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Keywords:

  • chronic illness;
  • hope;
  • metasynthesis;
  • nursing;
  • older adults;
  • nurses;
  • nursing

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

duggleby w., hicks d., nekolaichuk c., holtslander l., williams a., chambers t. & eby j. (2012) Hope, older adults, and chronic illness: a metasynthesis of qualitative research. Journal of Advanced Nursing68(6), 1211–1223.

Abstract

Aim.  To report a metasynthesis review of qualitative research studies exploring the hope experience of older persons with chronic illness.

Background.  Hope is a psychosocial resource used by persons to deal with their chronic illness experience.

Data sources.  A comprehensive search of multiple databases for studies of the hope experience (published 1980–2010) was completed. Inclusion criteria were included qualitative studies of the hope experience of persons (all genders; mean age 60 years and older), with chronic illnesses, and publications in any language and country.

Review methods.  The metasynthesis followed four procedural steps: (a) comprehensive search, (b) quality appraisal, (c) classification of studies, and (d) synthesis of findings.

Results.  Twenty studies were included in the metasynthesis representing research from a variety of different countries and populations with differing medical diagnoses. The characteristics of hope included: (a) dynamic or situational nature, (b) multiple co-existing types, (c) objects that were desirable realistic possibilities, (d) future-focused, and (e) involvement of choice/will. Hope as ‘transcending possibilities’ represented the integration of two processes of transcendence and positive reappraisal. Reaching inwardly and outwardly and finding meaning and purpose were sub-processes of transcendence, whereas re-evaluating hope in light of illness and finding positive possibilities were sub-processes of positive reappraisal.

Conclusions.  The concept of hope may differ for older adults vs. younger adults in its interaction with suffering. Resources for hope are both internal and external. Finding meaning and positive reappraisal are important strategies to help older adults with chronic illness maintain their hope.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information
  •  Hope helps persons with chronic illness deal with their illness.
  •  Hope changes in different situations.
  •  Hope has many dimensions.

What this paper adds

  •  Hope in older persons with chronic illness involves transcendence from a difficult situation and positive reappraisal.
  •  Transcendence involves reaching inwardly and outwardly to others and finding meaning.
  •  Positive reappraisal involves evaluating hope in the light of illness and finding positive possibilities.
Implications for practice and/or policy
  •  Assessment of the hope of older adults with life-threatening illness should include the processes of transcendence and positive reappraisal.
  •  Fostering the inner strength and relationships with others may help engender hope.
  •  Strategies such as adjustment to transitions and losses, life review, reminiscence therapy and spiritual support may also help people find hope.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

The World Health Organization (2010) suggests that chronic disease has a major impact on the quality of life of individuals. With the increasing numbers of persons with chronic disease and persons over the age of 65 worldwide, there is an escalating need to find ways to support older persons with chronic illness. Hope is an important psychological resource for persons with chronic illness and has been described as essential to life (Eliott & Olver 2009). It has been defined as a ‘multidimensional dynamic life force characterized by a confident yet uncertain expectation of achieving future good which, to the hoping person, is realistically possible and personally significant’ (Dufault & Martocchio 1985, p. 380). As a dynamic multidimensional concept, hope changes over time and across important life events, such as chronic illness and ageing.

Only a few hope interventions have been developed and reported to have an important impact on the hope of older adults with chronic illness (Staats 1991, Tollett & Thomas 1995, Duggleby et al. 2007). This may be because of the complex multidimensional nature of hope that makes conceptual clarification a challenge. The theories and conceptual models of hope vary significantly with respect to how hope is conceptualized (Wiles et al. 2008) and have been developed with different populations (Dufault & Martocchio 1985, Farran et al. 1995, Morse & Doberneck 1995, Synder 2000, Duggleby & Wright 2005). For example, Synder’s theory of hope focuses on cognitive goal setting, whereas Duggleby and Wright’s grounded theory suggests that finding meaning and purpose is an important process of hope.

Although studies of hope of persons with chronic illness support the importance of hope for this population, their findings also vary significantly in terms of how hope is conceptualized (Wiles et al. 2008). This variation might be the result of many factors, including the diversity of the illness experience, and the methodological approach used to study the hope experience. For example, the hope experience of a person with terminal cancer appears to differ from a person with a non-terminal disease (Perakyla 1991). Approaches chosen to study the hope experience also reflect a difference in the conceptualization of hope. Phenomenological studies of the hope experience of persons with terminal illness describe the essence of the experience (i.e. Benzein et al. 2001), although those using grounded theory view hope as a process and describe the processes of hope (i.e. Duggleby & Wright 2005). Whatever the reason there is a lack of clarity of the concept of hope in persons with chronic illness.

Metasynthesis is a method that brings together qualitative exploratory studies to enhance their contribution to the development of more formalized knowledge (Zimmer 2006). Similar to other qualitative approaches, to understand hope conceptually, the metasynthesis approach seeks diversity in studies to explore how disparate findings are conceptually related to each other and to clarify the defining and overlapping attributes (Sandelowski & Barroso 2007). For example, assumptions are not made that studies from different cultures and contexts are the same; rather a conceptual understanding of hope will include their diversities and similarities. The resultant conceptualization from metasynthesis provides a global picture of the phenomenon under study (Hammer et al. 2009).

Previous hope metasyntheses have explored hope and expectations in people recovering from illness using narrative analysis (Wiles et al. 2008), the meaning of hope with people who were healthy and those who were ill in nursing research (Hammer et al. 2009), the hope experience of family carers of persons with chronic illness (Duggleby et al. 2010b) and despair and hopelessness in the context of HIV (Kylma 2005). All these published metasyntheses include studies of persons with chronic illness (except for Duggleby et al. 2010b) with a wide range of ages and not specifically considering hope in older persons with chronic illnesses. Inclusion of studies of all age groups ignores the physical, psychosocial, and spiritual changes that occur with normal ageing. These changes influence how older adults deal with chronic illnesses and hope. Older persons rely on different methods of maintaining hope than younger persons (Herth 1993, Duggleby & Wright 2005). Hope is one psychosocial resource older adults use to cope with life’s adversities (Westburg 2003) and given the complex construct of hope and the essential nature of hope to older persons with chronic illness, it is important to develop knowledge in this area.

The review

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

Aim

The purpose of this metasynthesis review was to explore the hope experience of older persons with chronic illness. The specific aims were to identify qualitative research in this area, and through synthesis of the study findings describe the characteristics and processes of hope.

Design

This metasynthesis of qualitative research studies on hope of older adults with chronic illness followed the procedures outlined by Sandelowski and Barroso (2007). The procedural steps included (a) a comprehensive search, (b) appraising reports of qualitative studies, (c) classification of studies, and (d) synthesis of the findings.

Search method

An experienced medical librarian searched nine databases for research articles published from January 1980 – March 2010 using keywords and subject headings of hope, hopeless, and despair. A qualitative and mixed methods study filter was used. In each search a combination of subject headings, keywords, and words in title were used as were search strategies modified depending upon the database and the controlled vocabularies available. The nine databases searched included: OVID Medline In-Process & Other Non-Indexed Citations, Medline, EBSCOhost CINAHL, and ISI Science Citation Index Expanded chosen for their coverage of health issues; OVID PsycINFO for its coverage of the psychological literature; OVID Ageline for it coverage of the older people; EBSCOhost ATLA Religion Database for theological literature; CSA Sociological Abstracts and ISI Social Sciences Citation Index for sociology; and Scopus for its interdisciplinary coverage.

The team members then studied titles and abstracts of all studies and identified those appropriate for the metasynthesis based on inclusion/exclusion criteria. Inclusion criteria for the metasynthesis were (a) studies of the hope experience of persons (all genders, mean age of 60 years and older) with chronic illnesses, (b) studies published in any language and country, (c) published peer-reviewed research studies, (d) qualitative and/or mixed methods designs, and (e) studies published between 1980 and 2010. Studies reporting the hope experience of patients, families and/or healthcare professionals were included if the hope experience of persons with chronic conditions were also reported. Abstracts, metasynthesis, and secondary analysis studies were excluded.

Search outcome

Figure 1 outlines the search method and outcome. In total, 5232 citations were retrieved of which 2021 were duplicates. After title and abstract screening, based upon the inclusion criteria, 19 were included. One article was removed as it reported findings from a study that was also published elsewhere. One additional article was located by hand. Authors of the studies were contacted and asked if they had additional published, submitted or accepted publications that they would be willing to share. Ten authors responded to the request and one additional in press article was obtained, which has since been published, for a total of 20 articles published between 1985 – 2010. Of the 20, one article written in Finnish and another in Japanese were translated into English by researchers whose first language was Finnish and Japanese and who were living in Finland and Japan, respectively. These researchers/translators were also asked to clarify and check their translations for accuracy through back translation. Table 1 lists the included studies, and their purpose, method, and quality appraisals.

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Figure 1.  Flow diagram of search.

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Table 1.   Summary of articles included in the metasynthesis.
Source/countryPurposeMethod/data collectionFindings classification and CASP total
  1. CASP, Critical Appraisal Skills Program; HHI, Herth Hope Index; COPD, chronic obstructive pulmonary disease.

Bays (2001) (USA)To explore the phenomenon of hope in older adults who have experienced a strokeThematic/descriptive Open-ended interviews with nine persons who had a strokeThematic survey CASP = 20
Benzein et al. (2001) (Sweden)To illuminate the meaning of the lived experience of hope in patients with cancer in palliative home carePhenomenology Interviews with 11 palliative care patientsInterpretive CASP = 21
Buckley and Herth (2004) (UK)To explore the meaning of hope of terminally ill patientsMixed methods BDF, HHI, and interviews with 16 persons with multiple diagnosisThematic survey CASP = 21
Daly et al. (1999) (Australia)To explore the meaning of the experience of hope for survivors of acute myocardial infarctionThematic/descriptive In-depth interviews with 8 persons with acute myocardial infarctionConceptual/thematic CASP = 18
Davison and Simpson (2006) (Canada)To understand hope in the context of advance care planning from the perspective of patients with end-stage renal diseaseThematic/descriptive Open-ended interviews with 19 patients with end-stage renal diseaseInterpretive CASP = 21
Dufault and Martocchio (1985) (USA)To describe hope and its spheres and dimensionsThematic/descriptive Semi-structured interviews and observations with 35 patients with cancerInterpretive CASP = 14
Duggleby et al. (2010a) (Canada)To explore the current societal discourse on hope and the hope of older terminally ill patients with cancer, their important others, and their primary nurseDiscourse analysis Interviews with three palliative patients with cancerInterpretive CASP = 20
Duggleby and Wright (2005) (Canada)To describe, using a grounded theory approach, the processes by which palliative patients live with hopeGrounded theory Open-ended interviews with 10 palliative patients with cancerInterpretive CASP = 21
Eliott and Olver (2007) (Australia)To examine the use of hope, as spontaneously used in interviews with patients with cancerDiscourse analysis Semi-structured interviews with 28 advanced patients with cancerInterpretive CASP = 20
Eliott and Olver (2009) (Australia)To examine unsolicited hope-talk and to assess the impact of dominant cultural beliefs about hopeDiscourse analysis Semi-structured interviews with 28 advanced patients with cancerInterpretive CASP = 22
Flemming (1997) (USA)To explore the meaning of hope to patients with cancer who are receiving palliative carePhenomenology Semi-structured interviews with 4 advanced cancerThematic survey CASP = 16
Forbes (1999) (USA)Use phenomenology and concept mapping to build a model of hope in older adults facing chronic illnessPhenomenology/concept mapping Interviews and concept mappingConceptual Thematic Survey CASP = 16
Herth (1993) (USA)To understand hope and identify strategies that older persons use to regain or maintain hope so as to develop environments within which hope can be fosteredThematic/descriptive Semi-structured interviews; HHI with 10 persons with unspecified diagnosisThematic survey CASP = 21
Kylma (1998) (Finland)To describe the meanings older people aged 70 and over attach to the dynamics of hopePhenomenology/concept mapping Interviews with 4 persons with multiple diagnosesInterpretive CASP = 23
Matsumoto and Doi (2006) (Japan)To identify threats to hope in people with severe COPDUnclear from translation Semi-structured interviews with 10 persons with COPDThematic survey CASP = 15
Mattioli et al. (2008) (USA)To explore and describe the meaning of hope and social support in patients receiving chemotherapyThematic/descriptive Semi-structured interviews with 14 patients with cancerThematic survey CASP = 20
Milne et al. (2009) (Australia)To report the meaning of hope in people living with COPDPhenomenology Interviews with 7 COPD patientsThematic survey CASP = 22
Mok et al. (2010) (China)To examine the meaning of hope from the perspective of Chinese advanced patients with cancer in Hong KongContent analysis Semi-structured interviews with 17 advanced patients with cancerConceptual/thematic CASP = 18
Sanatani et al. (2008) (Canada)Is there a difference in level of hope between those patients being curatively and those palliatively treated, and how does this change over time?Mixed methods HHI with a qualitative thematic analysis applied to responses with 50 patients with cancerThematic survey CASP = 13
Weil (2000) (USA)To explore the definitions and sources of hope in patients with end-stage renal disease receiving chronic haemodialysisThematic/descriptive Semi-structured interviews with 14 persons with renal diseaseThematic survey CASP = 13

Quality appraisal

The purpose of the appraisal was to become familiar with the reports and to evaluate them for quality using the [Critical Appraisal Skills Program (CASP) 1998]. The CASP provides a standardized mechanism for appraising qualitative studies using metasynthesis (Feder et al. 2006). It consists of 10 questions: two for screening out inapplicable studies and eight about the research design, data collection and analyses, ethics, reflexivity, and implications of qualitative studies. Using a three-point rating system developed by (Feder et al.2006) a score was calculated for each article for each of the CASP’s eight questions. A weak score (one point) was assigned to articles that offered little to no justification or explanation for a particular issue (e.g. where, when, or how the data were collected was not mentioned). A moderate score (two points) was given to articles that addressed the issue but did not fully elaborate on it (e.g. the justification for using constant comparisons was presented but the procedure itself was not explained). A strong score (three points) was assigned to articles that extensively justified and explained the issue at hand (e.g. the authors explained that semi-structured interviews were used, transcribed verbatim and modified part way through the study, and then offered some sample interview questions). For each article a score was calculated for all eight questions and then totalled with a maximum score of 24. For the 20 articles included, the mean CASP score was 18·83 with a standard deviation of 2·98 (range of 13–23). The CASP was used to describe the quality of the studies as one aspect of the context for the metasynthesis findings. As recommended by Sandelowski and Barroso (2007) articles were not excluded based on the CASP score.

Data abstraction and synthesis

The findings of the studies were classified using Sandelowski and Barroso’s (2007) classification system. The purpose of this procedure was to reveal the actual analytical work performed (vs. what was stated). The stated methodological approaches were: (a) 11 employing thematic/descriptive analysis (Dufault & Martocchio 1985, Herth 1993, Daly et al. 1999, Weil 2000, Bays 2001, Buckley & Herth 2004, Davison & Simpson 2006, Matsumoto & Doi 2006, Mattioli et al. 2008; Sanatani et al. 2008, Mok et al. 2010), (b) five using phenomenology (Flemming 1997; Kylma 1998, Forbes 1999, Benzein et al. 2001, Milne et al. 2009), (c) three discourse analysis (Eliott & Olver 2007, 2009, Duggleby et al. 2010a), and (d) one employing grounded theory (Duggleby & Wright 2005). Using Sandelowski and Barroso’s (2007) classification based on the findings of the studies: (a) nine were thematic survey, (b) three used conceptual/thematic description and (c) eight used interpretive explanation. Sandelowski and Barroso suggest that topical survey studies should be excluded from a metasynthesis: however, none of the studies reviewed was classified as such, and thus none was excluded for this reason.

The findings from the articles were entered into NVIVO 8 software. The synthesis was guided by reading the findings from the articles as a whole and team discussions to define the concepts. Synthesis of the findings was achieved using taxonomical analysis, a constant comparison grounded theory approach and reciprocal translation (Sandelowski & Barroso 2007). The purpose of the taxonomic analysis was to identify important underlying concepts and conceptual relationships. The study findings were then evaluated for similarities and differences to clarify and define hope and discern relationships among the interpreted concepts. A reciprocal translation of the concepts was used to integrate the metasynthesis findings through importing concepts that further interpret and integrate the findings.

Validity

The descriptive validity for this metasynthesis, as suggested by Sandelowski and Barroso (2007), was maintained by: (a) a comprehensive search for literature; (b) team discussion and decisions on search terms and inclusion criteria; (c) team assessment of appraisal and assignment of CASP scores; (d) communication with authors of reviewed studies for additional information; and (e) maintenance of an audit trail of search results and decisions. The team also discussed findings of the studies and themes until agreement was reached through consensus.

Results

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

The 20 studies included in the metasynthesis had a total sample of 305 and a mean age of 65·5 (SD 6·47). The studies represented research conducted on hope in a variety of different countries and populations with differing medical diagnoses. The medical illnesses (when reported) were all life threatening in nature. They included cancer, renal disease, chronic obstructive pulmonary disease, stroke, and acute myocardial infarction. As a result the context of hope for the metasynthesis was one where participants were experiencing: (a) uncertainty (unknown future outcomes) (Flemming 1997, Benzein et al. 2001, Eliott & Olver 2007); (b) major transitions (Dufault & Martocchio 1985, Flemming 1997); (c) loss (Dufault & Martocchio 1985, Flemming 1997); and (d) suffering (Flemming 1997, Daly et al. 1999, Duggleby & Wright 2005, Matsumoto & Doi 2006). Hope occurred in everyday interactions with others (Eliott & Olver 2007) and the environment (Bays 2001). The findings (see main concepts and references in supporting information Table S1) of this metasynthesis were interpreted in this context.

Attributes of hope

In all the studies reviewed, hope was described as an important psychological resource that helped participants deal with chronic illness. Many positive attributes were associated with hope including improved: sense of self (Forbes 1999, Buckley & Herth 2004), feelings of control (Flemming 1997, Duggleby & Wright 2005, Eliott & Olver 2007), relationships with others (Herth 1993, Matsumoto & Doi 2006, Mattioli et al. 2008), and quality of life (Benzein et al. 2001, Milne et al. 2009, Duggleby et al. 2010a).

Characteristics of hope

Several characteristics of hope were found including: (a) dynamic or situational nature; (b) multiple co-existing types; (c) hope objects that were desirable realistic possibilities; (d) future-focused; and (e) involvement of choice/will. Hope was situational as it changed in response to different conditions (Daly et al. 1999) either increasing, decreasing or disappearing as situations changed (Eliott & Olver 2009). Multiple types of coexisting hopes were described such as hope for comfort, and peace, hope for their families and hope for a cure (Dufault & Martocchio 1985, Benzein et al. 2001, Duggleby et al. 2010a). The objects of hope, or what participants were hoping for were realistic (Dufault & Martocchio 1985, Bays 2001) and desirable possibilities (Dufault & Matocchio, Eliott & Olver 2009, Duggleby & Wright 2005).

Hope was future focused within the concept of refocused time. Herth (1993) described refocused time as time that is not focused on clock hours, but linked to objects of hope. Refocused time was also described in other studies as redefined future in which future was defined as moments or hours and/or non-specific (Dufault & Martocchio 1985, Herth 1993, Duggleby & Wright 2005). Hope was a choice (Duggleby & Wright 2005), involved will (Daly et al. 1999) and was a never-ending process (Forbes 1999, Duggleby & Wright 2005).

Transcendence

Transcendence was one of the two main overlapping processes emerging from the data. The results of the studies reflected the transcendence of older persons with chronic illness beyond their difficult present. For example, several of the studies used the word transcending in their findings (Dufault & Martocchio 1985, Flemming 1997, Forbes 1999, Benzein et al. 2001). In other studies, transcendence was referred to as moving beyond their current state (Herth 1993, Eliott & Olver 2007, Mattioli et al. 2008), or moving forwards (Bays 2001). The process of transcending involved the sub-processes of reaching inwardly and outwardly and finding meaning and purpose.

Reaching inwardly and outwardly

Herth (1993) suggested that older persons have a perceived sense of linking within and without the self (with others). There was an inner strength or core that persons with long-term disease reach for to maintain their hope (Herth 1993, Bays 2001). This ‘inward self’ involved beliefs and past experiences and uplifting memories (Herth 1993). It also included a positive outlook or optimistic approach (Herth 1993, Duggleby & Wright 2005).

As well as reaching inwardly, older persons with chronic illness reached out to connect with family and friends, healthcare professionals, nature, and a higher power (Daly et al. 1999, Duggleby & Wright 2005, Matsumoto & Doi 2006, Mattioli et al. 2008, Eliott & Olver 2009). Positive supportive relationships with others were important for this process to occur. Reaching out and connecting with others increased their awareness of others and their environment and helped them take on a broader perspective of what was happening to them (Eliott & Olver 2009). For example, they focused less on themselves and more on others (Eliott & Olver 2009). It was through this inwardly and outwardly reaching that older persons with chronic illness began their search for positive meaning and purpose in their life.

Finding meaning and purpose

Several studies described searching for meaning and purpose as an important process of hope. The process of searching for meaning for older persons with chronic illness involved reflecting upon what was important to them and examination of their values and priorities (Dufault & Martocchio 1985, Benzein et al. 2001, Davison & Simpson 2006). Finding meaning helped to define what was of value and a priority in their life (Benzein et al. 2001, Duggleby & Wright 2005, Davison & Simpson 2006). Examples of priorities included returning to normal (as much as possible) (Benzein et al. 2001, Mattioli et al. 2008, Sanatani et al. 2008, Mok et al. 2010), maintaining positive health outcomes (not suffering) (Daly et al. 1999, Duggleby & Wright 2005, Sanatani et al. 2008) and maintaining relationships with others (Duggleby & Wright 2005, Sanatani et al. 2008). The relationship of finding positive meaning and purpose to hope is best described by a study participant with chronic renal disease: ‘… you’ve still got something to do in your life and your hope is to get it done.’ (Weil 2000, p. 220).

Positive reappraisal

The process of positive reappraisal was also a major process evident in the findings and included subprocesses of re-evaluating hope and seeing positive possibilities.

Re-evaluating hope in light of illness

Findings of several of the studies made reference to persons with chronic illness recognizing that their situation had changed as a result of their chronic illness (Flemming 1997, Forbes 1999, Duggleby & Wright 2005, Mattioli et al. 2008, Eliott & Olver 2009). With this recognition and acknowledgement they began the re-evaluation of previous hope in light of their chronic illness (Flemming1997, Forbes 1999). With this re-evaluation there was loss of some hopes (Dufault & Martocchio 1985, Forbes 1999, Duggleby & Wright 2005, Eliott & Olver 2009) or leaving old hopes behind (Forbes 1999, Milne et al. 2009).

Seeing positive possibilities

Seeing positive possibilities was reflected in all the studies where persons with chronic illness, even those who were dying, were able to perceive positive aspects of their future. This refers to the essence of hope as possibilities of a better future. There was an acknowledgement that both negative and positive possibilities may occur, but there was a choice to focus on the positive (Eliott & Olver 2007). This resulted in the possibility of different kinds of hope (Milne et al. 2009), or new hopes emerging (Forbes 1999, Duggleby & Wright 2005).

Hope: transcending possibilities

Conceptually integrating the processes of transcendence and positive reappraisal illustrates the interrelationships of these concepts. In Figure 2, the outer circle reflects the context of the physical and psychosocial environment, uncertainty, loss, and suffering in which hope occurs. The dynamic nature of the two processes and their relationship with each other is represented by the lines between the two concepts. For example the re-evaluation of hope in the light of illness is influenced by the transcendence subprocess of reaching inwards and outwards and finding purpose and meaning as they determine priorities of hope which, in turn, provides a new structure to evaluate hope. This new structure may be based on prioritizing hope for peace and comfort rather than hope for a cure. The re-evaluation of hope triggers the need for the transcendence processes to occur as old hopes are lost. The process of hope for an older person with chronic illness is an unending process.

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Figure 2.  Transcending possibilities.

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Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

Limitations

There are several limitations to this study. The articles included in the metasynthesis represented various contexts and cultures. As such, the contextual and cultural nuances (particularly through translation) may have been lost. However, the intent of ensuring diversity adds to the global nature of the understanding of the concept of hope in older adults with chronic illness. Another limitation is that assumptions made by the authors of the studies are continued in the metasynthesis, as the findings and not actual data are synthesized. Another limitation is the variety of methodological approaches used in the included studies. The findings of the different studies reflect these approaches, which also have differing philosophical assumptions. In addition, the metasynthesis reported findings from studies of older persons with chronic illnesses with a wide range of illnesses. Although the studies reflected similar concepts, such as hope is situational and is influenced by the illness experience, the findings may be different if the metasynthesis focused on one illness only. The life-threatening nature of the illnesses may have influenced the findings as well. Future research should be conducted about the hope of persons with chronic illnesses that are not life threatening.

Findings

The major findings of this metasynthesis study are the two inter-related processes of transcendence and positive reappraisal. Although these findings are significantly different from other hope metasynthesis studies, they give more clarity about some of these previous findings. For example, Wiles et al. (2008), found a lack of clarity around whether hope was a want or hope was an expectation. For persons with chronic illness, during the process of transcendence, they identified what was most important or desirable to them which became the focus of their hope. In this way hope was something that was desirable or wanted. The process of positive reappraisal identified what was realistically possible through evaluation of their situation and finding possibilities. Thus in essence, hope is desirable (wanted) possibilities.

Six dimensions of hope were articulated in the metasynthesis study of the meaning of hope in nursing research (Hammer et al. 2009): living in hope, hoping for something, hope as a light on the horizon, hope as a human to human relationship, hope vs. hopelessness, and hope as weathering a storm. These dimensions reflect the transcendence and positive reappraisal of hope found in our metasynthesis. For example, hope as weathering a storm may be a reflection of the transcending nature of hope from a difficult present (suffering) to a positive future. Hope as a light on the horizon refers to the positive nature of hope for a better future. Living in hope and hope as a human to human relationship may reflect the inward and outward searching and finding meaning and purpose that were aspects of the transcendence of hope. The existential nature of hope (living in hope) is evident in the inward searching and finding meaning and purpose. Outward searching and connecting is an important aspect of hope as human to human relationship. The importance of connecting with others and or a higher power as a process in hope possibly explains why faith, families, friends, and healthcare professionals were described as being a source of hope in several of the studies of older persons with chronic illness. Through the process of finding meaning and purpose, what was of value and a priority for hope is the foundation of the object of hope, and the dimension of hoping for something. Hoping for something also involves the process of positive reappraisal, as it is through seeing possibilities, that a person can have something to focus their hope upon.

Positive reappraisal was an integral part of the conceptual model developed by Duggleby et al. (2010b) in their metasynthesis study of hope of family members of persons with chronic illness. They described appraisal of the conditions of hope and the uncertainty that their hope was achievable. Similar to persons with chronic illness, this appraisal also included awareness of changes in conditions. Cognitive reappraisal theory suggests that an individual’s subjective appraisal of an event and positive reframing of the event, changes their consequent emotional response (Lazarus & Folkman 1984, Gross 1998). As a result reappraisal decreases stress and depression and is associated with positive health outcomes (Troy et al. 2010). Duggleby et al. (2010b) suggest that the hope of family members of persons with chronic illness results in positive health outcomes. This is similar to the findings of the metasynthesis of hope in persons with chronic illness. The positive reappraisal process may be one explanation for the positive relationship between hope and health.

Transcendence is linked with positive health and well being (Reed 2008, p. 108). Transcendence is moving beyond one’s current situation to a broader awareness of others and the environment (Reed 2008). Frankl (1963) suggests that transcendence involves the processes of reaching inwardly and outwardly and finding meaning and purpose. Although these processes were found in the hope studies of persons with chronic illness they were not described in Duggleby et al.’s (2010b) metasynthesis findings of hope of family carers of persons with chronic illness. Reasons for these differences may include: (a) the hope of family caregivers vs. the hope of persons with chronic illnesses, (b) the age of the person (younger vs. older adults), and (c) experiences associated with suffering and awareness of personal mortality. In a qualitative study of family carers of persons with dementia, Acton (2002) found little evidence of transcendence. She suggested carers have little opportunity to engage in transcendence activities because of their social isolation, ambivalence and burden of care. Another reason maybe that the Duggleby et al.’s (2010b) metasynthesis study included qualitative studies of family carers of all ages (mean age of 47) and did not focus on older adults. Gerotranscendence theories suggest that self-transcendence views and behaviours are characteristic of older adults (Tornstam 1996, Reed 2008). Thus, the focus on older adults with chronic illness may explain the finding of transcendence. However, Reed (2008), p. 105) suggests that transcendence occurs in any situation where a person feels an awareness of their personal mortality. More research on the potential differences in the hope experience: (a) with different age groups and (b) family carers and persons with chronic illness is needed to understand if differences exist.

The studies of persons with chronic illness included in this hope metasynthesis, described their participants as suffering and dealing with chronic illnesses that were life threatening. It is possible that hope changes in interaction with suffering. Suffering is the experience of deep physical, emotional, and existential pain and distress (Kahn & Steeves 1986). For persons experiencing chronic illness, suffering is the loss of self and meaning and purpose in life (Charmaz 1983) and is not unique to older adults. Future research should focus on exploring the relationships between hope and suffering of persons with chronic illnesses.

The emerging conceptual model of hope as an integration of transcendence and positive reappraisal adds to our understanding of the complex dynamic nature of hope. It explains why hope of older persons with chronic illness may differ from other populations and why studies that include participants with diverse age ranges may have mixed findings on hope. It also explains some of the variation found in current theories of hope. For example, Synder’s (2000) theory of hope focuses on cognitive reappraisal and goal setting as it was conducted with students, whereas Duggleby and Wright’s (2005) emerging theory was conducted with older palliative care patients. The emerging conceptual hope model ‘Transcending Possibilities’ suggests the possibility of different hope processes for older persons with chronic illness compared to relatively healthy younger students. Most importantly, the findings of this metasynthesis further our understanding of the nature and importance of relationships with others and spirituality. An important aspect of transcendence is reaching inwardly (drawing on inner strength) and outwardly to others; having hope may be difficult without inner strength to drawn upon and in isolation from others.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

The findings from this study provide a unique way of thinking about the concept of hope, through the lens of ageing and chronic illness, based on participants’ experiences. Hope is integrated with an older persons’ illness experience in important multidimensional and diverse ways. For example, hope for older persons with chronic illness may change based on its interactions with suffering with two interrelated processes of transcendence and cognitive appraisal. As such conceptual frameworks of gerotranscendence in combination with cognitive reappraisal may be useful to guide future research about hope.

Hope, as a concept, may differ for older adults than for younger adults, which adds important insight into the tailoring hope interventions for this population. For example, ways to foster hope with older adults with chronic illness may include strategies for finding meaning and purpose which is a process of transcendence. Strategies such as adjustment to transitions and losses, life review, reminiscence therapy, and spiritual support can help people find meaning and purpose, and transcend their experience of suffering. Hope is maintained through relationships with family, friends, healthcare professionals, and spiritual connections. Thus, assessment of hope and strategies to foster hope should include ways to maintain relationships and spiritual connections. The finding of hope as an important psychological resource of persons with chronic illness to help deal with their experience, underscores the value of finding ways to engender hope in this population.

Author Contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

WD, CN, LH, AW, and TC were responsible for the study conception and design. WD, DH, and TC performed the data collection. WD, DH, CN, LH, AW, and TC performed the data analysis. WD and DH were responsible for the drafting of the manuscript. WD, DH, CN, LH, AW, and TC made critical revisions to the article for important intellectual content. DH provided administrative, technical or material support.

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  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The review
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author Contributions
  12. References
  13. Supporting Information

Table S1. Main Concepts and Specific References

FilenameFormatSizeDescription
JAN_5919_sm_TableS1.doc30KSupporting info item

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