 18: 167-179. 17. Kinney MR, Burfitt SN, Stullenbarger E, Rees B, DeBolt MR. Quality of life in cardiac patient research: A metaanalysis. Nurs Res 1996; 45: 173-180. 18. Cooper HM. Integrating Research: A Guide for Literature Reviews (2nd ed.) Newbury Park: Sage Publications. 19. Padilla GV, Ferrell B, Grant MM, Rhiner M. Defining the content domain of quality of life for cancer patients with pain. Cancer Nurs 1990; 13: 108115. 20. Ferrans CE. Development of a quality of life index for patients with cancer. Oncol Nurs Forum Suppl 1990; 17: 15-19. 21. Grant M, Padilla GV, Ferrell BR, Rhiner M. Assessment of quality of life with a single instrument. Semin Oncol Nurs 1990; 6: 260-270. 22. Anderson KA, Burckhardt CS. Conceptualization and measurement of quality of life as an outcome variable for health care intervention and research. J Adv Nurs 1999; 29: 298-306. 23. Lawton M. The Philadelphia Geriatric Center Morale Scale: A revision. J Gerontol 1975; 30: 85-89. 24. Neugarten BL, Havighurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol 1961; 16: 134143. 25. Ferrans CE, Powers MJ. Quality of life index: Development and psychometric properties. Adv Nurs Sci 1985; 8: 15-24. 26. Burckhardt CS, Woods SL, Schultz AA, Ziebarth DM. Quality of life adults with chronic illness: a psychometric study. Res Nurs Health 1989; 12: 347354. 27. Padilla GV, Presant C, Grant MM, et al. Quality of life index for patients with cancer. Res Nurs Health 1983; 6: 117-126.

STUDIES USED IN RESEARCH REVIEW 28. Abraham IL, Neudorfer MM, Currie LJ. Effects of group interventions on cognition and depression in nursing home residents. Nurs Res 1992; 41: 196-202.

29. Allen CI, Turner PS. The effect of an intervention program on interactions on a continuing care ward for older people. J Adv Nurs 1991; 16: 11711177. 30. Alt-White AC. An interdisciplinary approach to improving the quality of life for nursing home residents. Nurs Connections 1993; 6: 51-59. 31. Andersen MD, Smereck GA, Braunstein MS. Light Model: an effective intervention model to change highrisk AIDS behaviors among hard-toreach urban drug users. Am J Drug Alcohol Abuse 1993; 19: 309-325. 32. Bennett RM, Burckhardt CS, Clark SR, O’Reilly CA, Wiens AN, Campbell SM. Group treatment of fibromyalgia: a 6 month outpatient program. J Rheumatol 1996; 23: 521-528. 33. Braden CJ. Patterns of change over time in learned-response to chronic illness among participants in a systemic lupus erythematosus self-help course. Arthritis Care Res 1991; 4: 158-167. 34. Burckhardt CS, Mannerkorpi K, Hedenberg L, Bjelle A. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994; 21: 714720. 35. Burnside IM. The effect of reminiscence groups on fatigue, affect and life satisfaction in older women. Doctoral Dissertation. Austin:University of Texas at Austin, 1990. 36. Cook EA. The effects of reminiscence on psychological measure of ego integrity in elderly nursing home residents. Arch Psychiatric Nurs 1991; 5: 292-298. 37. Cook EA. Effects of reminiscence on life satisfaction of elderly female nursing home residents. Health Care Women Int 1998; 19: 109-118. 38. Cox CL, Kaeser L, Montgomery AC, Marion LH. Quality of life nursing care. An experimental trial in long-term care. J Gero Nurs 1991; 7(4): 6-11. 39. Dungan JM, Brown AV, Ramsey MA. Health maintenance for the independent frail older adult: can it improve physical and mental well-being? J Adv Nurs 1996; 23: 1185-1193.

40. Erickson H, Swain MA. Mobilizing self-care resources, a nursing intervention for hypertension. Issues in Mental Health Nurs 1990; 11: 217-235. 41. Ferrell B, Wisdom C, Wenzl C, Brown J. Effects of controlled-release morphine on quality of life for cancer pain. Oncol Nurs Forum 1989; 16: 521526. 42. Ferrell BR, Ferrell BA, Ahn C, Tran K. Pain management for elderly patients with cancer at home. Cancer 1994; 74: 139-146. 43. Fridlund B, Högstedt B. Lidell E, Larsson PA. Recovery after myocardial infarction: effects of a caring rehabilitation program. Scand J Caring Sc 1991; 5: 23-32. 44. Fürst CJ, Johansson S, Fredrikson M, Hursti T, Steineck G, Peterson C. Control of cisplatin induced emesis - a multidisciplinary intervention strategy. Med Oncol Tumor Pharmacother 1992; 9: 81-86. 45. Gillis CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tompkins C. A randomized clinical trial of nursing care for recovery from cardiac surgery. Heart Lung 1993; 22: 125-133. 46. Goldberg WG, Fitzpatrick JJ. Movement therapy with the aged. Nurs Res 1980; 29: 339-346. 47. Grant M. Effects of a structured teaching program for cancer patients undergoing head and neck radiation therapy on anorexia, nutritional status, functional status, treatment response and quality of life. Doctoral Dissertation. San Fransisco: University of California San Francisco, 1988. 48. Haight BK. Long-term effects of a structured life review process. J Gerontol, 1992; 47: 312-315. 49. Haight BK, Dias JK. Examining key variables in selected reminiscing modalities. Int Psychogeriatrics 1992; 4: 279290. 50. Haight BK. The therapeutic role of a structured life review process in homebound elderly subjects. J Gerontol 1988; 43: 40-44. 51. Hawthorne MH, Hixon ME. Functional status, mood disturbance and

quality of life in patients with heart failure. Prog Cardiovascular Nurs 1994; 9: 22-32. 52. Heslop AP, Bagnall P. A study to evaluate the intervention of a nurse visiting patients with disabling cheest disease in the community. J Adv Nurs 1988; 13: 71-77. 53. Holloway F, Carson J. Intensive case management for the severely mentally ill. Br J Psychiatry, 1998; 172:19-22. 54. Kay M. DeZapien JG, Wilson CA, Yoder M. Evaluating treatment efficacy by triangulation. Soc Sci Med 1993; 36: 1545-1554. 55. Larsson G, Starrin B. Relaxation training as an integral part of caring activities for cancer patient’s effects on well-being. Scand J Caring Sci 1992; 6: 179-185. 56. LeFort SM, Gray-Donald K, Rowat KM, Jeans ME. Randomized, controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain 1998; 74:297-306. 57. Manzetti JD, Hoffman LA, Sereika SM, Sciurba FC, Griffith BP. Exercise, education and quality of life in lung transplant candidates. J Heart Lung Transplant 1994; 13: 297-305.

58. McCain NL, Zeller JM, Cella DF, Urbanski PA, Novak RM. The influence of stress management training in HIV disease. Nurs Res 1996; 45: 246-253. 59. McEwan RT, Davison N, Forster DP, Pearson P, Stirling E. Screening elderly people in primary care: a randomized controlled trial. Br J Gen Practice 1990; 40: 94-97. 60. McMillan SC, Mahon M. The impact of hospice services on the quality of life of primary caregivers. Oncology Nurs Forum 1994; 21: 11891195. 61. McMillan SC, Mahon M. A study of quality of life of hospice patients on admission and at week 3. Cancer Nurs 1994; 17: 52-60. 62. McMillan SC. The quality of life of patients with cancer receiving hospice care. Oncology Nurs Forum 1996; 23: 1221-1228.

63. Mirolo BR, Bunce IH, Chapman M, Olsen T, Eliadis P, Hennessy JM, Ward LC, Jones LC. Psychosocial benefits of post-mastectomy lymphedema therapy. Cancer Nurs 1995; 18: 197-205. 64. Moody LE, Fraser M, Yarandi H. Effects of guided imagery in patients with chronic bronchitis and emphysema. Clin Nurs Res 1993; 2: 478-486. 65. Nickel JT, Salsberry PJ, Caswell RJ, Keller MD, Long T, O’Connell M. Quality of life in nurse case management of persons with AIDS receiving home care. Res Nurs Health 1996; 19: 91-99. 66. Reele BL. Effect of counseling on quality of life for individuals with cancer and their families. Cancer Nurs 1994; 17: 101-112. 67. Richardson MA, Post-White P, Grimm EA, Moye LA, Singletary SE, Justice B. Coping, life attitudes, and immune responses to imagery and group support after breast cancer treatment. Alternative Ther Health Med 1997; 3(5): 62-70. 68. Ruffing-Rahal MA. Evaluation of group health promotion with community-dwelling older women. Public Health Nurs 1994; 11: 38-48. 69. Rustøen T, Wiklund I, Hanestad BR, Moum T. Nursing intervention to increase hope and quality of life in newly diagnosed cancer patients. Cancer Nurs 1998; 21:235-245. 70. Scherer YK, Janelli LM, Schmieder L. The effects of a pulmonary education program on quality of life in patients with chronic obstructive pulmonary disease. Rehab Nurs Res 1994; 3: 62-68. 71. Stevenson JS, Topp R. Effect of moderate and low intensity long-term exercise by older adults. Res Nurs Health 1990; 13: 209-218. 72. Undén AL, Schenck-Gustafsson PO, Axelsson I, Karlsson K, Orth-Gomér K, Ydrefors A-M. Positive effects of increased nurse support for male patients after acute myocardial infarction. Qual Life Res 1993; 2: 121-127. 73. Zauszniewski JA. Teaching resourcefulness skills to older adults. J Gero Nurs 1997; 23(2): 14-20. CAROL BURCKHARDT OG BERIT R. HANESTAD

9