Patients' perception of hope in palliative care: A systematic review and narrative synthesis

OBJECTIVE

The aim of this study was to systematically review and synthesize the literature on patients' perceptions of hope in palliative care.

METHODS

PubMed, Scopus, SocINDEX, Cochrane, and Web of Science were screened against the eligibility criteria. After familiarization with the data and conduction of the coding process, studies were thematically analyzed using Braun and Clarke's methodology. The research question guiding our analysis was: what is said about hope from patients in PC?

RESULTS

The database searches yielded 24 eligible studies. Three main themes emerged from the studies: Hope beliefs (encompassing patients' understanding of hope and characteristics assigned to it), Hope functions (including the role that hope plays for patients) and Hope work (highlighting aspects that in patients' perspective cultivate hope).

CONCLUSION

This review emphasizes the importance of acknowledging patients' understanding of hope, its role, and the efforts required to sustain it. In particular, it suggests that hope serves as a valuable strategy, fostering meaningful personal relationships towards end of life.

PRACTICE IMPLICATIONS

In order to address communication challenges in clinical practice, a potential fruitful strategy for nurturing hope could involve engaging family and friends in hope interventions facilitated by healthcare professionals.

Hope in the context of life-threatening illness and the end of life

Recent research shows the importance of hope in the context of life-threatening illness and the end of life for patients and their families. While some patients and family members continue to hope for a cure or extending life, others may develop more complex hopes related to quality of life and making the most of the time left. Clinicians often worry about taking hope away with bad news about the patient's prognosis, but patients and family members often appreciate honesty without losing hope. Clinicians should recognize that hopes in the context of serious, progressive illness may be complex, contradictory, culturally based, and evolve over time. Recent interventions have been developed to support hope for these patients, caregivers, and parents.

Indirect Effects of Forgiveness on Psychological Health Through Anger and Hope: A Parallel Mediation Analysis

Forgiveness often discussed as a religious idea is also a popular topic in psychology. Empirical studies have shown that forgiveness decreases anger, anxiety, and depression and increases self-esteem and hopefulness for the future. However, research on the relationship between various outcomes of forgiveness is scarce. Thus, we aimed at examining the mediating roles of anger and hope in the relationship between forgiveness and psychological health outcomes. A sample of college students from a large non-profit university (N = 202) filled out self-report measures on forgiveness, anger, anxiety, depression, hope, and self-esteem. A parallel mediation analysis examining the role of anger and hope in the forgiveness-psychological health link was conducted. Results supported the indirect effect of forgiveness on psychological health through anger and hope, and the two mediators had a comparable size of magnitude. Implications, limitations, and future directions are discussed.

A Systematic Review and Narrative Synthesis of the Evidence Underpinning Theoretical Perspectives and Cultural Influences on Forgiveness in Palliative Care

Background: The process of forgiveness is proposed to reduce patient and family conflict and suffering in the face of life-limiting illness. However, it is unclear which theoretical perspectives underpin the concept of forgiveness in palliative care, and how culture may influence it. Objectives: To identify and synthesize primary evidence that underpins the concept of forgiveness within palliative care, and identify theoretical perspectives, including cultural assumptions. Design: A systematic review of studies on forgiveness in palliative care regardless of design was prospectively registered on PROSPERO. Narrative synthesis was conducted and the modified Seven-Point Checklist and modified Status Assessment Tool applied to appraise study quality (level 1) and contributions to theory building (level 2). Data Sources: Reference chaining and hand-searching were conducted for 10 electronic databases from 1960 to June 30, 2020. Results: Thirty-nine studies were included. Seven provided a definition of forgiveness, and six studies reported a process model. Twelve patient studies scored "high" on quality level 1 and nine scored "high" on level 2. Conceptualization of forgiveness included a conscious decision to abandon negative thoughts, feelings, and behaviors associated with conflicts, to find positive outcomes through processing of negative affect and cognitive reframing of conflicts. The process of forgiveness develops through time paralleled by an attributional movement from an external to an internal locus of control. Theoretical perspectives of systems, exchange and choice, social constructionism, behaviorism, and humanism were identified. Cultural contexts impact forgiveness. Conclusion: The synthesized model is based on primary evidence of mixed quality. Future research needs better theoretical conceptualization utilizing cultural perspectives. Forgiveness interventions with consideration of cultural influences are encouraged.

Effects of Psychotherapy on Hope/Hopelessness in Adults with Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Although psychotherapy is a common treatment for hopelessness and hope, the effectiveness remains controversial. The purpose of this study was to quantitatively synthesize available evidence related to the effect of a broad range of psychotherapy interventions on hope/hopelessness in cancer patients.

METHOD

Eight electronic databases were searched for studies with adult cancer patients (mean age ≥ 18 years) receiving psychotherapy interventions with hope/hopelessness measured as outcomes and written in English. We used the random-effects model to compute effect size using Hedges' g and conducted moderator analyses.

RESULTS

We found 27 primary studies which included 1,998 participants who were 57.6 ± 8.0 years old across studies. The psychotherapy effect size ranged from - 0.86 to 2.92. Researchers who conducted psychotherapy at hospital/health centers showed higher effects, that is, improved hope scores (g = 0.63), than those who conducted psychotherapy in the community (g = 0.05). When researchers enrolled participants alone, psychotherapy resulted in higher effects (g = 0.62) than when partners/caregivers were involved (g = - 0.04). Researchers who included group discussion showed lower effects (g = 0.36) than without group discussion (g = 1.10). Researchers who examined fidelity found lower effects (g = 0.16) than researchers who did not examine fidelity (g = 0.66). Interestingly, researchers who studied people with breast cancer showed higher effects (g = 0.96) than those who studied people with other types of cancer (g = 0.26). Researchers who included higher percentages of women showed greater effects (slope = 0.008, Q_model = 3.99, p = 0.046). Finally, the greater the time span between psychotherapy and the measurement of hope, the lower the psychotherapy effects (slope = - 0.002, Q_model = 4.25, p = 0.039).

CONCLUSION

Psychotherapy had a solid moderate effect on reducing hopelessness and improving hope in cancer patients compared to controls.

Nursing, psychotherapy and advanced cancer: A scoping review

PURPOSE

Many individuals with advanced cancer have unmet psychological needs and often lack access to supportive care. Psychotherapy for adults with advanced cancer is a promising way to address some of the challenges in meeting these care needs. Nurses are the largest cohort of healthcare workers who can practice as psychotherapists and are positioned ideally to integrate these interventions as part of routine care. The purpose of this scoping review is to map the literature on psychotherapeutic interventions among adults with advanced cancer and to explore the nursing role in this body of evidence.

METHODS

We conducted a scoping review for relevant quantitative, qualitative, and mixed methods studies. The content of included studies was analyzed and grouped based on two broad categories that describe how nursing's role was mentioned, described, and utilized: 1. Nurses are not the interventionist/psychotherapist and, 2. Nurses are mentioned as the interventionist/psychotherapist.

RESULTS

Eighty-six studies were included. Overall, majority of studies did not mention a role for nursing in any capacity. Some studies mentioned a non-interventionist role for nursing in the research study. Fourteen studies mentioned nurses as interventionists/psychotherapists. These studies focused on feasibility, acceptability and patient related outcomes of brief psychotherapies. Dignity therapy was the most common psychotherapy in studies where nurses were utilized as interventionists, followed by life review and supportive expressive therapies. Very few studies discussed nursing's role in this area and nursing's capacity to deliver this form of care.

CONCLUSION

There is paucity in nursing research focused on psychotherapy for adults with advanced cancer. It is feasible and acceptable for nurses to deliver brief psychotherapies to adults with advanced cancer, and the integration of these techniques in everyday practice has great potential that must be explored. The development of this knowledge base is needed to support future education, research, and practice policy agendas.

Spiritual AIM: assessment and documentation of spiritual needs in patients with cancer

The chaplain is an essential member of the palliative care (PC) team, yet, standard methods to document chaplain assessments are lacking. The study team performed a retrospective analysis of chaplaincy documentation in an outpatient PC clinic at an academic medical center over 6 months (April 2017 to October 2017). The study team identified unique adult patients with cancer, then manually extracted variables from the electronic medical record. The primary objective was to assess the number of spiritual assessments documented by the chaplain. Secondary objectives included descriptive analysis of identified spiritual needs. Out of the 376 total patient encounters, 292 (77.8%) included documentation of a chaplain's spiritual assessment. The most frequent spiritual need was self-worth/community (n = 163, 55.8%).This study demonstrates that chaplains can effectively document Spiritual AIM-based screening and assessment. Moreover, this may be an effective documentation method across institutions to facilitate chaplain-based data.

Conceptual Models and Mechanisms of Action that Underpin End-of-Life Care Interventions to Improve Spiritual Well-Being

Background: Understanding the conceptual models that underpin interventions, and the linkage between mechanisms of action and their intended outcomes, makes replication possible. Aim: To identify and appraise conceptual models and mechanisms of action underpinning end-of-life care interventions to improve spiritual well-being. Design: A systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis was conducted. Data sources: A comprehensive search was performed in eight databases from inception to January 12, 2021. Results: A logic model was developed and potential mechanisms of action were identified from the seven included studies. Conclusion: First, conceptual models that have relevance and appropriateness to cultural setting are required to underpin future intervention development and implementation. Second, careful intervention development should articulate the link between concept, mechanisms, and outcomes. Third, selection of valid outcome measured must have a strong justification of how the construct being measured relates to the intervention goals.

Forgiveness and Health Outcomes in Cancer Survivorship: A Scoping Review

BACKGROUND

Religious and spiritual beliefs including forgiveness are an important aspect of cancer survivorship; however, the relationship between forgiveness and health is not well understood.

OBJECTIVE

The aim of this study was to conduct a scoping review that examines and maps the current research regarding relationships between forgiveness and health outcomes in individuals with cancer.

METHODS

We searched 5 electronic databases using key search terms related to forgiveness and cancer. Using a scoping review framework, we synthesized the existing literature regarding forgiveness and health among individuals with cancer and examined forgiveness as a process for coping with cancer.

RESULTS

We located 277 articles for review; 24 met inclusion criteria. Forgiveness in interpersonal relationships emerged more often as forgiveness coping than other types of forgiveness. Most studies reported a positive association between forgiveness and mental health. Fewer studies were available regarding relationships between forgiveness and physical health, and findings were mixed.

CONCLUSIONS

Forgiveness in interpersonal relationships is a spiritual concern for individuals with cancer. Addressing forgiveness needs may promote mental health in cancer survivors. More empirical evidence is needed to understand the role of forgiveness in physical health in individuals with cancer.

IMPLICATIONS FOR PRACTICE

Acknowledging forgiveness beliefs is a psychosocial-spiritual intervention that nurses can provide to support mental health in individuals with cancer. The potential role of forgiveness in physical health for individuals with cancer requires further study.

Forgiveness facilitation in palliative care: a scoping review

OBJECTIVE

The objective of this review is to map the nature and extent of forgiveness facilitation intervention implemented and evaluated in palliative care contexts.

INTRODUCTION

Spiritual beliefs often include reconciliation and forgiveness, which are critical to patients and families in palliative care. Forgiveness facilitation can represent a valuable response as a multidisciplinary and non-pharmacological intervention to reduce suffering.

INCLUSION CRITERIA

Studies including palliative care patients aged 18 years or over and assisted by palliative care teams, including all healthcare professionals, chaplains, and volunteers, were included in this review.

METHODS

This scoping review is based on JBI methodology. The search was conducted in June 2017 and updated in December 2018 using international databases and gray literature in English, Spanish, German, Italian, and Portuguese.

RESULTS

A total of 23 articles were included in this review. The results suggest a growing interest in forgiveness facilitation in palliative care in different spiritual and religious traditions. Most studies are based on a psychological perspective. Several activities related to the intervention have been identified, but few details or characteristics are described. Social workers, nurses, doctors, and psychologists were most identified as healthcare staff involved in forgiveness facilitation. The outcomes related to the intervention are mental, physical, and relational well-being; quality of life, decision-making and communication; self-esteem and hope; depression, anger, and anxiety; and inner peace.

CONCLUSIONS

Forgiveness facilitation is critical in palliative care and is grounded in a multidisciplinary approach, but further evidence is needed to inform clinical implementation. These results open new perspectives for research and training on palliative healthcare staff.

The effectiveness of hope-fostering interventions in palliative care: A systematic review and meta-analysis

BACKGROUND

The concept of hope is an important theme in chronic illness and palliative care and has been associated with increased psycho-spiritual well-being and quality of life. Psycho-spiritual interventions have been described in this population, but no systematic review of hope-enhancing interventions or hopelessness-reducing interventions has been conducted for persons with palliative care diseases.

AIM

To describe and assess the effectiveness of interventions in palliative care that measure hope and/or hopelessness as an outcome.

DESIGN

This systematic review and meta-analysis was pre-registered (Prospero ID: CRD42019119956).

DATA SOURCES

Electronic databases, journals, and references were searched. We used the Cochrane criteria to assess the risk of bias within studies.

RESULTS

Thirty-five studies (24 randomized controlled trials, 5 quasi-experimental, 6 pre-post studies) involving a total of 3296 palliative care patients were included. Compared with usual/standard cancer care alone, interventions significantly increased hope levels at a medium effect size (g = 0.61, 95% confidence interval (CI) = 0.28-0.93) but did not significantly reduce hopelessness (g = -0.08, 95% CI = -0.18 to 0.02). It was found that interventions significantly increase spirituality (g = 0.70, 95% CI = 0.02-1.37) and decrease depression (g = -0.29, 95% CI = -0.51 to -0.07), but had no significant effect over anxiety, quality of life, and symptom burden. Overall, quality of evidence across the included studies was rated as low.

CONCLUSIONS

Evidence suggests that interventions can be effective in increasing hope in palliative care patients.

A Systematic Review of Interventions for Hope/Hopelessness in Older Adults

Objectives: Hope/hopelessness is an important determinant of health and death, and is a modifiable risk factor for older adults. The present review aimed to evaluate the effectiveness of interventions on hope among older populations. Methods: PsychINFO and PubMed were systematically searched. Publications reporting on interventions delivered to older adults that included quantitative data on hope/hopelessness were systematically reviewed. Results: Thirty-six studies were included, most with hope/hopelessness as a secondary outcome. Interventions based on CBT alone or combined with antidepressants significantly decreased hopelessness in depressed older adults. Psychological interventions based on life review effectively improved hope/hopelessness in a range of samples, including depressed, bereaving, or medically ill older adults. Little to no support was found for exercise programs for healthy older adults, educational interventions for medically ill individuals, or Dignity Therapy for palliative care patients. Conclusions: Hope/hopelessness in older adults can be improved using psychological interventions based on CBT and life review. Controlled trials with hope/hopelessness as a primary objective are needed to more clearly demonstrate effectiveness. Clinical implications: Cognitive-behavioral interventions can improve hopelessness in depressed older adults. Life-review based interventions can positively impact hope in a range of older populations. Dignity Therapy, physical exercise, and educational programs may not effectively improve hope/hopelessness in older adults.

Holding onto Hurt: The Prevalence of Interpersonal Hurt and Need for Forgiveness-Focused Solutions for Hospice Family Caregivers

Background: Interpersonal hurt or offenses are common human experiences. Bereavement may be impacted for caregivers of a terminally ill loved one when these experiences occur. Objective: To determine the prevalence and impact of interpersonal hurt-based experiences for hospice caregivers and interest in forgiveness-based support. Design: Cross-sectional, mixed methods needs assessment. Settings/Subjects: Bereaved hospice caregivers (n = 162) and direct care hospice clinicians (n = 133) were surveyed through mail-in and online surveys. Measurements: Participants completed ad hoc surveys to assess prevalence and impact of interpersonal hurt experiences and interest in forgiveness-based support. Bereaved caregivers also completed the Core Bereavement Items (CBI). Results: 41.98% of the bereaved experienced an interpersonal hurt or offense during the care or passing of their loved one. Those with hurt experiences felt highly impacted (63.2%), "sometimes" or "often" revisited the experience (91.2%), felt that their bereavement was affected (61.5%), and experienced physical symptoms (46.3%). CBI scores positively correlated with the impact of the experience. Hurt caregivers had higher CBI scores compared with those who did not. Of those who had not forgiven the offender, 46.3% felt that they could benefit from forgiveness-based support services. Qualitative analysis revealed themes of Disagreements with Decisions, Lack of Support, Relational Interactions, and Impact on Bereavement. Clinician responses supported these results. Conclusions: Interpersonal hurt experiences can greatly impact the offended caregiver during caregiving and in bereavement. However, it should be noted that the decision to forgive is ultimately a personal choice and therefore forgiveness-based for forgiveness-specific interventions may not be appropriate for all individuals. Future research should assess the feasibility and usefulness of this type of support for caregivers and the bereaved.

Trauma and healing in the underserved populations of homelessness and corrections: Forgiveness Therapy as an added component to intervention

The purpose of this article is to begin applying the principles of the psychology of forgiveness to people who are without homes and people who are in prisons. A review of the literature shows trauma for both groups. When the trauma is caused by unjust treatment by others, then excessive anger can result, compromising one's psychological and physical health. We review the interventions that have been offered for those without homes and the imprisoned to examine which existing programmes address such anger. Forgiveness Therapy, although untried in these two settings, may be one beneficial approach for substantially reducing unhealthy anger. Forgiveness interventions have shown a cause-and-effect relationship between learning to forgive and overcoming psychological compromise such as strong resentment and clinical levels of anxiety and depression. The literature review here suggests that forgiveness therapy for those without homes and the imprisoned may be a new and important consideration for ameliorating anger and aiding in a changed life pattern.

The Efficacy of Individual Psychological Interventions With Non-Clinical Older Adults

Abstract. A number of reviews and meta-analyses have consistently documented the positive effect of individual psychological intervention with clinical older adults suffering from late-life depression, anxiety disorders, or other mental illnesses. However, many older adults without clinical disorders might seek and benefit from individual psychological interventions too. Given the aging populations across the globe, knowing the potential efficacy of individual psychological interventions with non-clinical older adults therefore is important. However, the research on this topic has not been reviewed systematically. This was the primary aim of the present review. Secondarily, we wanted to find out how many of these studies were conducted in a European context. A systematic literature search identified nine eligible studies yielding an aggregated sample size of 983. Two of these were European. Eight of the nine studies (including one European) reported significant positive effects of individual psychological interventions, that is, increases in psychological well-being and decreases in depression symptoms and distress. Effect sizes were extracted or calculated when possible to estimate the magnitude of the intervention effects. These effect sizes varied across studies and ranged from trivial in size to large and even very large, the median being a medium effect size. The results from the present review suggest that non-clinical older adults benefit from individual psychological interventions. However, the limited number of studies available for review precludes conclusions regarding the comparative efficacy of different types of psychological interventions in this population. Directions for future research are discussed.

Forgiveness: Moving on can be healthy

Forgiveness as a procedure has been gaining prominence. The objective of this article is to provide the basics of forgiveness as an intervention so primary care clinicians can facilitate its use. These clinicians include but are not limited to physicians, nurses, medical assistants, pharmacy professionals, physical therapists, social workers, psychologists, case managers, and clergy. This narrative explains the rationale for understanding forgiveness as a procedure and ways to explain it. To assist clinicians and patients in making informed decisions, samples of forgiveness research are included that describe its positive relationship to specific physical health situations. The article also describes an evidence-based forgiveness therapy, circumstances in which it is harmful to forgive oneself or others, describes the limitations of this article, and suggests future directions.

Forgiveness and Reconciliation Processes in Dying Patients With Cancer

This article studies forgiveness and reconciliation (F/R) in patients with cancer. It focuses on the end of life, when family conflicts resurface and unfinished business challenges patients and causes spiritual distress. Forgiveness and reconciliation may intensify patient–family relationships and facilitate peace of mind and peaceful death. Existing forgiveness models and interventions focus on coping in life, yet no study has examined F/R processes until death. Our mixed-method exploratory study hypothesized that F/R processes occur in phases, repeatedly, and are spurred by approaching death. Three interdisciplinary units at a major Swiss hospital observed 50 dying patients with cancer experiencing severe conflicts with relatives, themselves, and/or with fate/God. Participant observation was combined with interpretative phenomenological analysis and descriptive statistical analysis. A semi-structured observation protocol was developed based on a 5-phase model. The protocol included space for notes (emotions, interventions, effects on dying processes). It was assessed by 20 professionals for 1 year. Analysis was supported by international interdisciplinary experts. We found that conflicts were complex and involved relational, biographical, and spiritual layers. In 62% of patients, F/R processes occurred repeatedly. Many patients died after finding F/R (22 within 48 hours). Patients indicated that imminent death, a mediating third party, acceptance, and experiences of hope motivated them to seek F/R. Although deep relationships may support F/R processes, our limited data on near-death experience/spiritual experiences restrict interpretation. Forgiveness and reconciliation processes oscillate between 5 phases: denial, crisis, experience of hope, decision, and finding F/R. Understanding F/R processes, empathy, hope, and a neutral third party may support patients in seeking forgiveness.

Psychosocial interventions for advanced cancer patients: A systematic review

OBJECTIVE

Psychosocial care for advanced cancer encompasses a wide range of interventions that help patients make life-changing decisions, manage debilitating symptoms, confront impending mortality, and improve other patient outcomes. Psychosocial care is becoming increasingly available to advanced cancer patients; however, an overview of the various types of interventions is lacking.

METHODS

The current review systematically examined randomised-controlled trials of psychosocial interventions for advanced cancer patients from January 2007 to June 2018. MEDLINE, CINAHL Plus, PsycINFO, and Scopus databases were searched, and a total of 68 studies were included in the review.

RESULTS

We found a range of psychosocial interventions studies and grouped them based on six theoretical/clinical approaches: cognitive behavioural therapy based; meaning enhancing; dignity, life review, and narrative; other counselling; education only; and music, writing, and others. The different psychosocial interventions had significantly varied characteristics (eg, format, duration, and resources used) to address issues faced by advanced cancer patients. There is compelling evidence for the use of meaning-centred psychotherapy to improve meaning and quality of life and use of question prompt lists and communication skills training to improve communication with health care providers.

CONCLUSIONS

Some psychosocial interventions are further along in establishing evidence for effectiveness. Our findings demonstrate a growing capacity within the field to meet the psychosocial needs of advanced cancer patients. Lessons and direction in clinical practice and future research endeavours are discussed.

Psychometric properties of the Chinese mainland version of the Palliative Care Spiritual Care Competency Scale (PCSCCS-M) in nursing: a cross-sectional study

BACKGROUND

Spiritual care competencies are among the primary professional skills that enable best practices in nursing. Assessing these competencies and identifying those that are insufficient are important tasks. The traditional Chinese version of the Palliative Care Spiritual Care Competency Scale (PCSCCS) used in Taiwan is a well-validated tool to measure palliative caregivers' competencies in providing spiritual care. However, whether this scale is valid and reliable for use with nurses in other health-care contexts is unknown. The purpose of this study is to determine this version's validity and reliability for use with nurses in mainland China.

METHODS

The PCSCCS was first converted into a simplified Chinese version (PCSCCS-M) from the traditional Chinese version used in Taiwan such that mainland nurses could read and understand it easily. Then, the validity and reliability of the PCSCCS-M was evaluated with 400 Chinese nurses recruited using convenience sampling from three university-affiliated comprehensive hospitals, two cancer hospitals, one psychiatric hospital, two traditional Chinese medicine hospitals, one marital and child service care center, and one community health service center. Concurrent validity was assessed using Pearson's correlation coefficients of the PCSCCS-M and the Chinese version of the Spiritual Care-Giving Scale (C-SCGS). Exploratory factor analysis (EFA) was performed to determine the construct validity. Confirmatory factor analysis (CFA) was conducted using another sample of 351 nurses to verify the quality of the factor structures of the PCSCCS-M. An internal consistency test based on Cronbach's alpha coefficient and a stability test based on the Guttman split-half coefficient were also conducted.

RESULTS

Useful data were obtained from 356 participants (response rate: 89%). EFA confirmed a three-dimensional structure of the scale after one item was deleted, and the three factors explained 63.839% of the total variance. Cronbach's alpha coefficients of the three subscales were 0.811, 0.889 and 0.896, and the Guttman split-half coefficient for the PCSCCS-M was 0.862. Modified CFA indicated a well-fitting model. The correlation between the PCSCCS-M and C-SCGS was 0.340 (p < 0.01).

CONCLUSIONS

The PCSCCS-M is a brief, easy-to-understand, and psychometrically sound measurement tool to evaluate spiritual care competencies in nurses from mainland China.

Empathy and cultural competence in clinical nurses: A structural equation modelling approach

BACKGROUND

Forgiveness has the potential to resolve painful feelings arising from nurse-patient conflicts. It would be useful to evaluate direct and indirect important factors which are related to forgiveness in order to design interventions that try to facilitate forgiveness.

AIM/OBJECTIVE

The purpose of this study was to evaluate the intermediating role of empathy in the cultural competence-forgiveness association among nurses using structural equation modeling.

RESEARCH DESIGN

The research applied a cross-sectional correlational design.

PARTICIPANTS AND RESEARCH CONTEXT

The study included 380 nurses eight hospitals in southern Iran.

ETHICAL CONSIDERATIONS

The Ethics and Research Committee of Birjand University of Medical Sciences approved the study protocol. The voluntary nature of participation was explained consent was obtained from participants, and anonymity was guaranteed.

FINDINGS

Most of the participants were married and female and fell in the 20- to 30-year-old category. Most of them (89.5%) had a working experience of 1-10 years. The proposed model showed that nurses' empathy intermediated the association between nurses' cultural competence and forgiveness which has fitted the data acceptably (root mean square error approximation = 0.070; comparative fit index = 0.993; goodness-of-fit index = 0.983; and χ²/df = 2.85).

CONCLUSION

Empathy skills and cultural competence training were essential for interventions aimed at increasing the tendency to forgive patients. In such interventions, planners should aim at increasing nurses' cultural competence in order to enhance their empathy toward patients, which can, in turn, lead to a greater wish to forgive patients.

A snapshot of Australian social workers in palliative care and their work with estranged clients

This paper describes a mixed method survey that was administered to a group of Australian palliative care social workers (n = 27). Specifically, it aimed to investigate the ways that social workers understood and worked with clients who were estranged from family at the end of life. Respondents suggested that estrangement potentially impacted clients emotionally, practically, and existentially. They were challenged to make clear assessments, provide emotional support, encourage news ways of thinking about estrangement, to manage practical issues, work with the client's family, and monitor their own professional role. Theories and models of intervention and levels of training are also discussed.

Effectiveness of nursing intervention for increasing hope in patients with cancer: a meta-analysis

Objective:

to evaluate the efficacy of nursing interventions to increase the level of hope in cancer patients, in a meta-analysis.

Methods:

electronic databases were searched. Two of the authors independently extracted data from the eligible studies, and Stata 13.0 software was used to pool the data.

Results:

nine randomized controlled trials were included, and methodological quality of each randomized controlled trial (RCT) was evaluated using Cochrane handbook recommendations. A random effects model was used to combine results from eligible studies. The pooled results using the fixed effects model showed that scores to first effects increase significantly after the use of nursing intervention between the groups. Heterogeneity was observed among the studies for posttest (df = 8, P = 0.000; I² =76.1 %). The results indicated significant heterogeneity across the nine selected studies. The test for heterogeneity showed no homogeneity among studies for follow-up (df = 8, P = 0.328; I² = 12.9 %), and there was no statistical significance.

Conclusion:

the current evidence suggests that nursing intervention has a positive effect on hope in cancer patients. However, more large-scale and high-quality randomized controlled trials are needed to confirm these results.

The effects of life review interventions on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Life review interventions have been used to alleviate psycho-spiritual distress in people near the end of life. However, their effectiveness remains inconclusive.

AIM

To evaluate the effects of therapeutic life review on spiritual well-being, psychological distress, and quality of life in patients with terminal or advanced cancer.

DESIGN

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.

DATA SOURCES

Five databases were searched from their respective inception through February 2017 for relevant randomized controlled trials. The effects of therapeutic life review were pooled across the trials. Standardized mean differences were calculated for the pooled effects. Heterogeneity was assessed using the I² test. Study quality was assessed using the Cochrane criteria.

RESULTS

Eight randomized controlled trials met the inclusion criteria. The pooled results suggested a desirable effect of therapeutic life review on the meaning of life domain of spiritual well-being (standardized mean difference = 0.33; 95% confidence interval, 0.12 to 0.53), general distress (standardized mean difference = -0.32; 95% confidence interval, -0.55 to -0.09), and overall quality of life (standardized mean difference = 0.35; 95% confidence interval, 0.15 to 0.56) when compared to usual care only. Of the three outcomes examined, only the pooled effect on overall quality of life remained statistically significant at follow-ups up to 3 months after the intervention (standardized mean difference = 0.82; 95% confidence interval, 0.47 to 1.18).

CONCLUSIONS

Therapeutic life review is potentially beneficial for people near the end of life. However, the results should be interpreted with caution due to the limited number of randomized controlled trials and associated methodological weaknesses. Further rigorously designed randomized controlled trials are warranted.

The psychosocial experiences of older palliative patients while participating in a Living with Hope Program

Objective:

Several studies have reported the effectiveness of a variety of psychosocial interventions in increasing levels of hope in palliative care patients. The experience of palliative patients while participating in these interventions is unknown. Understanding these experiences would provide a rich understanding of how the interventions work to foster hope. The purpose of the present study was to describe the psychosocial processes that participants with advanced cancer receiving palliative care experienced when taking part in a Living with Hope Program (LWHP).

Method:

In the context of a study evaluating the LWHP, data were collected from 13 dyads (persons with advanced cancer and their caregivers) at two timepoints (one week apart). A thematic qualitative analysis of 52 open-ended audiotaped interviews was conducted that focused on the psychosocial processes that occurred during the LWHP.

Results:

The average age of palliative participants was 67 (SD = 6.6) and of their family caregivers 61 years of age (SD = 13.9). A thematic analysis suggested that the participants experienced the following psychosocial processes while participating in the LWHP: (1) reminiscing, (2) leaving a legacy, (3) positive reappraisal, and (4) motivational processes. These processes are the mechanisms by which the LWHP fosters the positive outcomes of increasing hope and improving quality of life. As well, the finding of motivational processes suggested that the LWHP may also increase life satisfaction, which is an outcome of motivational processes.

Significance of the results:

The findings from our study underscore the importance of uncovering the psychosocial processes through which the LWHP works to foster hope. They will assist in making revisions to the intervention that will increase its effectiveness, as well as providing a better understanding of hope in persons with advanced cancer.

Treatment of holistic suffering in cancer: A systematic literature review

BACKGROUND

Holistic suffering is a debilitating problem for cancer patients. Although many treatments have been suggested for its alleviation, they have not been compared for effectiveness.

AIM

This literature review seeks to identify what interventions are effective in treatment of holistic suffering of cancer patients.

DESIGN

A systematic review was conducted to identify and evaluate studies of interventions for holistic suffering in adult cancer patients. Search terms were generated iteratively from the literature.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Library and PsycINFO databases were searched for the years 1992-2015. Included studies were peer-reviewed, English language reports of either a controlled trial or a randomised controlled trial focusing on therapies aimed at relieving suffering in adult cancer patients. Articles were excluded if focused predominantly on spiritual or existential issues or concerns not leading to suffering. Studies were graded for quality using the QualSyst quantitative checklist. Levels of evidence were ascertained by completing the National Health and Medical Research Council criteria. Results are reported according to AMSTAR guidelines.

RESULTS

The studies represented seven intervention types. Meaning-centred, hope-centred and stress-reduction interventions were found to be effective. Results of both psycho-educational and spiritual interventions in improving spiritual well-being were mixed. Supportive-expressive interventions - with the exception of forgiveness therapy - were not efficacious. There was little or no evidence for the efficacy of creative and healing arts and other assessed interventions such as animal therapy and haptotherapy.

CONCLUSION

This systematic review found that spiritual well-being, meaning, hope and benefit finding can be positively impacted by a variety of treatment modalities.

Therapeutic life review in palliative care: a systematic review of quantitative evaluations

CONTEXT

There is increasing interest in providing nonpharmacological treatments, including therapeutic life review interventions, to enhance palliative care patients' existential/spiritual domains.

OBJECTIVES

To review quantitative evaluations of therapeutic life review interventions to assist palliative care patients with prognoses of 6 months or fewer in addressing existential and spiritual domains.

METHODS

Comprehensive searches of PubMed, Medline, Web of Science, CINAHL, Scopus, and PsycINFO were undertaken using a validated palliative care search filter in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Each publication that met the inclusion criteria was read and classified according to the American Heart Association's Disease Management Taxonomy, Consolidated Standards of Reporting Trials, QualSyst, and the Task Force on Psychological Interventions. Intervention procedures and outcomes were described.

RESULTS

The searches yielded 1768 articles, of which 14 met the inclusion criteria. The articles reported six interventions evaluated once and four interventions evaluated twice, resulting in 10 distinct interventions. The interventions were evaluated in randomized controlled trials (n = 9), single-arm studies (n = 3), and a cohort study (n = 1). Interventions were conducted in one to eight 15-160 minute sessions by psychologists, social workers, and nurses. Attrition rates were 12%-50% because of patient death and deterioration. Participants lived 28-110 days after completion. Significant results were reported in 11 of 14 studies.

CONCLUSION

There are few studies evaluating therapeutic life review interventions, although results are promising. Further studies are required that use stricter selection criteria to demonstrate efficacy before these interventions are adopted into clinical practice. Further study may include the effect of these interventions on the interventionist and the bereaved family and caregivers in long-term follow-up.

Let me hear of your mercy in the mourning: forgiveness, grief, and continuing bonds

Clarity about the utility of continuing bonds (CB) continues to be evasive in the research. In 2 different correlational studies, the authors explored the relationship between CB and 2 other variables: 1 representing mental health (forgiveness of the deceased) and the other representing psychological distress (prolonged grief). Although researchers have addressed the latter relationship in the literature, assessing the relationship between CB and forgiveness has not been undertaken. Results suggest that forgiveness in general, and affective aspects of forgiveness in particular, predict psychological forms of CB. Results related to grief depended on how CB was assessed. These findings provide evidence of the relative health of certain types of relationship with deceased persons and also suggest that forgiveness interventions may be a way of promoting such healthy bonds.

How are palliative care cancer populations characterized in randomized controlled trials? A literature review

CONTEXT

The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research.

OBJECTIVES

To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs).

METHODS

The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles.

RESULTS

The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported.

CONCLUSION

A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.

Nurses' responses to requests for forgiveness at the end of life

CONTEXT

Patients or family members facing serious illness often express regrets over life events or the need for forgiveness. Professionals, including nurses as the prominent discipline at the bedside, witness these expressions of regret or needs for forgiveness but may not be adequately prepared to optimally address patient concerns regarding forgiveness.

OBJECTIVES

The objectives of this descriptive study were to 1) identify contexts in which nurses have witnessed expressions of regret or the need for forgiveness and 2) describe nurses' responses to these clinical experiences related to forgiveness.

METHODS

Nurses attending palliative care educational programs shared narratives of their experiences in caring for patients who expressed regret or the need for forgiveness. Study narratives were analyzed qualitatively, using content analysis. Themes were identified.

RESULTS

Narratives were provided by 339 nurses from courses throughout the U.S. and Belize, India, the Philippines, and Romania.

CONCLUSION

Nurses provide clinical care for patients with advanced illness who struggle with issues of forgiveness. Nurses would benefit from additional education regarding how best to address these concerns.

Prospective associations between unforgiveness and physical health and positive mediating mechanisms in a nationally representative sample of older adults

OBJECTIVE

This study examined the prospective association between unforgiveness and self-reported physical health and potential positive psychological mediators of this association.

DESIGN

Participants were a national sample of 1024 USA's adults of ages 66 years and older. Data were collected at two time points separated by three years.

MAIN OUTCOME MEASURES

Measures of trait unforgiveness, self-rated physical health, socio-demographics, health behaviours and positive psychological traits (e.g. life satisfaction, self-esteem) were included in a comprehensive survey known as the 'Religion, Aging, and Health Survey.'

RESULTS

The results indicated that unforgiveness was prospectively associated with declines in self-reported physical health three years later, and poor initial self-reported health status did not predict increases in unforgiveness across time. Furthermore, the prospective association of unforgiveness with self-reported health was mediated by a latent positive psychological traits variable.

CONCLUSION

These results confirm cross-sectional findings suggesting that unforgiveness is related to health. The present study also suggests that unforgiveness has a prospective, but not reciprocal, association with self-reported physical health. Unforgiveness may have its association with self-reported physical health through its interruption of other positive traits that typically confer health benefits.

Spiritual needs in patients suffering from fibromyalgia

The objective of this study was to assess spiritual needs of patients with fibromyalgia syndrome (FMS) and to evaluate correlations with disease and health associated variables. Using a set of standardized questionnaires (i.e., Spiritual Needs Questionnaire, Fibromyalgia Impact Questionnaire, SF-36's Quality of Life, Brief Multidimensional Life Satisfaction Scale, etc.), we enrolled 141 patients (95% women, mean age 58 ± 10 years). Here, needs for inner peace and giving/generativity scored the highest, while existential needs and religious needs scored lowest. Particularly inner peace needs and existential needs correlated with different domains of reduced mental health, particularly with anxiety, the intention to escape from illness, and psychosocial restrictions. Thirty-eight percent of the patients stated needs to be forgiven and nearly half to forgive someone from their past life. Therefore, the specific spiritual needs of patients with chronic diseases should be addressed in clinical care in order to identify potential therapeutic avenues to support and stabilize their psychoemotional situation.

Spiritual Experiences of Transcendence in Patients With Advanced Cancer

Purpose:

Spirituality encompasses a wide range of meanings between holistic wellbeing and mysticism. We explored advanced cancer patients' spiritual experiences of transcendence.

Methods:

A total of 251 patients with advanced cancer were included and observed (participant observation) over 12 months by a psycho-oncologist/music-therapist. She recorded and documented patients' spontaneously expressed spiritual experiences during hospitalisation. Interpretative Phenomenological Analysis was applied.

Results:

135 patients communicated a spiritual experience, as expressed by altered body-awareness, less pain, less anxiety, higher acceptance of illness/death, new spiritual identity. Spiritual experiences were communicated by patients across different religious affiliations/attitudes. We identified types of spiritual experiences.

Conclusion:

The occurrence of spiritual experiences seems to be frequent and associated with profound, powerful reactions. Our results indicate that experienced-based spiritual care may complement current needs-based approaches.

Defining the palliative care patient: a systematic review

BACKGROUND

The lack of a clear definition of the palliative care patient hampers the comparison of results across different studies and impedes implementation of research findings in everyday practice.

AIM

The aim of this article is to propose minimum characteristics that define a palliative care patient.

DESIGN

The design involved a systematic review of medical literature searching randomised controlled trials (RCTs) in palliative care for clear descriptions of their palliative care patients. We systematically describe relevant characteristics of the study populations of 60 eligible RCTs.

DATA SOURCES

The data sources used were MEDLINE, EMBASE, CINAHL, and PSYCHINFO, including all non-cancer RCTs (1 January 1995-4 March 2010) and an equivalent number of the most recent cancer RCTs (1 January 2003-4 March 2010).

RESULTS

Half of the non-cancer studies were excluded because they did not relate to palliative care. We conclude that published RCTs have no clear definitions of their palliative care patients and illustrate the diversity of this patient, the lack of consensus concerning the attributes of illnesses needing palliation and the ambiguous use of the adjective 'palliative'.

CONCLUSIONS

We propose elements of the patients' health status (e.g. a progressive, life-threatening disease with no possibility of obtaining remission or stabilisation, or modifying the course of the illness) and the care delivered to them (e.g. a holistic interdisciplinary approach that focuses on supporting the quality of the end of life) to be included in the definition of a palliative care patient. We also suggest considering the patients' readiness to accept palliative care and a vision of palliative care shared by the patient and all caregivers involved as potentially important elements in this definition.

Effects of Psycho-Oncologic Interventions on Emotional Distress and Quality of Life in Adult Patients With Cancer: Systematic Review and Meta-Analysis

Purpose

This study aimed to evaluate the effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer.

Methods

Literature databases were searched to identify randomized controlled trials that compared a psycho-oncologic intervention delivered face-to face with a control condition. The main outcome measures were emotional distress, anxiety, depression, and quality of life. Outcomes were evaluated for three time periods: post-treatment, ≤ 6 months, and more than 6 months. We applied standard meta-analytic techniques to analyze both published and unpublished data from the retrieved studies. Sensitivity analyses and meta-regression were used to explore reasons for heterogeneity.

Results

We retrieved 198 studies (covering 22,238 patients) that report 218 treatment-control comparisons. Significant small-to-medium effects were observed for individual and group psychotherapy and psychoeducation. These effects were sustained, in part, in the medium term (≤ 6 months) and long term (> 6 months). Short-term effects were evident for relaxation training. Studies that preselected participants according to increased distress produced large effects at post-treatment. A moderator effect was found for the moderator variable “duration of the intervention,” with longer interventions producing more sustained effects. Indicators of study quality were often not reported. Small-sample bias indicative of possible publication bias was found for some effects, particularly with individual psychotherapy and relaxation training.

Conclusion

Various types of psycho-oncologic interventions are associated with significant, small-to-medium effects on emotional distress and quality of life. These results should be interpreted with caution, however, because of the low quality of reporting in many of the trials.

The lack of standard definitions in the supportive and palliative oncology literature

CONTEXT

Multiple organizations have raised concerns about the lack of standard definitions for terminology in the supportive and palliative oncology literature.

OBJECTIVES

We aimed to determine 1) the frequency of 10 commonly used terms in the supportive and palliative oncology literature, 2) the proportion of articles that provided definitions for each term, and 3) how each term was defined.

METHODS

We systematically searched MEDLINE, PubMed, PsycINFO, the Cochrane Library, Embase, ISI Web of Science, and Cumulative Index to Nursing and Allied Health Literature for original studies, review articles, and systematic reviews related to palliative care and cancer in the first six months of 2004 and 2009. We counted the number of occurrences for "palliative care," "supportive care," "best supportive care," "hospice care," "terminal care," "end-of-life," "terminally ill," "goals of care," "actively dying," and "transition of care" in each article, reviewed them for the presence of definitions, and documented the journal characteristics.

RESULTS

Among the 1213 articles found, 678 (56%) were from 2009. "Palliative care" and "end-of-life" were the most frequently used terms. "Palliative care," "end-of-life," and "terminally ill" appeared more frequently in palliative care journals, whereas "supportive care" and "best supportive care" were used more often in oncology journals (P<0.001). Among 35 of 601 (6%) articles with a definition for "palliative care," there were 16 different variations (21 of 35 articles used the World Health Organization definition). "Hospice care" had 13 definitions among 13 of 151 (9%) articles. "Supportive care" and other terms were rarely defined (less than 5% of articles that used the term).

CONCLUSION

Our findings highlight the lack of definitional clarity for many important terms in the supportive and palliative oncology literature. Standard definitions are needed to improve administrative, clinical, and research operations.