An integrative review of the use of the concept of reassurance in clinical practice

Abstract Aim To synthesize evidence on the concept of reassurance in nursing practice. Design Integrative review. Review Method PubMed, OVID MEDLINE, CINAHL and PsycINFO were searched from their inception to the 30 May 2020. The search results were screened. We assessed the quality of primary studies using the Mixed Method Appraisal Tool. Included studies were analysed using narrative synthesis. The review protocol was pre‐registered (PROSPERO‐CRD42020186962). Results Thirty‐two papers out of the 2,771 search results met our inclusion criteria. The synthesis of evidence generated three intricate themes, namely “antecedents of reassurance,” “defining attributes of reassurance” and “outcomes of reassurance.” Emotional distress was the main antecedent of reassurance. The three sub‐themes identified under defining attributes of reassurance include self‐awareness, emotional connectedness and verbal and non‐verbal techniques. Ultimately, reposing the confidence of patients and their families in healthcare professionals and the care delivery process to enable them to overcome their challenges constitutes the outcomes of reassurance.

care a central part of their daily care routines. One of such psychological care is "reassurance." Reassurance is vital to a wide-range of patient groups including those with long-term medical conditions and those that require palliative care (Sinclair et al., 2017) as well as users of emergency ambulance services (Togher et al., 2015), and patients with non-specific conditions (Traeger et al., 2017).
Although reassurance as a psychological intervention is widely used in clinical practice, there are some inconsistencies in the characterization of the intervention.

| Background
One core duty of the nurse is to provide comfort and allay fears and anxieties of patients and families through therapeutic communication (Pincus et al., 2013). This therapeutic nurse-patient communication often constitutes reassurance. Reassurance in nursing may refer to the totality of non-specific actions that are carried out by the nurse and geared towards restoring confidence and hope and reducing uncertainty in patients. It is also said to be the removal of fears and concerns about illness, and may refer to the behaviour of the caregiver or the response of the patient. This nursing intervention is pivotal in carrying out compassionate nursing care (Clarke, 2014).
Nurses provide more hands-on care and spend the most time with patients than other health professionals do. Westbrook et al. (2011) indicate that the time spent for hands-on care to patients constitutes more than three-quarters of nurses' time. Majority of this time is spent communicating with patients (Yen et al., 2018).
This constant and preponderant nurse-patient interaction presents a unique opportunity for nurses to be at the forefront of identifying and helping distressed patients and relatives. It is thus not surprising that nursing documentation is dominated by at least one variant of the statement: "patient was reassured." However, despite its widespread acceptance and usage in the nursing profession, reassurance remains a poorly defined term (Rolfe & Burton, 2013), and this was noted decades ago (Teasdale, 1989).
Its meaning could range from a reassuring presence of health professionals (Lucas et al., 2008;Traeger et al., 2017) to disclosing information that forecasts positive outcomes (Teasdale, 1989). Another query is whether the form and scope of reassurance changes within a particular framework, such as primary care and clinical care, acute and long-term settings, as well as the end-of-life setting. Some questions remain unanswered about reassurance including (a) what exactly do nurses do to reassure patients (how to reassure), and (b) what nursing actions could patients consider reassuring.
Although a reassurance guide for patients with non-specific disease exists (Traeger et al., 2017), there has not been a systematic review that comprehensively addresses how nurses reassure patients and what nursing actions and attributes are considered reassuring by patients.
Therefore, this review aimed to explore the state of the evidence regarding the meaning and usage of reassurance in nursing practice and possibly arrive at uniformity in the use of reassurance. We also developed a tentative conceptual framework for reassurance as a nursing intervention. We believe that these would be useful for future nursing research and competence training in nursing education.

| Aims
This integrative review attempted to answer the following 3 questions: 1. What is the concept of reassurance as used in clinical practice by nurses? 2. How do nurses reassure patients? 3. What are the outcomes of reassurance in nursing care?

| Design
We conducted an integrative review of the evidence on the concept and use of reassurance in nursing practice. For this study, nurses refer to both qualified nurses and student nurses. We followed Whittemore and Knafl's (2005) updated integrative review methodology, which involves problem identification, literature search, data evaluation, data analysis and presentation. This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2009). The study's protocol was registered on the PROSPERO International prospective register for systematic reviews (CRD42020186962).

| Search methods
An electronic search was planned and executed on 30 May 2020 on PubMed, OVID MEDLINE, CINAHL and PsycINFO. PsycINFO helped to cover the psychological nature of the concept under review, CINAHL provided coverage on nursing-related studies, MEDLINE and PubMed provided wider access to the medical literature. The search was conducted using variants of the search terms: "reassurance" and "nurse." Both index terms and free texts were incorporated into the search strategy to make our search as sensitive as possible. We limited the search to journal articles and studies with human subjects. No date limit was applied to the search.
The search results were imported into Covidence, a systematic review management software. Subsequently, two reviewers independently conducted title and abstract screening; a third reviewer was consulted where there were disagreements. The use of the three reviewers ensured objectivity in the selection and synthesis of the evidence. The eligibility criteria used were: (a) studies that described reassurance, (b) reassurance delivered by a nurse, (c) patients/relatives as recipients of the reassurance, (d) articles published in English and (e) studies of all designs. We excluded studies that (a) focused on the use of reassurance by other health professionals, and (b) dissertations, abstracts, conference articles and journal articles with no available full text. Full texts of tentatively eligible studies were further assessed to determine whether they fully met the inclusion and exclusion criteria.

| Quality appraisal
Since there is no standardized framework for assessing the quality of reflective essays, editorials and opinion pieces, we only evaluated the quality of primary studies. The methodological quality of the included primary or empirical studies was assessed using the 5-point Mixed Methods Appraisal Tool (MMAT) version 2018 (Hong et al., 2018). The MMAT has proven useful in the critique of qualitative, randomized controlled trials, quantitative non-randomized, quantitative descriptive and mixed-method reviews. The tool assesses the appropriateness of a study's aim, study design, participant recruitment, data collection, data analysis, presentation of findings, authors' discussions and conclusions (Hong et al., 2018). Studies were, however, not excluded based on quality as typical of integrative reviews (Whittemore & Knafl, 2005).

| Data abstraction and synthesis
The synthesis of relevant studies was guided by Whittemore and Knafl's five-pronged approach to data analysis in integrative review: data reduction, data display, data comparison, verification and conclusion. In data reduction, included studies were divided into two subgroups: empirical and non-empirical studies. For empirical studies, we extracted data on the names of the authors, country and study objectives. We also carefully summarized the relevant findings of each empirical study. For the other study types (including reflective essays), we summarized the main ideas or themes highlighted by the papers. The reduced data were then put in a table or data matrix during the data display stage. This allowed for patterns across the data to emerge. In data comparison, two reviewers inductively coded the data. The codes were then iteratively compared across the studies and categorized into themes. This was done while being mindful of the various patterns and contrasting ideas that are evident in the data. The generated themes were then compared to the reduced data to ensure fidelity to the core meaning of our original data.
Conclusions were then drawn about the themes that appropriately and wholly answered our research questions. These last bits of the data analysis process constitute verification and conclusion drawing.

| Search outcomes
Overall, the electronic search produced N = 2,771 results. After removal of duplicates, N = 1,903 records remained for the title and abstract screening. N = 1,782 articles were removed after the title and abstract screenings and N = 121 records were subjected to full-text review. Out of these, N = 87 studies were excluded with reasons depicted in the PRISMA chart (Figure 1), and N = 32 studies that met the inclusion criteria were included in the final analysis.

| Characteristics of included studies
The details of the included studies are shown in Tables 1 and 2. The review included empirical (N = 19) and non-empirical studies (N = 13). The empirical studies were of qualitative (N = 14), quantitative (N = 3) and mixed-method (N = 2) designs. The empirical studies were conducted in the United Kingdom (N = 6), North America (N = 6), Australia (N = 4) and Sweden (N = 2). One study, however, was not clear about the country of origin. The primary studies looked at reassurance from the perspectives of nurses, nursing students, patients and family members. The empirical studies were published between 1976-2019, with most studies being published more than a decade ago (N = 12). The sample size used across studies varied considerably (ranged from 1-431).
The non-empirical studies included conceptual papers and reflective essays that respectively provided in-depth analyses of the concept and the accounts of personal experiences on the application of reassurance in nursing care. Across primary and non-empirical studies, reassurance was discussed in the context of compassionate nursing care and effective patient-nurse communication.

| Results of the data evaluation
The Supplemental Tables summarize the results of the quality ap-praisal of included studies. Overall, the studies had clear research questions and collected appropriate data. For the qualitative studies, the data analysis and interpretation were rooted in the data as evident by the various verbatim quotes used to support the data interpretation. For one qualitative study, it was unclear whether the findings were adequately derived from the data and whether any interpretation could be substantiated by the data (Jay, 1996). The quantitative studies were of sound methodological rigour except for the high risk for non-response observed in one cross-sectional study (Cossette et al., 2002). One study, which used a mixed-method design, did not provide any explicit justification for using both quantitative and qualitative methods (Beaver & Luker, 2005). The mixed-method studies did not highlight and explain any divergence in quantitative and qualitative data.

| Synthesis of evidence on reassurance
Three themes were generated from the synthesis: antecedents, defining attributes and outcomes of reassurance.

| Defining attributes of reassurance
The theme focuses on the characteristics of the concept.
Reassurance is a complex concept characterized by the use of interpersonal skills to intentionally develop and maintain emotional connectedness with the patient and family (Fareed, 1996;Wocial et al., 2014). It requires that the nurse demonstrates self-awareness, emotional connectedness and apply verbal and non-verbal techniques to help restore confidence and empower patients as described below:

| Self-awareness
Self-awareness is regarded as preliminary to the actual reassuring actions undertaken by the nurse. Reassurance requires the nurse to be consciously aware of her emotions and the religious and/or cultural context within which he/she operates. Anxious patients may make nurses apprehensive (Chauhan & Long, 2000).
Thus, it is likely that the nurse may be reassuring him/herself in an attempt to reassure the patient (Chauhan & Long, 2000). Also, the nervous nurse is at risk for projecting his/her emotions to the patient (Boyd & Munhall, 1989) as well as triggering an exacerbation of the patient's fears (French, 1979). Therefore, the nurse needs to acknowledge or even overcome his/her emotional F I G U R E 1 PRISMA flow chart (Moher et al., 2009)  This pilot aimed to test study procedures and inform sample size for a future multicentre trial and to gain initial estimates of the effectiveness of the discussion intervention 120 patients with chest pain About 40% of patients attending the clinic took part in the study 1. A 5-item patient-reported scale was used to measure the level of reassurance at month 1 and 6 (higher score indicating higher levels of reassurance). Validity of the questionnaire (Cronbach's alpha = 0.68) 2. Although there was no significant difference between those who discussed with a nurse and those who received pamphlets alone, there was evidence of high levels of reassurance reported.
3. That suggests that reassurance can be in the form of discussion and giving information (pamphlet).  Gustafsson (2018), Sweden

Descriptive interpretive design
To explore the need for patients to feel reassured when receiving telephone nursing for minor illnesses? N = 11 patients Patients feel reassured when they see the nurse as another human being who understands their situation and sympathizes with them. This is often achieved by the nurse sharing their personal experiences with patients and "coming to the level of patients." Participants felt reassured when the nurse was professional, calm and factual. The nurse being alert and asking the right questions was seen as reassuring.
Patients get anxious when the cause of the symptoms is unknown. Patients feel reassured when a competent nurse provides a clear explanation of the symptoms to allow them to have a good picture of their risk level and the actions they need to take.  Boyd (1989), USA

Qualitative study design
To explore how nurses offer reassurance to patients 15 female registered nurses Reassurance is mostly needed by patients when they start going through uncertainty about their health or treatment/ intervention outcomes. Most nurses initiate the process of reassurance upon seeing signs of distress in patients (crying, restlessness and asking plenty of questions. Other nurses are a little more "presumptuous." Such nurses analyse the facts of the client's situation and assume that the client must be going through so much distress that requires reassurance. Though this may indicate that the nurse is emotionally availing herself to assist the patient, the nurse also risks projecting her feelings wrongly onto the patient Nurses reassure patients by giving them factual and accurate theoretical information. This included providing results of lab tests, explaining procedures and a trusting relationship, an assertion of optimism and a perceived therapeutic environment.
Patients seem to feel the therapeutic effect of reassurance where the environment in which they are nursed is seen to be informal, unthreatening and caring. These are characteristics of a ward, where the staff are friendly, kind, pleasant and where patients are encouraged to express their feelings.
The effects of reassurance are perceived as consisting of two components-external and internal factors. The external factor refers to the perception of things outside of the person, whereas the internal factor refers to temporality.
Since the loss of control is evident during hospitalization, gaining control over the situation one is in, is a form of reassurance The presence of the nurse was highlighted as an important factor in reassurance. The nurses did not physically have to be next to the patient The knowledge that they were accessible was enough to convey a sense of security  Barr (1992), UK

Case study (Qualitative)
To outline the nursing management of a patient with breathing difficulties A 75-year-old woman with congestive heart failure and COPD The patient found it reassuring when the nurse held her hands The nurse reassured the patient by "normalizing" and accepting the patient's emotions and reactions (e.g. making the patient feel that she is not being a nuisance by repeatedly requesting for bedpan) The nurse reassured the patient by ensuring that the patient's pre-illness identity, dignity and self-esteem remained intact. These were expressed in both deeds and words The nurse also provided words of encouragement to patients. (such as "she will recover," "she will wake up if she goes to sleep")

Sub-themes
Themes Gregg (1955) The purpose of reassurance is to help the patient restore confidence in himself and his ability to solve his problems. Patients feel reassured when: indecisive feelings disappear, someone listens to their problems, they feel respected, accurate information is provided, the patient observes technical competence in the nurse The nurse's role in reassurance involves identifying signs of distress in patients (overt signs such as facial expressions, crying and covert signs such as the type of questions patient asks), not making light of patients problems (by avoiding the usage of phrases such as "it is not that bad," or "you will be fine" -"reassurance noises," asking probing questions while showing genuine and sincere interest in helping the patient, maintaining a non-judgemental attitude) In the end, the patients must be empowered to find solutions to their problems. Diversionary measures, therefore, may be a less useful strategy  Blackhall (2011) Reassurance involves the provision of information to patients. The VERA framework as a guideline for compassionate communication could also provide a skeletal framework for reassurance as a nursing intervention. The first step is to validate or accept patients' perception of their problem in a non-judgmental way and the patient is encouraged to verbalize their problems. The next step is to establish an empathetic connection with the patient. Reassuring words are then provided that everything will be all right. Lastly, an activity is constructed to integrate patients' emotions rather than invalidating them 3. The nurse should be able to describe and carry out a repertoire of behaviours that she may use to attempt to restore the person's confidence. 4. The nurse should be able to identify when these behaviours have been successful, and state what she will do when they are not successful. Behaviours twitch may need to be adopted to achieve reassurance include: 1. Explanation-It involves the provision of information about anxiety-provoking situations and the future.
2. Familiarizing an unfamiliar situation-the escorted tour of the ward which some nurses allow the patient on admission.
3. Introducing a familiar element to unfamiliar situations-admitting the mother with her child, and allowing the patient's possessions, clothing, toys, photographs, etc., around him in hospital.
4. Touch-human contact is a form of nonverbal communication that can provide comfort. 5. Proximity (physical presence of the nurse)-the mere presence of a fellow human being can provide reassurance when loneliness may cause more apprehension 6. Conveying emotional stability in the nurse's manner using non-verbal communication-If the patient identifies anxiety or apprehension in the nurse it can confirm his fears or lead him to suspect actual danger or problems.
7. Counselling and helping patients to use their skills to overcome fears-this can engender the feeling of having control over the situation.
8. Clarification of facts-This is similar to explanation, but the emphasis is on placing the patient's knowledge of his disease or prognosis in the correct perspective.

Verbalization and ventilation of fears by the patient-a verbal expression of doubts and fears by the patient is important in reassurance.
10. Diversional techniques-a conversation with others, group activities, recreational activities and occupational therapy. The nurse can provide these situations.
11. Portraying the expected role-if an individual nurse's appearance or behaviour does not fit the patient's expectations it will cause some apprehension 12. Knowledge and competence-Inefficiency, incompetence and clumsiness rarely inspire confidence.
The concept of reassurance should not be taken for granted. It should be adopted as a nursing skill and not be regarded as a vague phenomenon that is achieved in some magical way. All nurses should attempt to realize the activities which they may perform to attempt to reassure people (patients, relatives and colleagues alike)

Sub-themes
Themes Halm (1992) US Support and personal needs have been empirically validated as two of the most important family need categories during critical illness. Perhaps overshadowed during the initial critical care phase by a need for relief of initial anxiety and reassurance of quality care and information, support needs emerge as family members recognize the impact of the stressful illness experience on themselves. Critical care nurses can provide social support to family members through family assessment, counselling and support groups. Although not empirically tested, it is generally believed that such support will influence the ability of family members to provide support to the patient and thereby influence a positive recovery from critical illness.
Social support to family and critically ill patients It is possible to think "when patients don't need a prescription, treatment, or further diagnostic testing, I sometimes think I have offered them nothing. I didn't "do" anything for them. But then I see the relief on a mother's face after I've given her my input."  Fareed (1994) UK "The phenomenon of "reassurance" is an attribute of caring that is commonly used in the delivery of nursing care. If caring is considered central to the concept of nursing, a case is made that the therapeutic value of reassurance needs to be analysed." Reassurance is used as a general term in everyday life. It is central to care, which in turn underlines nursing practice. However, its philosophical underpinnings in nursing care need to be explored. It has been widely reported to contribute to coping mechanisms by patients and therefore there is a need to explore how exactly this happens. It has been described as both therapeutic and non-therapeutic in literature. Different uses have been described and need to be explored contextually. Optimistic assertions are sometimes equated to reassurance and require in-depth exploration.

Reassurance goes beyond prescriptions and diagnostic procedures
"It seems therefore that reassurance is an intimately bound attribute of the caring notion. This is a very important issue since it is claimed that 'caring is the essence of nursing'" "It is necessary to examine the effects of reassurance on coping because it seems that assumptions are made that when someone (or a patient) is given reassurance he/she is more able to come to terms (or cope) with whatever was causing the conflict. This assumption is not only weak but also takes a mechanistic (cognitive) view of the person." The Concise Oxford English Dictionary defines reassurance (as a noun) as "renewed or repeated assurance, renewed or restored confidence," and (as a verb) "to restore confidence, to remove the fears or doubts of." "Some authors posit that reassurance might be termed "a technique for handling anxiety when it refers to a purposeful, skilled therapeutic move interpersonal relations." However, others take a contradictory view, labelling reassurance as a "non-therapeutic technique" The concept of reassurance was analysed using a structured approach, and the authors came out with three uses of the term in healthcare settings: "reassurance as a state of mind," "reassurance as a purposeful attempt to restore confidence" and "reassurance as an optimistic assertion" "In using the term reassurance to mean 'a purposeful attempt to restore confidence', Some authors took a behavioural approach by elaborating on the activities that the nurse should do to perform the act of reassuring, or what the patient should do to restore assurance These activities include explaining, familiarizing an unfamiliar situation, introducing a familiar element to unfamiliar situations, touch, proximity (physical presence of the nurse), conveying emotional stability in the nurse's manner using non-verbal communication, counselling and helping the patients to use their skills to overcome fears, clarification of facts, verbalization and ventilation of fears by the patient, and diversional techniques." Reassurance is associated with caring Nature of reassurance Defining attribute of reassurance Scott (2006), UK This was a reflective account of a student nurse's experience of dealing with distress from the death of a patient on the ward. The reflection expressed a positive reassuring experience when one's emotions were recognized with encouraging remarks.

Sub-themes
Themes Teasdale (1995), UK The study explored the concept of reassurance in healthcare settings by conducting a literature review on the different types of anxiety-management interventions and classified them under four major strategies: uncertainty reduction, patient control, cognitive re-framing and using an attachment. The author considered the following strategies more reassuring: using cognitive interventions that allow patients to have positive perceptions about situations that they initially considered as threatening.
the use of supportive attachment relationships to make patients feel confident and safe.
The study further asserted that reassuring techniques should allow patients to remain passive and reduce their anxiety. Hence, anxiety-reducing strategies like "patient control" which empowers patients to take action for themselves were not considered as reassuring. This reiterates the idea that "patient autonomy is not always compatible with reassurance." Types of reassurance, enabling positive appraisal of a situation (outcome), making patients feel confident and safe (outcome), patient passivity Nature of reassurance Defining attribute of reassurance, consequences/

outcomes of reassurance
Price (2017), UK Patients who are scheduled for medical interventions are normally anxious. Nurses are encouraged to attempt reassurance for these patients by sharing detailed information about the planned procedure to relieve their anxiety. This is in line with the NMC Code to "prioritize people" by acknowledging when they are in distress and caring compassionately. Patients especially feel reassured when they receive information and clarity from HCPs who will be involved in the specific intervention.
state, vulnerabilities or humanness and make attempts to make the patient the centre of his/her reassuring efforts (Chauhan & Long, 2000;Easby, 2013). The nurse, in effect, can provide effective patient-centred reassurance if he/she remains true to his/ her emotions or self. Also, the choice of reassurance technique depends on the culture (Chauhan & Long, 2000), geographical settings (Cossette et al., 2002;Hicks et al., 2014) and religious affiliation of patients (Diggins, 2012). The nurse provides appropriate, acceptable and effective reassurance by demonstrating cultural and religious sensitivity or awareness (Barr, 1992;Chauhan & Long, 2000;Diggins, 2012). For instance, therapeutic touch may not be appropriate in certain cultural contexts especially when delivered by the opposite sex (Chauhan & Long, 2000).

| Emotional connectedness
This sub-theme discusses the need to establish an emotional connection with patients during reassurance. Through this connectedness, nurses avail themselves emotionally to connect with the patient (Boyd & Munhall, 1989;Gregg, 1955;Jay, 1996;Teasdale & Kent, 1995;Wocial et al., 2014) within an enabling environment (Fareed, 1996). Emotional connectedness and compassion facilitate the sharing of each other's lived experiences through which the nurse can recognize and accept the patient's emotions (Barr, 1992;Wocial et al., 2014). The nurse comes to the level of the patient and shares with the patient personal stories that resonate with him/her (Gustafsson et al., 2018;Usher & Monkley, 2001). This strengthens the nurse-patient bond and allows the patient to freely verbalize his/her concerns and develop trust in the nurse. The emotional connection is also facilitated by the nurse showing genuine interest in the patient's concerns, being honest, respectful, caring, empathetic and non-judgmental (Blackhall et al., 2011;Gregg, 1955;Wocial et al., 2014). These nurse attributes constitute some of the factors that influence the success of reassurance. Aside from the emotional attributes demonstrated by the nurse, physical appearance is also of the essence as it may convey reassurance (Wocial et al., 2014).
The relationship that emerges makes the patient and family feel safe (Fareed, 1996), develop trust in the practitioner (Jay, 1996), able to acknowledge their fears or emotional distress (Hermann et al., 2019) and work towards acceptance (Gregg, 1955).

| Verbal and non-verbal forms of reassurance
Another key characteristic that emerged from the data reflects the forms of reassurance that enable the patient and family to regain their emotional balance or stability (Fareed, 1996). The forms were broadly categorized as verbal and non-verbal. Non-verbal forms of reassurance included therapeutic touch, maintaining eye contact, active listening, calm voice (Al-Mutair et al., 2014;Barr, 1992;Boyd & Munhall, 1989;Chauhan & Long, 2000;Cossette et al., 2002;Karlsson et al., 2012); being nice (Beaver & Luker, 2005); being Citation Reduced data (written summary)

Sub-themes
Themes Teasdale, UK, 1989 Several meanings for reassurance are identified in both nursing literature and practice. Reassurance had three main definitions identified in the Oxford English Dictionary as: (a) Renewed or restored confidence, (b) renewed or repeated assurance and (c) reinsurance. The first two are used in nursing whereas the third form "reinsurance" is not employed in nursing. The author conducted a concept analysis of the term "reassurance" and its occurrences in Nursing times in 1986. Three main usages of the term were identified in clinical settings in addition to the dictionary definitions. These included: Usage 1-reassurance as a state of mind: as a noun, it explains a state of renewed or restored confidence. An example suggesting that a state of reassurance has been achieved is when a patient states "I was really worried before you told me that, but now I know that I have nothing to fear." Usage 2-reassurance as a purposeful attempt to restore confidence: used in a verb form to act purposefully to restore a person to a state of confidence. Usage 3-reassurance as an optimistic assertion. This is a less common usage than the first two. Unlike usages 1 and 2, which emphasize "states" or "outcomes," usage 3 stresses an "action." As a noun, it means a renewed assurance given by one person to another. In practice words such as "don't worry" or "we'll take care of you" may be considered as ways to purposefully attempt restoring confidence to patients The controversy in literature arises from the inability to differentiate between the three usages of reassurance. Some researchers had classified usage 3 as non-therapeutic. Understanding the concept of reassurance in nursing requires identifying it's specific usage and supporting evidence from published accounts authentically present with the patient and family (Fareed, 1996;Monk, 2019;Usher & Monkley, 2001); and demonstrating respect (Gregg, 1955).
Verbal forms of reassurance noted in the data included offering words of encouragement (Al-Mutair et al., 2014;Barr, 1992;Hermann et al., 2019), and demonstrating professional competence (Gibb & O'Brien, 1990;Gregg, 1955;Hermann et al., 2019;Karlsson et al., 2012). Other forms of reassurance were communicating adequate, clear, honest and accurate feedback (Al-Mutair et al., 2014;Boyd & Munhall, 1989;Cossette et al., 2002;Gibb & O'Brien, 1990;Gustafsson et al., 2018;Jones et al., 2007;Usher & Monkley, 2001); and keeping the patient and family informed and encouraging them to verbalize their concerns (Blackhall et al., 2011;Fareed, 1996;Wocial et al., 2014). This encouragement should, however, be devoid of deception, as such practices amount to false reassurance which has been shown to be ineffective, and in some cases detrimental to patients' well-being (Chauhan & Long, 2000). Gregg (1955) also noted that the generic and mundane use of certain verbal responses such as "you will be fine" and "it is not that bad" may be regarded as "reassurance noises." The nurse should use such words cautiously (especially before any proper assessment of patient's complaint is done) as it may suggest to patients that their problems are being belittled.

| Outcomes of reassurance
This theme highlights the outcomes or consequences of reassurance in patients. A common expected outcome of reassurance is the restoration of patients' confidence in their ability to find solutions to their problems (Gregg, 1955). Reassured patients thus feel empowered to take control over their health. One study typified renewal of confidence with statements like "I was really worried before you told me that, but now I know that I have nothing to fear" (Teasdale, 1989). Reassurance instils hope in patients and offers patients optimistic viewpoints of any emotional or physical challenges they may be facing (Al-Mutair et al., 2014;Fareed, 1996;Teasdale, 1989). Moreover, reassurance helps to keep intact the patient's pre-illness identity, dignity and self-esteem (Barr, 1992).

| D ISCUSS I ON
The review sought to synthesize existing studies to understand the application of the term "reassurance" as used in clinical practice.
Reassurance emerged as a complex phenomenon characterized by three interconnected themes: (a) antecedents, (b) defining attributes and (c) outcomes. Emotional distress across the continuum of care was the main antecedent to the process of reassurance following which a connection between the nurse and the patient facilitated the resolution of the distress using verbal and non-verbal approaches.
The review findings highlight the concept of "reassurance" as an ongoing active process although it may appear latent to the nurse and patient. Our findings should increase awareness of what seems to be a "taken-for-granted" phenomenon and encourage nurses to reflect on and document their full reassurance episodes to facilitate better mapping of the process to emerging outcomes.
In medical practice, reassurance is often employed when discussing a patient's symptoms or diagnostic results (Kroenke, 2013;Redberg et al., 2011;Spence, 2018). The current review findings, however, suggest that the use of the concept of "reassurance" by nurses in clinical practice goes beyond these confines to include any episode of actual or potential emotional distress experienced by the patient and family, thereby highlighting a greater affinity of the concept to nursing practice. Additionally, the review findings suggest that reassurance transcends the physical state of the patient and family to connect emotionally with the nurse. These findings may be related to the core mandate of nursing which is to care instead of to cure (Watson, 1997). Caring endorses the professional identity of nursing, which provides avenues to respond to human dimensions of health and illness (Watson, 2007). Interestingly, how this important term (i.e. reassurance) is articulated in pre-registration nursing education curricula and taught in nursing schools is rather vague.
Although the concept may be resonated in specialist oncology, pain management, palliative and end-of-life care programmes (Buller et al., 2019;Linton et al., 2008;Wittenberg et al., 2018), the prevalence of emotional distress across patient groups makes it cogent to streamline the concept of "reassurance" in both undergraduate and graduate nursing curricula to prepare nurses. Perhaps, this may help to increase nurses' self-awareness and sensitivity to any clinical situation requiring reassuring interventions.
Further to the above, the review findings observed that nurses employed a variety of approaches to reassure patients and their families. These include verbal (such as words of encouragement and honest communication) and non-verbal (therapeutic touch and active listening) approaches, which are similar to those employed by other practitioners (Giroldi et al., 2014;Pincus et al., 2013). The studies included in this review offer insight into the subjective usage of these approaches albeit how these were objectively carried out remain unclear. The authors agree that some of these approaches, particularly the non-verbal approaches, represent the art of nursing, which may make it difficult to replicate or standardize. Aesthetic expressions such as empathy or therapeutic touches are often too complex to be reduced to a single definition that may make it difficult to express once the situation is over. However, as Carper asserts, the art of nursing or aesthetics remain one of the major patterns of knowing which cannot be ignored (Carper, 1978). Nurses should, therefore, be encouraged to reflect and document their reassurance experiences to strengthen the evidence-base of these aesthetic expressions. By establishing a plethora of these experiences, common themes may be identified which relate to delivering reassurance. Of note, nursing is a process and interventions are mostly carried out by a team, hence the need to have a standardized way of reporting nuanced interventions such as reassurance (Johansen & Ervik, 2018;Kilner & Sheppard, 2010).
Reassurance is a complex intervention that can lead to varied outcomes (Giroldi et al., 2014), including ensuring the dignity of the patients (Sailian et al., 2021). The more complex psychological and emotional care needs of a patient, the more the need for reassurance. Reassurance is at the heart of effective communication that ensures respectful and compassionate care as well as shared decision making in palliative and end-of-life care (Virdun et al., 2017).
In the current review, patient empowerment and instilling hope emerged as outcomes associated with reassurance. Only one study used an objective measure to ascertain reassurance among persons with chest pains (Hicks et al., 2014). Outcome measures exist to evaluate anxiety, but as noted in this review, the concept of "reassurance" goes beyond anxiety which warrants the development of more situation-specific outcome measures. Therefore, "outcome" in this context is part of the resource process rather than a stand-alone step as illustrated in Figure 2. Figure 2 illustrates the interconnectedness of the three themes that constitute the reassurance process. Nurses as health professionals should actively look out for signs that suggest that the patient is emotionally and psychologically unstable (antecedents of reassurance). Some patients may not verbalize what their worry is, while others will do. Therefore, the nurse should be approachable and be ready to listen to patients' concerns and actively look for both actual and potential sources of distress. This can be achieved by being self-aware of the antecedents that warrant reassurance, by adopting empathetic connection with the patient through both expressed words and non-verbal gestures (defining attributes of reassurance).

| A conceptual framework for reassurance in clinical care
The nurse should complete the reassurance process by evaluating the consequences of the act of reassurance (the outcome of the reassurance). If the evaluation indicates that the reassurance was not fully achieved, then the process is repeated. Therefore, reassurance is a cyclical process of problem identification, intervention and evaluation.

| Strengths and limitations
This review presents a framework for reassurance in clinical care, and this could guide future research focusing on developing a tool for reassurance. The unique integration of evidence from reflective essays, theoretical papers and primary studies allowed us to present more nuanced and granular details on the use of reassurance in nursing practice. Moreover, the use of a highly sensitive search strategy, multiple electronic databases and no date filters reduced the likelihood of missing relevant papers.
However, an important limitation of the current review was the exclusion of non-English papers, conference presentations and dissertations. This exclusion is likely to have resulted in the potential loss of some evidence.

| Recommendations
Most reassurance interventions do not follow any evidencebased framework, and therefore, there is a lack of consistency in reporting what was done and in evaluating the effectiveness of the nurse's reassuring actions. We recommend the development of an evaluation tool for reassurance. While we acknowledge that there are tools that currently assess the psychological state of distressed patients (anxious, stressed, depressed, among others), we believe that the perfunctory nature and use of reassurance requires a shorter validated assessment tool that could be rapidly used by nurses within the context of their busy work

Antecedents of reassurance
•Emotional distress (e.g hospitalisation, fear of the unknown).
•The antecedent could be either overt or covert.
•Holistic assessment of the patient's care needs.

Defining attributes of reassurance
•Self-awareness of both the nurse and the patient.
•Verbal and nonverbal techniques using compasionate communication.

Outcomes of reassurance
•Being confident.
•May be assessed subjectively or objectively and compared with baseline data (Antecedent).
of specific reassurance techniques. This would help nurses adopt a more evidence-based approach to reassurance.

| CON CLUS ION
This study reviewed the concept of reassurance as used in clinical practice and found three major themes: antecedents to, defining attributes of and outcomes of reassurance. Overall, this review reveals a stark lack of evidence about the standardization of the concept of reassurance for patients and their families in the clinical setting.
Specifically, looking at what reassurance means from different perspectives (e.g. patients, family caregivers, healthcare professionals), settings (acute and long term facilities), type of disease (acute episode, chronic conditions and end of life), among others will harness the development of a standardized evidence-based framework for reassurance that will be applicable in most context, and situations.
This framework for reassurance could provide a guide for nursing education and practice, offering a flexible approach to the provision of compassionate and context-appropriate reassurance to patients and families. Creating a checklist of items to report when documenting reassurance for both clinical and research purposes could be a consideration for future research.

ACK N OWLED G EM ENT
None.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
As a systematic review, we relied solely on publicly published data.