ARTICLE IN PRESS

International Journal of Nursing Studies 43 (2006) 891–901

www.elsevier.com/locate/ijnurstu

Critique on the conceptualisation of quality of life: A review

and evaluation of different conceptual approaches
Philip Moonsa,b,, Werner Budtsb, Sabina De Geesta,c
a
Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
b
Division of Congenital Cardiology, University Hospitals of Leuven, Herestraat 49, B-3000 Leuven, Belgium
c
Institute of Nursing Science, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
Received 13 October 2005; received in revised form 18 March 2006; accepted 25 March 2006

Abstract

Over the past decades, the concept of quality of life has been of paramount importance for evaluating the quality and
outcome of health care. Despite its importance, there is still no consensus on the definition or proper measurement of
quality of life. Several concept analyses of quality of life have been published. However, they appear to have had a
rather limited impact on how empirical studies are conducted. Therefore, we present an overview and critique of
different conceptualisations of quality of life, with the ultimate goal of making quality of life a less ambiguous concept.
We also describe six conceptual problems. These problems were used as criteria to evaluate the appropriateness of
different conceptualisations. This evaluation suggests that defining quality of life in terms of life satisfaction is most
appropriate, because this definition successfully deals with all the conceptual problems discussed. The result of our
concept evaluation was not surprising for it corroborated the results of several concept analyses and the findings of a
structural equation modelling study. Based on the findings revealed by our review, we propose that the scientific
community should revitalise the conceptual discussion on quality of life. Furthermore, our findings can assist
researchers in developing more rigourous quality-of-life research.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Concept formation; Life satisfaction; Nurse; Nursing; Quality of life; Review

What is already known about the topic?
 The concept of quality of life has been increasingly
used in biomedical and nursing research during the
past decades
 There is no consensus on the definition and
measurement of quality of life
What this paper adds
 Six conceptual problems are described and discussed
 The different conceptualisations are evaluated in the
context of the six conceptual problems
 Quality of life is most appropriately defined in terms
of life satisfaction

Corresponding author. Center for Health Services and

Nursing Research, Katholieke Universiteit Leuven, Kapucij-
nenvoer 35/4, B-3000 Leuven, Belgium. Tel.: +32 16 336984;
fax: +32 16 336970.
E-mail address: Philip.Moons@med.kuleuven.be
(P. Moons).
1. Introduction
Since the early 1970s, interest in the concept of quality
of life has increased significantly, both in research and
clinical practice. Quality of life has emerged as an

0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.03.015
 ARTICLE IN PRESS
892 P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901

important parameter for evaluating the quality and
outcome of health care. This is especially the case for
patients with chronic disorders for whom quality of life
has become a critical outcome measure, since complete
cure of disease is often unlikely.
The increasing attention focused on quality of life is
reflected in an accumulating number of relevant pub-
lications in the biomedical, psychological, and social
sciences literature. A Pubmed search of articles pub-
lished from 1966 to 2005 identified 76,698 articles
containing ‘‘quality of life’’ as a Medical Subject
Heading or as a title or abstract term. Since the mid-
1960s, the number of publications on this subject has
grown exponentially (Fig. 1: grey bars). In addition to
the growth in absolute numbers, the proportion of
quality-of-life studies versus all publications cited in
Pubmed has also grown over the past decades. In 1966,
0.002% of all publications were on quality of life,
whereas this proportion has raised to 1.36% in 2005
(Fig. 1: black line).
There are two possible explanations for the increasing
interest in quality of life in health care. One explanation
is an increased life expectancy resulting from improved
medical therapies. As a result, many more individuals
are diagnosed with chronic, clinically manageable ill-
nesses, rather than with terminal illnesses. Some argue
that, in addition to mortality and morbidity, quality of
life must also be used to assess health care outcomes
(Macduff, 2000). A second explanation is the prolifera-
tion and advancement of medical and surgical technol-
ogies. With the increase in available treatments,
thorough consideration of the benefit-burden ratio of
equivalent therapies is now needed. Quality of life issues
are now included when health care professionals assess
the benefits of different treatment options. Hence,
research on quality of life affects how policymakers
allocate health care resources or determine reimburse-
ment policies (De Geest and Moons, 2000).
Despite the increasing interest in quality of life,
consensus is lacking on the definition of quality of life.
Also no consensus has emerged about whether quality of
life can or should be measured (Wolfensberger, 1994).
Quality of life is often used as a generic label to describe
an assortment of physical and psychosocial variables.
Therefore, quality of life often seems to be an umbrella
term (Feinstein, 1987), covering a variety of concepts,
such as functioning, health status, perceptions, life
conditions, behaviour, happiness, lifestyle, symptoms,
etc. (Simko, 1999). The absence of a uniform definition
makes quality of life to be an ambiguous concept.

10000 1.4
QOL articles Percentage of QOL articles vs all publications
9000
1.2

8000

Percentage of QOL articles vs all publications

1
7000
Number of publication

6000
0.8

5000

0.6
4000

3000 0.4

2000
0.2
1000

0 0
19 6
19 7
19 8
69
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
78
19 9
19 0
19 1
19 2
19 3
19 4
19 5
86
19 7
19 8
19 9
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
19 8
99
20 0
20 1
20 2
20 3
20 4
05
6
6
6

7
7
7
7
7
7
7
7

7
8
8
8
8
8
8

8
8
8
9
9
9
9
9
9
9
9
9

0
0
0
0
0
19

19

19

19

20

Fig. 1. Number of publications in the Pubmed database (1966–2005) referring to quality of life and the percentage of quality-of-life
articles versus all Pubmed publications (search performed March 17, 2006).
 ARTICLE IN PRESS
P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
In the 1990s, several concept evaluations of quality of
life were published (Felce, 1997; Ferrans, 1996, 1990;
Haas, 1999; Kleinpell, 1991; Meeberg, 1993; Stewart,
1992; Zhan, 1992). All of them, except for one (Felce,
1997) were published in nursing journals. The majority
of the concept evaluations were generic in that the
authors did not define quality of life for a specific group
of patients (Ferrans, 1996, 1990; Haas, 1999; Meeberg,
1993; Zhan, 1992). One author conducted a concept
evaluation of quality of life for use with intensive care
patients (Kleinpell, 1991), while another author ad-
vanced the idea that the concept evaluation should be
used for patients with intellectual disabilities (Felce,
1997). Although these concept analyses provide critical
information for quality-of-life researchers, they appar-
ently had a rather limited impact on how empirical
studies are conducted. Several concept analyses suggest
that quality of life ought to be defined in terms of life
satisfaction (Ferrans, 1996, 1990; Zhan, 1992). However,
most empirical studies assessed the concept in terms of
normal life or in terms of a utility measure (Haas, 1999).
In an effort to enhance the conceptual understanding
of quality of life, which will subsequently assist
researchers in developing more rigourous research
studies, we used an alternative approach to the
traditional concept analyses. In this review, we first
present an overview of the different conceptualisations
of quality of life. Next, we discuss problems associated
with these conceptualisations, and finally we use these
problems to evaluate the appropriateness of the
respective conceptualisations.
2. Conceptualisations of quality of life in biomedical and
nursing literature
A wide spectrum of quality of life definitions exists in
the literature. In the early 1990s, Ferrans developed a
useful taxonomy of quality of life conceptualisations
(Ferrans, 1996, 1990, 1992), grouping them into six
broad categories: (1) normal life, (2) social utility, (3)
happiness/affect, (4) satisfaction with life, (5) achieve-
ment of personal goals, and (6) natural capacities. In
addition to these six conceptual approaches, we also
recognised utility and satisfaction with specific domains
as possible conceptualisations. Although some of the
conceptualisations are more recently recognised as not
representing quality of life, some investigators still use
them in their quality-of-life research. Therefore, it is
useful to discuss each of these conceptualisations.
2.1. Normal life
Normal life is defined as the ability to supply basic
needs and to maintain health and well-being (Leidy,
1994), or alternatively, as the absence of limitations in
893
functional abilities, mental status, and prolonged life
(Clark and Bowling, 1989). In this respect, quality of life
is considered to be a broad concept that primarily
focuses on whether disease or impairment limits a
person’s ability to fulfil a normal role (Carr et al.,
2001). The conceptualisation of quality of life in terms of
a normal life compares the functioning of the respon-
dent with that of healthy persons or modal individuals
of the same age group (Ferrans, 1987). Perfect health is
commonly used as the standard for normalcy (Ferrans,
1990). According to this conceptualisation of quality of
life, the closer an individual’s life mirrors the standard
for normalcy, the better the quality of life (Ferrans,
1992). Hence, this approach predominantly focuses on
the functional abilities and health status of the patient.
2.2. Social utility
Social utility defines quality of life according to one’s
ability to lead a socially ‘‘useful’’ life (Edlund and
Tancredi, 1985). This definition considers a patient’s
ability to make meaningful contributions to society
through gainful employment or by fulfilling socially
valued roles, such as that of a teacher, volunteer, parent,
etc. (Ferrans, 1992). In this respect, employment status
or productivity impairment is often used as indicators of
quality of life. Quality of life, therefore, when defined in
terms of social utility, is strongly related to the physical
limitations or disease symptoms of the patient. It should
be noted that perceptions and prejudices of others can
also have a significant impact on whether a disabled
person can find employment or fulfil a socially valued
role.
2.3. Utility
Another perspective related to this particular con-
ceptualisation of quality of life is the notion of utility.
Utility refers to preference-based health state valuations,
which are frequently used in cost evaluations in health
care. Utility measures provide a quantitative estimate of
preferences for particular health states, primarily ob-
tained from a representative sample of the general
population. For each health state a corresponding index
value ranging from 0 to 1 is computed. An index of 0
corresponds to death while that of 1 corresponds to
perfect health (Dolan et al., 1996).
2.4. Happiness/affect
This conceptualisation of quality of life focuses on the
emotional status of the patient or respondent and
reflects his/her feelings at that moment. Happiness/
affect concerns the balance between positive feelings
(elation) and negative feelings (depression) (Ferrans,
1992). It is a temporary and sometimes short-term
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894 P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
affective state that is influenced by many external and
internal factors. Therefore, happiness/affect can fluctuate
significantly over time and may change from day-to-day.
With this conceptualisation, depressive symptoms and
mood states are often measured as indicators of quality
of life.
2.5. Satisfaction with life
Satisfaction with life is the degree to which a person
positively evaluates the overall quality of his/her life
(Veenhoven, 1996). Therefore, it refers to the level of
enjoyment and contentment with the life led so far
(Veenhoven, 1996). Satisfaction with life depends largely
on a patient’s ability to have a life that fulfils his/her
personal needs (Karan et al., 1990). Its appraisal is
preceded by a cognitive evaluation of one’s personal life
conditions. Thus, in this respect, satisfaction with life
differs from happiness/affect, which is more emotion
driven.
2.6. Satisfaction with specific domains
Another related conceptualisation is satisfaction with
specific domains, which refers to the satisfaction one
experiences in various domains of life, such as love,
marriage, friendship, leisure, job, etc. (Diener et al.,
1997; Ferrans, 1992) The level of satisfaction with
specific domains can range from deprivation to fulfil-
ment (Ferrans, 1992).
2.7. Achievement of personal goals
With this conceptualisation, quality of life is expressed
in terms of the discrepancy between an individual’s
actual status and what he/she desires or expects
(Sartorius, 1989). This difference between expectations
and actual experiences is referred to as Calman’s gap
(Calman, 1984). The concept of achievement of personal
goals assumes that quality of life is enhanced if an
individual can accomplish his/her goals. Personal fulfil-
ment, self-actualization, and satisfaction when compar-
ing oneself with others are critical elements that define
this conceptualisation of quality of life.
2.8. Natural capacity
Quality of life viewed in terms of natural capacity
encompasses the presence of normally inborn physical
and mental capabilities, both actual and potential.
Natural capacity deals with very fundamental needs:
for instance, relief of severe pain or being able to interact
with the environment. Definitions of quality of life in
terms of natural capacity are primarily developed for
ethical debates and for cases in which the condition of a
patient or an unborn child is such that health care
professionals are asked to end life (Farsides and
Dunlop, 2001). Quality of life, from this perspective, is
used to provide an answer to the question: Is this a life
worth living? Assessment of quality of life in terms of
natural capacity is often made by proxies—both health
care professionals and lay caregivers—who must em-
pathise closely with the patient, putting themselves in the
patient’s shoes in order to be able to make sound
decisions about how the patient’s health and health care
affects the patient’s quality of life (Addington-Hall and
Kalra, 2001).
3. Critique of the different conceptual approaches to
quality of life
The diversity of approaches to defining quality of life
compelled us to make a critical appraisal of the value of
the various quality of life conceptualisations by analys-
ing the limitations of each approach. Many articles and
book chapters about the concept of quality of life have
been published. However, to date, these publications
have primarily focused on measurement issues and
psychometric properties, leaving conceptual issues un-
addressed. Some articles anecdotally report conceptual
shortcomings. In her paper ‘‘Quality of life research:
Rigor or rigor mortis’’, Kinney (1995) introduced
several conceptual problems. Through a review of the
biomedical, psychological, and social sciences literature,
we elaborated on the Kinney critiques and describe six
conceptual problems inherent to the notion of quality of
life.
3.1. Quality of life vs. health status and functioning
The terms quality of life, health status, and functional
status are often used interchangeably (Bradley, 2001;
Gill and Feinstein, 1994; McDowell and Newell, 1996;
Muldoon et al., 1998; Nanda and Andresen, 1998),
usually by those who assume that a fully healthy life is
identical to a high quality of life (Testa and Simonson,
1996). This assumption can be challenged, because
patients with significant health and functional problems
do not necessarily have commensurable quality of life
scores (Carr and Higginson, 2001). Indeed, empirical
studies (Garratt and Ruta, 1999; Moons et al., 2005) and
a meta-analysis (Smith et al., 1999) substantiate that
quality of life and health status are two distinct
concepts, and should therefore not be used interchange-
ably. For instance, an ardent fisherman who is a
paraplegic—obviously, a bad health state in terms of
mobility—can still have a good quality of life if he is able
to go fishing, even though he is confined to his
wheelchair when doing so. The phenomenon of a high
quality of life against all odds is referred to as the
‘‘disability paradox’’ (Albrecht and Devlieger, 1999).
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P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
The interchangeable use of quality of life, health
status, and functional status is reflected in the measure-
ment of these concepts. For instance, several health
status instruments have been developed such as the
Medical Outcome Study—Short Form-36 (SF-36)
(Ware and Sherbourne, 1992), the Sickness Impact
Profile (SIP) (Bergner et al., 1976), and the Nottingham
Health Profile (NHP) (Hunt et al., 1981). While these
instruments were primarily developed to measure health,
many researchers erroneously use them to measure
quality of life or—what they call—‘health-related
quality of life’ (Andresen and Meyers, 2000; Wiklund,
1990). It is reasonable, therefore, to question why these
researchers often refer to these instruments as health-
related quality of life instruments when they were really
measuring perceived health (Moons, 2004). The term
‘health-related quality of life’ is discussed in detail under
heading 3.6.
3.2. Objective vs. subjective dimensions
There is much debate about whether quality of life
constitutes objective dimensions, subjective dimensions,
or both (Felce, 1997; Muldoon et al., 1998; Testa and
Simonson, 1996). Objective dimensions refer to obser-
vable life conditions or physical functioning that can be
operationalised by exercise tests. Subjective dimensions
refer to the respondent’s perceptions.
A conceptualisation of quality of life comprising both
objective (life conditions) and subjective dimensions
dominates research on quality of life (Felce, 1997; Haas,
1999; Testa and Simonson, 1996). However, there is a
growing consensus that quality of life is a purely
subjective experience (Cella, 1998; Haas, 1999), because
it is unlikely that quality of life is strongly determined by
one’s objective life condition, but rather, quality of life is
determined by one’s subjective appraisal of one’s life
condition. This conclusion is supported by findings from
the literature on the disability paradox (Albrecht and
Devlieger, 1999), which advances the idea that physi-
cally disabled persons unexpectedly experience a good
quality of life, even though most external observers may
assume that these people live an undesirable life
(Albrecht and Devlieger, 1999). The disability paradox,
therefore, addresses the disparity between objective
conditions and subjective experiences. Recall the para-
plegic fisherman. Objectively, his situation might appear
adverse; his appraisal, however, may be more positive
since he is still able to engage in his hobby. Furthermore,
objectively measured indicators of living conditions were
found to account for only about 15% of an individual’s
quality of life (Day and Jankey, 1996). Therefore, it can
be concluded that quality of life has more to do with
subjective well-being (de Weerdt et al., 1991) and life
satisfaction (Meeberg, 1993; Simko, 1999).
895
Consequently, individuals are the only ones who can
reliably estimate their own quality of life (Ferrans,
1996). This is especially apparent when comparing
quality of life scores obtained from proxies to those of
patients: The scores of proxies usually do not corre-
spond with those of patients. Additionally, quality of life
scores vary depending on the proxy. Nurses and lay
caregivers generally overestimate the psychosocial im-
pact of a condition, while doctors consistently underrate
the severity of symptoms (Addington-Hall and Kalra,
2001).
3.3. Distinction between indicators and determinants
There is a poor distinction between indicators and
determinants of quality of life (Stewart, 1992). Indica-
tors are events or conditions that typically characterise a
specific situation; they are ‘‘barometers’’. Determinants,
on the other hand, are defined as elements that
determine the nature of something (Merriam-Webster
online: http://www.m-w.com/dictionary/), and can
therefore be considered as external factors that affect a
phenomenon. For instance, an indicator for prostate
cancer is a significant rise in the production of serum
prostate-specific antigen, whereas determinants of
prostate cancer are age, race, diet, family history, etc.
From this example, it is obvious that the screening
and diagnosis of prostate cancer requires the assess-
ment of the indicators rather than assessment of the
determinants.
The distinction between indicators and determinants
is also crucial for conceptualising quality of life. In the
conceptualisation, one needs to distinguish between one
or more indicators of quality of life (e.g., What is quality
of life? What refers to quality of life?) and one or more
determinants of quality of life (e.g., What contributes to
quality of life? What influences quality of life?) (Smith
et al., 1999).
3.4. Changes over time
Quality of life cannot be considered to be a static trait
(Carr et al., 2001; Wolfensberger, 1994). Individuals
may appraise their quality of life differently over time
(Carr et al., 2001) due to ever-changing life events,
illness progress, coping abilities, or cultural changes. In
this context, the ‘‘Response Shift Model’’ was formu-
lated in an attempt to explain how quality of life changes
as a function of health state alterations (Sprangers and
Schwartz, 1999). A patient’s quality of life evolves,
because the relative weight of issues that are important
to an individual’s quality of life (O’Boyle et al., 1992) or
expectations with respect to his/her life may change over
time (Carr et al., 2001). For an adolescent, for instance,
factors that importantly dictate his/her quality of life
will change as he/she grows older, because values and
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896 P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
priorities continually change in response to life stages
and circumstances (Carr and Higginson, 2001).
Moreover, research of diverse patient populations
indicate that quality of life is independently determined
by the level of an individual’s depressive symptoms
(Mancuso et al., 2000; Moons et al., 2003; Ruo et al.,
2003). Since depressive symptoms reflect a temporary
affective state, quality of life will change accordingly.
Although we recognise that quality of life can change
over time, it is unlikely that it is highly dynamic, rather
quality of life probably fluctuates little from one day to
another.
3.5. Negative vs. positive components
According to Hyland (1999), quality of life is
primarily measured in terms of limitations and impedi-
ments, without considering positive elements that
contribute to quality of life. However, there are
numerous things that can contribute positively to a
person’s quality of life, as they add to life’s richness.
Even illnesses may be positively perceived. For example,
studies of cancer patients demonstrate that they have an
increased ability to appreciate each day, due to
enhanced personal strength, self assurance, and compas-
sion; the result is a higher overall quality of life
experienced by cancer patients compared to that of the
healthy population (Danoff et al., 1983; Fromm et al.,
1996; Taylor et al., 1984; Tempelaar et al., 1989). One’s
positive personality or disposition toward life can also
contribute positively to one’s quality of life. Therefore,
the conceptualisation of quality of life should explicitly
include both positive and negative factors.
3.6. Health-related quality of life
Health is consistently included as an important aspect
of quality of life. Consequently, health-related quality of
life has been developed to describe aspects of an
individual’s subjective experience that relate both
directly and indirectly to health, disease, disability, and
impairment (Carr et al., 2001) and to the effectiveness of
treatment. Health-related quality of life is often oper-
ationalised by assessing physical, mental/cognitive, and
social functioning domains and by relying on the WHO
definition of health: ‘‘a state of complete physical, mental
and social well-being and not merely absence of disease or
infirmity’’ (World Health Organisation, 1947).
This is in contrast to the assessment of quality of life
in healthy people, in whom overall quality of life is
measured. Note, however, that even in ill people the
distinction between overall quality of life and health-
related quality of life is artificial, since patients must
distinguish between the part of their life influenced by
health and other parts of their life not appreciably
influenced by health (Anderson and Burckhardt, 1999;
Macduff, 2000). Focusing on health-related quality of
life, investigators may substantially overestimate the
impact of health-related factors and conversely, may
seriously undervalue the effect of nonmedical phenom-
ena (Gill and Feinstein, 1994). For instance, research of
patients with obviously severe conditions, such as
Hodgkin’s disease patients and other patients requiring
peripheral blood stem cell transplants, shows that only
two-third of these patients indicated health as important
for their quality of life (Frick et al., 2004; Wettergren et
al., 2003). Moreover, people whose health has changed
may report the same level of quality of life over time
(Carr et al., 2001).
Hence, the concept of health-related quality of life is
subject for debate. Very often, health-related quality of
life is used by researchers and clinicians who are actually
referring to the perceived health of the patients (Moons,
2004).
4. Evaluation of different conceptualisations
To assess the appropriateness of conceptualisations or
definitions of quality of life, researchers should evaluate
these definitions on the basis of the conceptual problems
described here. Table 1 illustrates whether the respective
conceptualisations address the identified problems.
4.1. Normal life
Defining quality of life in terms of normal life is a very
functional approach and refers predominantly to the
patient’s health status. Frequently, objective parameters
of disease and health are used as indicators of quality of
life. Normal life emphasises functional problems but
fails to address positive elements contributing to quality
of life. This type of conceptualisation is very often
referred to as health-related quality of life. The one
problem avoided by the normal life conceptual approach
is that it recognises that the patient’s functional abilities/
health status may change over time, but does not
fluctuate greatly.
4.2. Social utility
Since productivity and employment are critical
elements in social utility, it is strongly linked with
performance and functional abilities. This relies pre-
dominantly on objectively observable roles. In this
respect, employment status, for instance, is presumed
to be an indicator of quality of life (Hoang et al., 2004;
Moons et al., 2004), even though employment status is
more likely to be a determinant of quality of life (Moons
et al., 2006). Focusing on socially valued roles is a
positive approach to defining quality of life. As with
normal life, social utility consider that quality of life can
Table 1
Evaluation of the different conceptualisations according to conceptual problems

Conceptualisations

Normal life Social Utility Happiness Affect Satisfaction Satisfaction Achievement Natural
utility with life with specific of personal capacity
domains goals

Conceptual problems Quality of life differs from health + + + + +

status and functionality status
Subjective appraisal of quality of + + + + + +
life, instead of objective
parameters
Distinction between indicators and +
determinants of quality of life
Changes over time, but not highly + + + + + + +
fluctuating
Quality of life can be positively or + + + + + +
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negatively influenced
Overall quality of life in favour of + + + + +
health-related quality of life

+: Conceptualisation address the problem.

: Conceptualisation does not address the problem
P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
897
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898 P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
have a dynamic aspect. Social utility mostly refers to the
effect of health on the social roles. Therefore, it is often
used in health-related quality-of-life studies.
4.3. Utility
Utility measures refer to preference-based valuation
of health states, and do therefore overlook overall
quality of life. This approach permits a subjective
appraisal. No distinction between indicators and deter-
minants is made. Since health state measures more aptly
highlight the negative aspects of disease, focusing on
health state valuations is more of a negative approach.
Also the utility conceptualisation considers that quality
of life can have a dynamic aspect.
4.4. Happiness/affect
The happiness/affect conceptualisation of quality of
life does not focus on health or functional status, but
focuses on emotions and feelings. Thus, by definition,
this conceptualisation is subjective. However, happiness/
affect can fluctuate significantly over time and may
change from day to day. Moreover, it is often regarded
as an indicator rather than a determinant of quality of
life. Happiness/affect can include both negative and
positive feelings, depending on how researchers oper-
ationalise it. Happiness is primarily used to depict
overall quality of life, while affect is primarily used in
health-related quality of life. Therefore, we have split
happiness and affect as distinct conceptualisations in
Table 1.
4.5. Satisfaction with life
Conceptualising quality of life as satisfaction with life
clearly distinguishes quality of life and health. Satisfac-
tion with life refers to a subjective appraisal of one’s
personal life. Overall satisfaction with life can be
considered to be an indicator of quality of life, because
one indicates how satisfied one is with one’s life as a
whole. Although satisfaction with life does change over
time, it clearly has some degree of constancy, even over
prolonged periods (Diener et al., 1997). Because
satisfaction with life is a concept that emerged from
the field of ‘‘positive psychology’’, it focuses on strengths
and talents as opposed to shortcomings and weaknesses.
Consequently, satisfaction with life corresponds to
overall quality of life and is not limited to health-related
quality of life.
4.6. Satisfaction with specific domains
In the fulfilment of the criteria, satisfaction with
specific domains is to a large extent comparable with
satisfaction with life. The only difference is that
satisfaction with specific domains is more likely to be a
determinant, rather than an indicator of quality of life,
because only few aspects of life are addressed.
4.7. Achievement of personal goals
Measuring quality of life in terms of achievement of
personal goals (i.e., the gap between expectations and
experiences) distinguishes quality of life from health.
Moreover, this concept of quality of life requires a
subjective judgment by the individual. The gap between
expectations and experiences is used as the indicator of
quality of life, even though it is more likely to be a
determinant. Indeed, deviation of experiences from
expectations is likely to have a negative impact on
quality of life. On the other hand, strong agreement
between experiences and expectations positively con-
tributes to quality of life. Both expectations and
experiences may change over time. Individuals can
adjust their expectations as a means of successful coping
to changing circumstances (Carr et al., 2001). Since
expectations and experiences are not restricted to health
issues, the gap between expectations and experiences
refers to overall quality of life rather than to health-
related quality of life.
4.8. Natural capacity
Quality of life viewed in terms of natural capacity
corresponds strongly to the presence or absence of a
normal healthy condition. A clear distinction between
quality of life and health in this approach is unlikely.
Natural capacity relies mostly on the appraisals of
health care professionals and lay caregivers, since
natural capacity is paramount in patients who are
unable to subjectively appraise their own quality of life
(Addington-Hall and Kalra, 2001). It is doubtful that
the absence of normal physical and mental capabilities is
deemed an indicator of quality of life, but rather a
determinant of quality of life. Although physical and
mental capabilities do not tend to fluctuate greatly,
alterations are possible. In this conceptualisation,
emphasis is placed on the negative aspects affecting
quality of life. Although natural capacity is strongly
associated with health, it is not necessarily limited to
health-related quality of life, since ethical debates on the
worthiness of life reflect all aspects of life.
5. Discussion
Despite the increased interest in quality of life, there is
still no consensus on the definition of this concept.
Moreover, it seems that the conceptual discussions has
tempered. To enhance the conceptual understanding of
quality of life, we used an alternative approach. In
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P. Moons et al. / International Journal of Nursing Studies 43 (2006) 891–901
contrast with the methods of concept analysis, we
identified problems of the various conceptualisations
of quality of life and evaluated the appropriateness of
these conceptualisations, which have been used pre-
viously in empirical quality-of-life research. To identify
the six problems, we largely relied on the work of
Kinney, who critically appraised state-of-the-art quality-
of-life research in 1995 (Kinney, 1995). We choose this
approach, because we observed that the traditional
concept analyses previously published had a rather
limited effect on quality-of-life research.
Evaluating the different conceptualisations in the
context of the conceptual problems revealed only one
conceptualisation that successfully addresses all the
conceptual problems: the conceptualisation that con-
siders quality of life in terms of satisfaction with life.
Consequently, satisfaction with life is the most suitable
approach for defining quality of life. This corroborates
findings from several concept analyses of quality of life
that defined quality of life in terms of satisfaction with
life (Ferrans, 1996, 1990; Zhan, 1992). Our conclusion is
also in line with the results of a study evaluating quality
of life using structural equation modelling: ‘‘quality of
life is a global, yet unidimensional, subjective assessment
of one’s satisfaction with life’’ (Beckie and Hayduk,
1997). Nonetheless, most empirical studies assess quality
of life in terms of normal life or in terms of a utility
measure. This may be due to the fact that no explicit
comparison of the respective conceptualisations has
been undertaken thus far. Another reason may be that
most of the existing concept analyses have been
published in nursing journals, whereas most empirical
quality-of-life studies have been published in medical
journals.
The problems described in this paper, and their use to
evaluate the existing conceptualisations, can be used as a
guide to help clarify the complex concept of quality of
life. However, our approach may have some limitations.
One limitation is that we only assessed quality-of-life
conceptualisations described by Ferrans (1996) comple-
mented with two additional conceptualisations. Other
possible conceptualisations not included in the present
review may exist. A second limitation is that the six
conceptual problems that we identified are not exhaus-
tive. Quality-of-life theorists can provide additional
problems; these problems in turn can be used to evaluate
the work presented in this article.
6. Conclusion
In order to stimulate the scientific community to
discuss concept underlying quality of life and to assist
researchers in developing more rigourous quality-of-life
research, we have evaluated the appropriateness of
different conceptualisations of quality of life. This
899
evaluation suggests that defining quality of life in terms
of satisfaction with life is most appropriate. Based on
this finding, researchers and theorists can initiate
conceptual debates with the aim of making quality of
life a less ambiguous concept. Furthermore, these
debates may trigger empirical studies and further
concept evaluations to confirm or reject the appropri-
ateness of satisfaction with life as a quality-of-life
indicator.
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