Chapter I

Introduction
Background of the study:
Every year, 17.1 million lives are taken away due to
tobacco use, an unhealthy diet, and physical inactivity,
factors which all lead to cardiovascular diseases, the
worlds largest killer. Cardiovascular diseases affect all
ages and gender; however, it is more perceptible in low and
middle income countries, where more than 80% of
cardiovascular related deaths occur. According to the latest
WHO data published in April 2011 Stroke Deaths in
Philippines reached 40,245 or 9.55% of total deaths. The age
adjusted Death Rate is 82.77 per 100,000 of population ranks
Philippines #106 in the world.
The researcher chose Cerebrovascular disease or stroke
as a topic for a case study in acute adult diseases for the
reason that stroke is a national research priority and there
is still minimal systematic investigation of stroke nursing,
especially practice. The researcher believes that through
studying the whole course of illness, insights and new
information can be obtained in dealing with cerebrovascular
disease which could help students, nurses and any researcher
who would endeavour in the study of cerebrovascular disease.

The researcher aimed to utilize Neuman Systems Model in

a client with stroke. This theory is holistically developed
to meet or complement for the clients needs. The researcher
wants to verify and to validate the theory if there will be
an improvement in the Quality of Life of a patient diagnosed
with cerebrovascular disease. The unique focus of the Neuman
Systems Model is the wellness of the client/client system in
relation to environmental stress and reactions to stress.
The Neuman Systems model introduces the notion of
perceived barriers that a person maintains in order to cope
with a change in environment or to preserve a wellness
state. The nurses role within the Systems Model is to
recognize the patient as a unique individual with their own
goals, beliefs, values, and coping abilities. While
implementing primary, secondary, and tertiary interventions,
the nurse works within a holistic view of the client and in
tandem with their protective barriers to help promote a
return to health as defined by the patient. Because
interactions and reactions a client experiences with their
environment is constantly changing, the nurse is also
frequently evaluating and re-evaluating interventions to
meet the needs of the client.

Statement of the problem:

Is there a significant improvement in the quality of

life of an adult stroke patient when Betty Neumans Systems
model will be utilize in the nursing process?

Significance of the study:

The study will be beneficial to the following:
Clients. The result of this study will help them become
aware of the different factors that contributes to an
effective or ineffective coping after stroke.
Family caregivers. The result of this study will help
them understand more about the disease and the different
measures to be taken to in the management of family member
recovering from stroke; they can be the tool to promote a
continuing care during the recovery and rehabilitative phase
of patients treatment
Staff nurses and other health care providers. The
result of this study will enhance the nurses and other
health care providers knowledge about stroke and improve
their ability to identify stressors and diminished sources
of an adult stroke patient
Clinical instructors. This study will serve as a guide
in imparting additional information to their students with
regards to the possible disease complications and its
nursing intervention

Hospital administration. The result of this study will

provide them with information that may be useful in
evaluating their existing treatment plan for stroke patients
The researcher. The result of this study will help the
researcher understand why cardiovascular diseases are the
worlds largest killer and understand the factors the lead
to this. This data could be helpful in creating modification
on treatment programs and be help in improving present
health condition.
Future researchers. The result of this research paper
will be beneficial to them and will serve as a reference
material whenever they will conduct a study of the same
topic and so, the can further improve their study

Community. The study will be beneficial to the entire

community for them to truly understand the disease and for
them to know how to manage, prevent and control the disease
process.

Chapter II
Review of related literature

This study is anchored on Betty Neumans System Model.

According to Sohier (2002), the Neuman Systems Model is a
unique, systems-based perspective that provides a unifying
focus for approaching a wide range of nursing concerns. The
Neuman Systems Model is a comprehensive guide for nursing
practice, research, education, and administration that is
open to creative implementation and has the potential for
unifying various health-related theories, clarifying the
relationships of variables in nursing care and role
definitions at various levels of nursing practice. The
multidimensionality and wholistic systemic perspective of
the Neuman Systems Model is increasingly demonstrating its
relevance and reliability in a wide variety of clinical and
educational settings throughout the world.
The Neuman Systems Model applies a comprehensive and
holistic approach to the care of patients based on the five
variables. According to Parker and Smith (2010), the Neuman
System Model is described as, wellness orientation, client
perception and motivation, and a dynamic systems perspective
of energy and variable interaction with the environment to
mitigate possible harm from internal and external
stressors.
The goal of nurses in applying the Neuman System Model
is, to maximizing the quality of life lived, maintaining

the highest level of independence possible, and preventing

exacerbations of the on-going illness (Ebersole, Hess,
Touhy, Jett, and Luggen, 2008).
Neuman believes that caregivers and clients work in
partnership to achieve optimal health (Fitzpatrick & Whall,
2005). So, Neuman also believes that the client must be
involved in their care so that a state of health can be
reached.
The main use of the Neuman Model in practice and in
research is that its concentric layers allow for a simple
classification of how severe a problem is. For example,
since the line of normal defense represents dynamic balance,
it represents homeostasis, and thus a lack of stress. If a
stress response is perceived by the patient or assessed by
the nurse, then there has been an invasion of the normal
line of defense and a major contraction of the flexible line
of defense. Infection or other invasion of the lines of
resistance indicates failure of both lines of defense. Thus,
the level of insult can be quantified allowing for graduated
interventions. Furthermore each person variable can be
operationalized and the relationship to the normal line of
defense or stress response can be analyzed. The drawback of
this is that there is no way to know whether our
operationalization of the person variables is a good

representation of the underlying theoretical structures.

(Heyman and Wolfe, 200)
Each layer, or concentric circle, of the Neuman model
is made up of the five person variables. Ideally, each of
the person variables should be considered simultaneously and
comprehensively. Physiological - refers of the
physicochemical structure and function of the body.
Psychological - refers to mental processes and emotions.
Sociocultural - refers to relationships; and social/cultural
expectations and activities. Spiritual - refers to the
influence of spiritual beliefs. Developmental - refers to
those processes related to development over the lifespan.
(Heyman and Wolfe, 2000)
Kirkevold (1997) described the therapeutic role of the
stroke nurse by dividing it into 4 categories:
Interpretative (help patients understand stroke); consoling
(provide emotional support); conserving (preventing
complications, 5 maintaining normal functions and meeting
essential patient needs); and integrative (helping patients
meet rehabilitation goals).
According the World Health Organization (WHO), stroke
is defined as a syndrome of rapidly developing clinical
signs of focal (or global) disturbance of cerebral function,

with symptoms lasting 24 hours or longer or leading to

death, with no apparent cause other than vascular origin
(WHO 1989). These definitions include brain haemorrhage,
brain infarction and subarachnoidal haemorrhage but not
transitory ischemic attack (TIA).
A stroke is the rapidly developing loss of brain
functions due to a disturbance in the blood vessels
supplying blood to the brain. This can be due to ischemia
caused by thrombosis or embolism or due to a hemorrhage. As
a result, the affected area of the brain is unable to
function, leading to inability to move one or more limbs on
one side of the body, inability to understand or formulate
speech or inability to see one side of the visual field
(Donnan GA, Fisher M. May 2008).
Stroke can be prevented by screening for high blood
pressure at least every two years, regular cholesterol check
up, treat high blood pressure, diabetes, high cholesterol
and heart disease, follow a low-fat diet, quit smoking,
exercise regularly, lose weight if you are over weight,
avoid excessive alcohol use (Goldstein LB, Adams R, Alberts
MJ et al. 2006).
Review of Related Studies
A study investigated on Quality of life after stroke:
the importance of a good recovery Health Related Quality of

Life (HRQoL) measures and HRQoL determinants in stroke

survivors are reviewed. Result was Stroke is the leading
cause of long-term disability in western countries. Specific
HRQoL scales have been developed in the last years, such as
the Stroke Impact Scale, the Stroke Specific Quality of Life
Scale, the Stroke and Aphasia HRQoL Scale, and the Burden of
Stroke Scale. Disability and post stroke depression are
consistent determinants of HRQoL. Other determinants include
female sex, coping strategies, and social support. Post
stroke depression affects HRQoL, functional recovery,
cognitive function and healthcare use in stroke survivors
Advancing age and anxiety in patients and caregivers, high
dependency and poor family support identify caregivers at
risk of adverse outcomes.
Dowswell et al (2000), investigating recovery from
stroke, found that people measured recovery in terms of
their pre-stroke stroke lives and had to adjust to accepting
that they will never be the same. Almost all the
participants in their study related how the stroke had
drastically changed their lives, even those whose stroke had
been mild and who had regained full physical function.
McCrum reflects on the loss of a former self and the efforts
to stick the pieces back together: the cruel fact is that
this former self is irretrievably shattered into a thousand

pieces, and try as one may to glue those pieces back

together again, the reconstituted version will never be
better than a cracked, imperfect assembly, a constant
mockery of ones former, successful individuality.
Personal goals Reviewing the literature on peoples
experience of stroke, Hafsteinsdottir and Grypdonck (1997)
concluded that survivors set their own goals and measure
their recovery in terms of returning to activities which
they value. They stress the need for more descriptive
studies, particularly those which are conducted some months
after the event. Burton (2000) tracked six people over a
year who had experienced stroke and describes how reengagement in the social world is more important to people
who have survived stroke than physical function. He suggests
that: Stroke is an intensely personal experience, involving
the rebuilding and restructuring of an individuals world
The social context of recovery was enabling participation in
the social world through adaptation and the development of
coping skills, rather than improvement in discrete physical
function alone.
A study conducted on Health-related quality of life
among chronic stroke survivors attending a rehabilitation
clinic in Singapore. Cross-sectional survey study of
patients who had survived one year or more after a stroke.

Subjects consisted of stroke patients attending the

outpatient clinic of a rehabilitation centre. HRQOL was
assessed using the Medical Outcomes 36-Item Short- Form
Health Survey (SF-36), functional status using the Modied
Barthel Index (MBI), and mood using the Becks Depression
Inventory (BDI). This study highlighted the almost 30
percent of these survivors have depression that affects
their HRQOL adversely.

Theoritical framework

Figure 1: Betty Neumans Systems Model

The Neuman Systems Model of nursing provided the
framework for this study. The Neuman Systems Model views the
client/client system as dynamic, interrelated variables that
interact continuously with stressors from the environment.
The client/client system can be defined as a single client,
a group, a family, or a community. All client systems have
five variables which are interrelated: (a) physiological,
(b) psychological, (c) Sociocultural, (d) developmental, and
(e) spiritual. These variables refer to the (a) bodily
structure and function, (b) mental processes and

relationships, (c) social and cultural functions, (d) life

developmental processes, and (e) spiritual beliefs that
influence the client system. The five variables work
together simultaneously as the client responds to the
stressors of the internal and external environment.
The basic structure of the client/client system is
represented as a series of concentric rings or circles,
which surround the core. The rings are divided into three
different type lines: (a) the flexible line of defense,
which represents the outer concentric ring (broken line) and
which acts as a buffer system for the clients normal state;
(b) the normal line of defense, which is the solid line that
lies between the flexible line of defense and the internal
lines of resistance and which represents the clients usual
wellness level or steady state; (c) the lines of resistance,
which represent the inner concentric circles (broken rings)
and which contain internal and external resource factors
which help protect the client against a stressor.
In the Neuman Systems Model, the environment is a key
concept which affects the client system. The environment is
defined as all the internal and external forces affecting
the client positively or negatively. This environment is
divided into internal, external, and created environment.
The internal environment includes influences internal to the

boundaries of the client system. This is where intrapersonal

factors or stressors (something that occurs within the
person) arise. The external environment contains all
influences and forces that exist outside the client system.
This is where the interpersonal (something that occurs
between people) and extrapersonal (something that occurs
outside the person) factors or stressors arise.
The created environment acts as an open system that
exchanges energy with the internal and external environment.
This environment is unconsciously created to help maintain
the integrity of the system and is viewed as a symbol of
system wholeness. This environment acts as an insulator that
helps to change the response of the client to stressors.
Thus, the objective of the created environment is to
stimulate the health of the client.

Conceptual Framework

ADDULT
STROKE
PATIENT

INDEPENDENT VARIABLE

INDEPENDENT VARIABLE

DEPRESSION

HEALTH AND
FUNCTIONING

SOCIOECONOMIC
PERCIEVED
SOCIAL SUPPORT
FAMILY

PSYCHOLOGICAL
/ SPIRITUAL

FUNCTIONAL
STATUS

IMPROVED QUALITY OF
LIFE

Figure 2: Framework for Quality of life

The Neuman Systems Model was used to guide this study

and determine if there is a significant improvement in the
quality of life of an adult stroke patient. This conceptual
model was chosen to help guide this study because it
provided a holistic and system-based approach, which focused
on the response of the client/client system to actual and
potential environmental stressors.
The modifying factors that will be considered in this
study are the health and functioning domain, socioeconomic
domain, family domain and psychological/spiritual domain.
These factors are considered since they initially affect the
patients quality of life. The independent variable in this
study will be the depression, perceived social support and
functional status. The identification of depression, social
support, and functional status as predictors of quality of
life suggests the need to assist stroke survivors in coping
and in maintaining and strengthening their support systems.
Assumption
It is assumed that the nurse shall utilize Neumans
Systems Model in the care of a client after stroke.

Definition of terms

Client. Refers conceptually defined as the person who

engages in the advice of another person. (kozier et. Al.,
2004)
Defines operationally to mr. T. With stroke is
diagnosed by a physician.

Quality of life. Refers conceptually to the general

well-being of individuals and societies(kozier et. Al.,
2004)
Defined operationally to "a person's sense of wellbeing that stems from satisfaction or dissatisfaction with
the areas of life that is important to him/her".

Stressors. Refers conceptually to a chemical or biological

agent, environmental condition, external stimulus or an
event that causes stress to an organism. (kozier et. Al.,
2004)
Defined operationally to an environmental factors,
intra (emotion, feeling), inter (role expectation), and
extra personal (job or finance pressure) in nature, that
have potential for disrupting system stability.

Prevention. Refers conceptually to

measures taken to

prevent diseases, (or injuries) rather than curing them or

treating their symptoms.
Defined operationally as the primary nursing
intervention. Focuses on keeping stressors and the stress
response from having a detrimental effect on the body.
Primary Prevention. Occurs before the system reacts to a
stressor. Strengthens the person (primary the flexible LOD)
to enable him to better deal with stressors. Includes health
promotion and maintenance of wellness.
Secondary Prevention. Occurs after the system reacts to a
stressor and is provided in terms of existing system.
Focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or
removing the stressor.
Tertiary Prevention. Occurs after the system has been
treated through secondary prevention strategies. Offers
support to the client and attempts to add energy to the
system or reduce energy needed in order to facilitate
reconstitution.

Chapter III
Application of the nursing theory
DEMOGRAPHIC DATA
Patients Name: N. E. S.
Address: E.B. Magalona, Negros Occidental
Age: 43 years old
Birthdate: August 4, 1970
Birth Place: E.B. Magalona, Negros Occidental
Gender: Female
Marital Status: Married
Nationality: Filipino
Occupation: Housewife / Businesswoman
Religion: Roman Catholic
Educational Level: College Level
Health Care Financing: Self pay
Date and Time of Admission: July 20, 2014

1:20PM

Whom to notify in case of emergency:

Usual Source of Medical Care: Hospital
Attending Physician: Dr. K.
Primary Source of Information: A. B. S.
Secondary Source of Information: Patients Chart
Chief Complaint: Loss of Consciousness
Provisional Diagnosis: CVD Bleed Right Basal Ganglia with
Intraventricular Extension

Admission data:

temperature

:37

degrees celsius

respiratory rate

:22 cpm

pulse rate

:82 bpm

blood pressure

:170/90 mm hg

cholesterol

:250mg/dl

hdl

cholesterol

:35mg/dl

ldl

cholesterol

:180mg/dl

weight

:78 kgs

height

:54

HISTORY OF PRESENT ILLNESS

Prior to hospitalization, patient had recurring
episodes of headache for almost a year. She did not seek any
medical attention because she thought that it is not a
serious illness. She took OTC drugs as a remedy to her
illness.
Three days prior to admission, patient was actively
involved as one of the main organizers in planning for their
Alumni Homecoming. A day prior to admission, while the
patient was facilitating the activities, she complained of a
sudden onset of headache and body weakness. She took
ibuprofen (Advil) to relieve the pain. After awhile, she
became unconscious and was brought to the Emergency
Department at Silay District Hospital managed for

Hemorrhagic Stroke, she was then given with Mannitol IV.

After initial interventions were made, patient was
transferred to DPOTMH.
On the day of admission at DPOTMH- Emergency
Department, the patient was on Glasgow Coma Scale of 6
(E2V1M3). Intubation was done. Stat CT Scan result revealed
Hemorrhagic Stroke at right basal ganglia with
intraventricular extension. Stat craniotomy evacuation of
hematoma was done, and then admitted to ICU for close
monitoring.

PAST HEALTH HISTORY

The patient has not been hospitalized nor undergone
surgery prior to admission. She had fever, cough and colds
and took over-the-counter drugs to manage her illnesses.
According to her husband, she didnt experience any serious
accident, and he could not recall if his wife had her
complete immunization. In 2013, she was diagnosed to be
hypertensive and was given amlodipine (Norvasc) 10mg as
maintenance but non-compliant.

FAMILY HEALTH HISTORY

DISEASES
Hypertension
Asthma
Cancer

FATHER
( + )
( - )
( - )

MOTHER
( + )
( - )
( - )

Diabetes

( - )

( + )

NUTRITION
The patient has a good appetite. She usually eats 3
meals and 2-3 snacks in a day. She drinks 7 to 9 glasses of
water a day. She prefers meat (pork) over fish as viand, and
wants her dish prepared either fried or grilled. She is fond
of eating crustaceans, it is their family business. Most of
her meal includes dried fish (uga) because it gives her a
good appetite. She also likes to eat fruits and vegetables.

ACTIVITY AND EXERCISE

Prior to admission, patient is able to ambulate freely
and do activities of daily living and self care activities
independently. She does not exercise regularly. The patient
spends most of her time doing household chores before going
out with her husband to manage their family business. She
used to watch TV series with her family at night, while
doing paper works of their business.
LIFESTYLE
The patient lives with her husband and three children.
They have a close and harmonious relationship with
occasional misunderstandings like normal families. One of
her routine responsibilities at home is preparing food for
her children before sending them to school, do some

household chores together with their helper, making sure

that she can still fulfill the needs of her loved ones.
Aside from being a fulltime mother, she also manages their
fisheries together with her husband and shes the only one
responsible in carrying out the payroll of their employees.
On very rare occasions, she drinks alcoholic beverages
with her closest friends. She doesnt smoke. Being the wife
of the Barangay Captain, she also attends to the needs of
the people who seek advice or ask for help.

REST AND SLEEPING PATTERN

The patient has regular sleeping pattern of 7-8 hours a day.
The patient sleeps at around 10 pm and wakes up at 6 in the
morning, drinks coffee with her husband and eats their
breakfast around 7:30 am together with their children. She
sometimes takes a nap in the morning and in the afternoon.

SPIRITUAL
Their family is Roman Catholic. She doesnt participate in
any church activities but they go to church every Sunday
with her family.

ENVIRONMENT
Their family lives in the coastal community of EB Magalona.
Their neighborhood is densely populated and houses are close
to one another.

PATTERNS OF HEALTH CARE

With regards to her medical care, she is not used to
seek medical attention, because she thinks that it is quite
expensive and adds more expense to their budget.
Methodology
Assessment tool
The assessment tool was adapted from Ferrans and
Powers Quality of Life Index-stroke version and based on
Betty Neumans Systems Model.
Quality Of Life was defined as satisfaction with
aspects of life that is important to the individual.
Therefore, QOL was measured by use of the Ferrans & Powers
Quality of Life Index-Stroke Version (QLI),which is a twopart scale that rates 38 items for satisfaction (part 1) and
importance (part 2). Likert-scaled responses range from 1
(very dissatisfied/very unimportant) to 6 (very
satisfied/very important). Scores are calculated for quality
of life overall and in four domains: health and functioning,
psychological/ spiritual, social and economic, and family).
The QLI possesses strong internal consistency (=.90 to .93)
and concurrent validity. The possible range of scores for
subscales and overall QLI is 0 to 30; lower scores indicate
lower QOL.

A number of versions of the QLI have been developed for

the used with various disorders and the general population.
For the purpose of this study the Stroke Version of the
Quality of Life Index was used. The QLI is a well
established instrument with substantial evidence of
reliablility, validity, and sensitivity (Biley & Ferrans,
1993).

Table 1
The Assessment tool

Very satisfied

Moderately satisfied

Slightly satisfied

Slightly dissatisfied

Moderately dissatisfied

Very dissatisfied
How satisfied are you with:
1. Your health?
2. Your health care
3. the amount of pain that you have
4. The amount of energy that you have
for everyday activities
5. Your ability to do things for
yourself?
6. Your ability to get around (for
example, to walk or use a
wheelchair)?
7. Your ability to go places outside
your home?
8. Your ability to speak?
9. The amount of control you have over
your life?
10. Your chances of living as long as
you would like?
11. Your familys health?
12. Your children?
13. Your familys happiness
14. Your spouse, lover, or partner?
15. Your sex life?
16. Your friends?
17. The emotional support you get from
your family?
18. The emotional support you get from
people other than your family?
19. Your ability to take care of
family responsibilities?
20. How useful you are to others?
21. The amount of worries in your

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

4
4
4
4
4
4
4

5
5
5
5
5
5
5

6
6
6
6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

6
6

1
1

2
2

3
3

4
4

5
5

6
6

1
1

2
2

3
3

4
4

5
5

6
6

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

5
5
5
5
5

6
6
6
6
6

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6
Very important

5
5

Moderately important

4
4

Slightly important

3
3

Slightly unimportant

2
2

Moderately unimportant

How important to you is:

1. Your health?
2. Your health care
3. Having no pain?
4. Having enough energy for everyday
activities?
5. To be able to do things for
yourself?
6. To be able to get around (for
example, to walk or use a
wheelchair)?

1
1

Very unimportant

life?
22. Your neighborhood?
23. Your home, apartment, or place
where you live?
24. Your job (if employed)?
25. Not having a job (if unemployed,
retired, or disabled)?
26. Your education?
27. How well can you take care of your
financial needs?
28. The things you do for fun?
29. Your chances for a happy future?
30. Your peace of mind?
31. Your faith in God?
32. Your achievement of personal
goals?
33. Your happiness in general?
34. Your life in general?
35. Your personal appearance?
36. Yourself in general?

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

7. To go places outside your home?

8. To be able to speak?
9. Having control over your life?
10. Living as long as you would like?
11. Your familys health?
12. Your children?
13. Your familys happiness?
14. Your spouse, lover, or partner?
15. Your sex life?
16. Your friends?
17. The emotional support you get from
your family?
18. The emotional support you get from
people other than your family?
19. Taking care of family
responsibilities?
20. Being useful to others?
21. Having no worries?
22. Your neighborhood?
23. Your home, apartment, or place
where you live?
24. Your job (if employed)?
25. Having a job (if unemployed,
retired, or disabled)?
26. Your education?
27. Being able to take care of your
financial needs?
28. Doing things for fun?
29. Having a happy future?
30. Peace of mind?
31. Your faith in God?
32. Achieving your personal goals
33. Your happiness in general?
34. Being satisfied with life?
35. Your personal appearance?
36. Are you to yourself?

1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

1
1

2
2

3
3

4
4

5
5

6
6

1
1

2
2

3
3

4
4

5
5

6
6

1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6

Validity and Reliability

There was no validity and reliability test
conducted in the questionnaire since this
questionnaire was adapted from Ferrans and Powers

and was subjected already to validity and

reliability test

Computation of clients score

Overall and subscale QLI scores were computed by

use of the established procedure. Each satisfaction
response was weighted with its corresponding
importance rating. Weighting was done by subtracting
3.5 from each satisfaction response to center the
satisfaction scale on 0. This procedure made 0 the
midpoint. Each recoded satisfaction item score was
multiplied by its paired importance score (possible
range=15.0 to 15.0). To calculate overall scores,
weighted items were summed and divided by the number
of items answered. To eliminate negative values, a
constant of 15 was added to calculate the final
score. The possible range of overall QLI scores was
0 to 30. Subscale scores were computed by
application of the same scoring procedure to items
in each subscale.
To determine the scores, each satisfaction item is
weighted by its corresponding importance item. Hence, the
values are combined, i.e., highest scores represent high
satisfaction and high importance, and the lowest scores
represent low satisfaction and high importance. This scoring

scheme is based on the belief that people highly satisfied

with areas of life they consider important have a better
quality of life than those who are unsatisfied with areas
they consider important(1,5).
The scoring procedure requires certain steps. First,
the satisfaction scores must be recoded with the purpose of
centering the scale on zero. This is done by subtracting 3.5
from satisfaction responses, which results in the following
scores: -2.5, -1.5, -0.5, +0.5, +1.5, and +2.5 for scores
that originally were 1, 2, 3, 4, 5, and 6, respectively.
Second, the recoded satisfaction scores are weighted by
their corresponding importance items, multiplying each
item's recoded value by the raw importance score (1, 2, 3,
4, 5, 6). Next, the total score is calculated by adding the
weighted values of every response and then dividing by the
total number of answered items. Up to this stage, the
possible variation is from -15 to +15. To avoid that final
score have a negative number, we add 15 to the obtained
values, resulting in the total score of the instrument,
which can vary from 0 to 30. Highest values represent better
quality of life(5-6).
The steps to obtain the scores of each domain are
exactly the same as the described above, considering the

total items of the domain being evaluated. The total score

of each domain also varies from 0 to 30.
In summary, QLI scores (total and by domain) are
determined using the equation below and the previously
mentioned instructions:
QLI = [(SAT rec x IMP) for each item number of answered
items] + 15,
where: SAT rec = recoded value for each satisfaction item (2,5 to +2,5)
IMP = raw value for each importance item (1 to 6).