Hope in Health Care: A Synthesis of Review Studies

The objectives of this study were (1) to provide an overview of review studies on hope in health care, and to describe (2) conceptualizations of hope, (3) antecedents and consequences of hope, and (4) ethical topics related to hope. Electronic databases were searched and 73 review studies were selected and thematically analyzed. Hope was conceptualized as (a) an expectation: appraisal of a future outcome, (b) resilience: endurance of adversity, and (c) a desire: expression of meaning. Opposite concepts to hope were fear/anxiety, hopelessness, despair, and depression. Inspiring relationships, particularly relationships with peers, were an important factor that increased hope in patients. Losses, like the loss of health or (inspiring) relationships, had a negative impact on hope. Also, hope had effects on motivation for change and making decisions. The ethics of hope was addressed in palliative care, where health care providers wanted to maintain patients ’ hope while being honest or realistic. In conclusion, this chapter offers an overview of hope in health care and offers conceptual clari ﬁ cation, including ethical issues related to hope. Future studies should broaden the ethics of hope by including other values than realism and they should include the hope of health care providers.


Introduction
Hope is of vital importance for societies because it is part of the vision of society. This vision may be an ecological one, or a vision of a just society, in which equality and respect for human rights will reign (Bloch 1968;Freire 1994;Moltmann 2005). At an individual level, writers have also emphasized the importance of hope, such as the crucial role of hope in enduring and surviving hardship (Frankl 2014). Christian writers have held hope in high esteem, as illustrated in Paul's triad "faith, hope, and love," whereas the ancient Greeks held mixed or negative views on hope (Eliott 2005, pp. 5-6;Nussbaum 1992, pp. 150, 461). Philosophers and other scholars have described some characteristics of hope: "(1) futurity-a future dimension of what is hoped for, (2) possibility-the outcome is possible but not certain (neither zero nor one), (3) desirability-what is hoped for is seen as good in some respect, and (4) agency-hoping agents engage in activities to reach their hope" (Olsman 2015, p. 8; see also, Averill et al. 1990, pp. 9-35;Martin 2014;Nunn 2005, pp. 63-77;Walker 2006, pp. 40-71).
Still, we should note that these characteristics cannot solve all conceptual problems. For example, some people with an incurable disease hope for a cure, and this calls into question the possibility of hope because the outcome of this hope will be zero. Other people hope that something bad will happen to a family member whom they hate, and this undermines the desirability of hope. Furthermore, hope may be conceptualized differently in various contexts, such as different health care contexts (Herrestad et al. 2014). An overview of the role of hope in these health care contexts, including conceptualizations of hope, has not been provided. The objectives of this study were (1) to provide an overview of review studies on hope in health care and to describe (2) conceptualizations of hope, (3) antecedents and consequences of hope, and (4) ethical topics related to hope. The findings will also aid reflection on the role of spirituality in health care, since hope is a central topic in spiritual care (Capps 2001;Gijsberts et al. 2019;Lester 1995;Olsman 2020).

Methods
A synthesis of review studies on hope in health care was conducted. Electronic databases were searched by a clinical librarian on March 21, 2019: PubMed (medicine), Embase (medicine), Emcare (nursing), and PsychINFO (psychology/psychiatry). The following search terms, and derivatives thereof, were used: (hope OR hopefulness) AND (review OR synthesis OR meta-analysis). Review studies were included when the Abstract explicitly mentioned hope as one of the findings, and when they described hope within the context of health care. The following were excluded: studies on hopelessness, or studies on hope in health (not on health care or illness), or studies that were publications other than journal papers, or studies with a title and abstract written in a language other than Dutch, English, German, French, or Spanish, or studies that had searched only one database, or studies that were not review, meta-synthesis or meta-analysis study The search led to 101 references in PubMed, 219 in Embase, 161 in Emcare, and 57 in PsycINFO. In total, 538 references were found, of which 144 were duplicates. The titles and abstracts of the 394 remaining references were screened first. Of the 394 references, 166 were excluded because they did not describe hope in health care, and 108 studies described the topic under investigation but were excluded because they were not review studies. The remaining 120 studies were then screened on fulltext. Of these studies, 21 had not systematically searched in two or more databases, 11 were untraceable, whereas eight references were not conducted within the context of health care. Four references did not describe, or barely described, hope in health care, one was not written in one of the chosen languages, one was not a journal paper, and one was a study protocol and not the review study itself. Hence, based on the screening of the full-texts (n ¼ 120), 47 references were excluded.
This meant that 73 references were included in this study. The characteristics of the studies selected, such as objective and their health care context, were described. The research objectives of our study were used to analyze the findings of these studies thematically, utilizing Microsoft Excel. A column was created for each objective: to describe conceptualizations of hope, antecedents and consequences of hope, and ethical topics related to hope. Then, each column was analyzed, looking for similarities and differences between the various review studies.

Included Studies
Seventy-three review studies were selected, published between 1997 and 2019, and are listed in Appendix Table 11.1, at the end of this chapter. For the sake of brevity, only author, year of publication, and objective of the review study are presented in this Appendix. The health care contexts of these studies were: mental health care (n ¼ 16), oncology (n ¼ 12), neurology (n ¼ 10), palliative care (n ¼ 9), pediatrics (n ¼ 7), geriatrics/elderly care (n ¼ 4), chronic health care (n ¼ 3), other (n ¼ 12).

Conceptualizations
Hope was found to be a multidimensional construct that might change over time (Duggleby et al. 2010;Kylmä and Vehviläinen-Julkunen 1997;Wayland et al. 2016). A frequently mentioned distinction was the difference between the doing and being of hope. The doing referred to the action or process of hoping for something in the future. The (relational) being of hope was a state of living with hope (Bright et al. 2011;Kylmä et al. 2009;Lohne 2001). I found three conceptualizations, in which these dimensions become tangible.
Hope was (1) an expectation, that was a positive, yet realistic, appraisal of an uncertain future outcome, like the hope of chronic heart failure patients that their condition would not worsen, or hope for transplants in children and adolescents with cystic fibrosis (Caboral et al. 2012;Connell et al. 2012;Duggleby et al. 2010Duggleby et al. , 2012Jamieson et al. 2014;Leamy et al. 2011;Olsman et al. 2014;Schrank et al. 2008;Tutton et al. 2009;Wiles et al. 2008).
Hope as (2) resilience meant that hope was the strength or a (coping) strategy to endure adversity, for example in the family members who hope for the return of a missing person or when this was no longer possible, for the return to life as it was before the loss (Chi 2007;Clarke et al. 2016;Ebenau et al. 2017;Griggs and Walker 2016;Kharrat et al. 2018;Olsman et al. 2014;Oyesanya and Ward 2016;Parslow et al. 2017;Prip et al. 2018;Schiavon et al. 2017;Similuk et al. 2016;Stewart and Yuen 2011;Tong et al. 2015;Wayland et al. 2016;Weaver et al. 2016). Within the context of mental illness, hope was a positive factor associated with recovery, empowerment, and stigma (resistance) (Deering and Williams 2018;Firmin et al. 2016;Kylmä et al. 2006;Leamy et al. 2011;Livingston and Boyd 2010;Shepherd et al. 2016;van Eck et al. 2018;van Weeghel et al. 2019;Wilson et al. 2018).
Hope as (3) a desire was the expression of something meaningful embedded in (everyday) life, like the desire for recovery or the hope for a life worth living in patients with a neurological disease (Jones et al. 2016;Olsman et al. 2014;Soundy and Condon 2015;Soundy et al. 2014b). Hope was also described as a life value and (significant) associations with quality of life and/or well-being were found (Ebenau et al. 2017;Machado et al. 2017;van Leeuwen et al. 2011;van Mierlo et al. 2014;Singh and Hodgson 2011).

Antecedents
Many studies described the antecedents of hope. Several psycho-socio-spiritual interventions had a positive effect on hope. The evidence for these interventions has been provided in children exposed to traumatic events in humanitarian settings in low-income countries (Purgato et al. 2018), and in oncology (Bauerreiß et al. 2018;Best et al. 2015;Olver 2012). In mental health care, several review studies suggested that recovery-focused interventions, especially those in which peer providers were involved, enhanced hope (Thomas et al. 2018;van Weeghel et al. 2019).
Hope-inspiring relationships, particularly with peers, were reported most frequently, as contributing to hope, for example, the hope of people who self-harm or people participating in rare disease support groups (Casellas-Grau et al. 2014;Deering and Williams 2018;Delisle et al. 2017;Koehn and Cutcliffe 2007;Li et al. 2018;Lloyd-Evans et al. 2014;Prip et al. 2018;Soundy et al. 2014a;Stenberg et al. 2016;Thomas et al. 2018). A study within the context of palliative care suggested that "affirmation of patient's worth" may be one of the underlying factors that supports hope in patients (Kylmä et al. 2009). Other hope-engendering factors were hearing of positive stories (Kharrat et al. 2018;Stenberg et al. 2016), the ability to review one's own expectations (Laugesen et al. 2016;Refsgaard and Frederiksen 2013), positive character traits (Broadhurst and Harrington 2016), and the use of spirituality in daily life (Agli et al. 2015;Baldacchino and Draper 2001).
Negative effects on hope were less frequently reported. The most frequently mentioned negative antecedents of hope were losses, such as the past losses of people with mental health problems, which affected their hope for the future, suggesting reduced opportunities for recovery (Connell et al. 2012). Hope was negatively affected in neurological patients who could no longer perform certain roles and/or who experienced a loss of control (Soundy et al. 2014a, b;Soundy and Condon 2015). An integrative review found that concurrent losses, such as the loss of health or income, or losing the professional interest of others, and a lack of symptom control all threatened the hope of patients with a life-threatening disease, as well as affecting their significant others (Kylmä et al. 2009). In sum, several psycho-socio-spiritual interventions and inspiring relationships, particularly peer support, engendered patients' hope, whereas losses had a negative impact on hope.

Consequences
The effects of hope bore a relationship to hope as resilience, since hope helps adversity to be endured, as described above. Nevertheless, the effects of hope cannot be reduced to hope as resilience. In (forensic) mental health care patients, hope was the motivation to change. This meant that hope helped these patients to see a new way of being and generated the belief that one's life is worth living. In that life, others who maintained hope were also important (Clarke et al. 2016). In the work of Leamy et al. (2011), hope was part of the contemplative phase of the transtheoretical model of change, after which-ideally-preparation, action, and maintenance and growth followed.
Hope affected the decisions of patients with cancer. For example, the hope for the future of patients with advanced cancer was an important drive in their decision to stop or continue anti-cancer therapy (Clarke et al. 2015). Hope for clinical benefit was the most commonly cited reason for clinical trial enrollment of young adults and adolescents with cancer (Forcina et al. 2018). This is in line with an earlier review study on the attitude toward research of patients with advanced cancer (Todd et al. 2009). In sum, hope was a motivation for change and it affected decisions on participation in research and on treatments. Hope in relation to treatments could also lead to ethical issues for health care providers, and this will be described below.

Ethics
The main ethical issue in relation to hope in health care was the tension between hope and truth/realism, which was addressed in palliative care. The moral background here is the duty of health care providers, especially physicians, to provide or maintain hope on the one hand, and to tell the truth, on the other. The tension between these two was intensified when patients avoided information about their poor prognosis or about the palliative rather than curative aims of a treatment (Barclay et al. 2011;Clarke et al. 2015;Clayton et al. 2008). Clinicians wanted to avoid "taking away hope" and did not want to alarm patients unnecessarily (Barclay et al. 2011;Clarke et al. 2015).
We found that the dilemma between hope and truth/realism is a dilemma between a realistic and functional perspective on hope. The former means that the basis of patients' hope should be truthful, which requires clinicians to adjust hope to truth, whereas the functional perspective acknowledges the helpfulness of hope as patients' way of coping with their disease, requiring clinicians to foster or maintain patients' hope (Olsman et al. 2014). Still, a focus on (the helpfulness of) hope and maintaining hope may lead to overlooking patients' other needs (Prip et al. 2018). In addition, clinicians may continue treatments, not only to maintain hope in their patients, but also because they have developed strong relationships with their patients (Clarke et al. 2015). A "solution" offered within the context of advanced cancer was to discuss prognosis and other issues honestly, providing it with understanding and empathy. In so doing, paradoxically, clinicians may foster hope (Clayton et al. 2008;van Gurp et al. 2013).

Discussion
The objective of this study was to describe hope in health care. As explained above, 73 review studies were included, covering a variety of health care contexts and the findings of these studies were thematically analyzed. This chapter suggests that hope is conceptualized as (1) an expectation: appraisal of a future outcome, (2) resilience: endurance of adversity, and (3) a desire: expression of meaning. Inspiring relationships, in particular relationships with peers, increase hope in patients. Losses, on the other hand, such as loss of health, relationships, or income, have a negative impact on hope. The findings also suggest that a central ethical issue is the tension between hope and truth in palliative care. Physicians want to be honest about poor prognosis and bad news, on one hand, while preventing harm and consequently not wanting to destroy patients' hope, on the other.
The three conceptualizations of hope can be placed against the philosophical background of Enlightenment, Romanticism, and Utilitarianism/Radical Enlightenment (cf. Taylor 1992). The idea of hope as an expectation can be seen against the background of the Enlightenment, in which reason is used to appraise a future outcome as realistically as possible. Hope as desire can be seen in relation to Romanticism, emphasizing the subjective experiences, including the meaning of these experiences for the individual. Hope as resilience can be understood against a background of Utilitarianism because of its focus on the consequences of hope, that it helps to endure (and minimize the effects of) adversity. Recognition of these backgrounds is essential because it helps to see that individuals not only conceptualize themselves in various ways (Gergen 2000), but they will also conceptualize their own hope in different ways.
For example, when the clinician tries to adjust hope to realism and the patient wants his desire to get better acknowledged, this may lead to conflict between them that harms their relationship. My suggestion for clinicians is to recognize the value of each conceptualization and address them as options. That would mean acknowledging a palliative care patient's unrealistic hope as a meaningful desire ("What does this hope mean to you?"), after which the clinician may ask, "Would you mind talking to me just once, about how you would feel if what you hope for were not to happen?" (Olsman 2015, pp. 115-120). Such a question also acknowledges the contradiction within patients who desire something unrealistic, while at the same time being aware that it may not come true (Olsman et al. 2015a;Robinson 2012;Sachs et al. 2013). Moreover, when the ethics of hope is limited to a binary contrast between the values of hope and realism/truth, health care providers tend to place themselves on the side of realism, while several studies suggest that health care providers may hold hopes that are unrealistic (Barclay et al. 2011;Buiting et al. 2011;Christakis and Lamont 2000;Clarke et al. 2015).
Therefore, I propose a relational approach to hope, which recognizes that hope plays a role for each individual and in relationships between individuals (Olsman 2015, pp. 115-120). I argue, in addition, that health care providers should build their relationship with patients by focusing on solicitude. Solicitude includes compassion (recognizing the patient's suffering) and empowerment (recognizing the patient's strengths) (Eliott 2013;Olsman et al. 2015b). Such an approach is furthermore important because relationships have the potential to foster hope. The importance of relationships in connection with hope has also been described in spiritual care (Capps 2001). The selected studies, in addition, suggest that peer support, in particular, can have a positive effect on hope, and this draws our attention to forms of peer support, something that deserves future research. One study, for example, suggested that besides its potential risks, peer support through online media has potential benefits, such as empowerment, an increase in hope, and resistance to stigma (Naslund et al. 2016).
The strength of this chapter is that, to the best of my knowledge, it provides a first overview of hope in various health care contexts, based on a systematic search in several databases. As well as providing this overview, it identifies gaps, offering possibilities for future studies. However, a limitation of this chapter is that the findings mainly apply to the so-called "Western" countries, requiring future studies to examine unexplored contexts. Another limitation is that only one author is responsible for the study, and as a consequence, it does not fit the criteria of a systematic review. Last but not least, an ongoing debate in hope research is how the objects of hope-in those cases where hope has an object-color (conceptualizations of) hope. It is, for example, worth exploring in future studies if objects of hope and conceptualizations of hope correspond.
In conclusion, the findings gained through this study have offered insight into hope in health care. This chapter has offered conceptual clarity on hope in health care and outlined the normative backgrounds and implications of these conceptualizations. In so doing, it offers several ways of addressing the (spiritual) topic of hope in clinical practice. I conclude that the ethics of hope needs to be developed in contexts other than palliative care and should be understood in terms wider than the dualism between hope and truth. A further conclusion is that future (synthesis) studies should examine the hope that is held by health care providers because their hope affects their care provision. My hope is that this chapter will support health care providers when they want to address the matter of hope during encounters with patients, patients' family members, and their colleagues. To map the state of the art of conceptualizing recovery, its promoting and impeding factors, recovery-oriented practice, and the assessment of recovery in mental illness Bauerreiß 2018 To synthesize the evidence of existential interventions in adult patients with cancer Deering 2018 To explore the lived experience of what activities might facilitate personal recovery for adults who continue to self-harm Forcina 2018 To identify perceptions and attitudes toward clinical trials in adolescents and young adults with cancer that influence trial participation Kharrat 2018 To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely premature infants Li 2018 To evaluate the efficacy of nursing interventions to increase the level of hope in cancer patients Orhan 2018 To systematically review the current evidence regarding the racial, ethnic and cultural alterations and differences in pain beliefs, cognitions, and behaviors in patients with chronic musculoskeletal pain Prip 2018 To summarize the literature of adult patients' experiences of and need for relationships and communication with healthcare professionals during chemotherapy in the oncology outpatient setting (continued) To assess the effectiveness of focused psychosocial support interventions, and to explore which children, exposed to traumatic events in humanitarian settings in low-and middle-income countries, are likely to benefit most Thomas 2018 To synthesize findings pertaining to the study of person-oriented recovery constructs in mental health care over time and concomitants of change van Eck 2018 To perform a meta-analysis investigating the relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders Wilson 2018 To examine the significance of factors associated with parents' treatment selection for their child with autism spectrum disorder Baek 2017 To examine attributes and verify the definition of the recovery-oriented psychiatric nursing concept, using the hybrid model suggested by Schwartz-Barcott and Kim Creighton 2017 To synthesize and summarize the studies examining the correlates and predictors of anxiety in older adults living in residential aged care Deslisle 2017 To map the available evidence on (1) (perceived) benefits of participating in rare disease support groups and (2) barriers and facilitators of establishing and maintaining these groups Ebenau 2017 To describe which life values play an important role in the lives of elderly people suffering from incurable cancer Machado 2017 To assess the effectiveness of interventions based on the constructs spirituality, happiness, optimism, and hope concerning the rehabilitation of adults and elderly Parslow 2017 To synthesize the qualitative studies of children's experiences of chronic fatigue syndrome/malgic encephalomyelitis Schiavon et al. 2017 To identify what the scientific literature says about the influence of optimism and hope on chronic disease treatment Broadhurst 2016 To review the qualitative literature and investigate the meaning of hope to patients receiving palliative care and to examine the themes that foster hope in those patients Clarke 2016 To review and narratively synthesize qualitative literature on forensic mental health patients' perceptions of recovery Firmin 2016 To better understand how stigma resistance impacts functioning-related domains Griggs 2016 To describe what is currently known about the role of hope in adolescents with a chronic illness Jones 2016 To investigate the role of spirituality in facilitating adjustment and resilience after spinal cord injury for the individual with spinal cord injury and their family members Laugesen 2016 To identify and synthesize the best available evidence on parenting experiences of living with a child with attention-deficit hyperactivity disorder, including their experiences of healthcare and other services Mahendran 2016 To examine the factors associated with hope and hopelessness in patients with cancer in Asian countries, and the instruments used to measure hope and hopelessness Oyesanya 2016 To examine and synthesize current literature focusing on women with traumatic brain injury, comorbid with depression, and hope (continued) To develop a model of the personal recovery process for people needing forensic mental health services Similuk 2016 To conduct a systematic review of the social, psychological, and behavioral literature on primary immune deficiency, provide a critical analysis, and synthesize with the broader literature Stenberg 2016 To give a comprehensive overview of benefits and challenges from participating in group based patient education programs that are carried out by health care professionals and lay participants, aimed at promoting self-management for people living with chronic illness Wayland 2016 To explore hope for families of missing people Weaver 2016 To identify current approaches to palliative care in the pediatric oncology setting to inform development of comprehensive psychosocial care standards for pediatric and adolescent patients with cancer and their families; and to analyze barriers to implementation and enabling factors Agli 2015 To systematically review the literature examining the effects of religion and spirituality on health outcomes such as cognitive functioning, coping strategies, and quality of life in people with dementia Best 2015 To identify what interventions are effective in treatment of holistic suffering of cancer patients Clarke 2015 To systematically review the literature concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on molecular targeted agents Soundy 2015 To consider and synthesize common experiences of motor neuron disease and better understand the effects of the illness on the patient's mental well-being and generalized hope Tong 2015 To describe patient experiences and attitudes to wait-listing for kidney transplantation Casellas-Grau 2014 To synthesize the evidence about the positive interventions utilized in breast cancer Germeni 2014 To synthesize published qualitative research to provide insight into patients' motivations for cancer information seeking and avoidance Jamieson 2014 To describe the experiences and perspectives of children and adolescents with cystic fibrosis to direct care toward areas that patients regard as important Lloyd-Evans 2014 To systematically review trials of community-based, peer-provided support for people with severe mental illness Olsman 2014 To describe healthcare professionals' perspectives on palliative care patients' hope found in the literature Soundy 2014a To help health-care professionals consider how hope is promoted and challenged during the rehabilitation of patients who have had a stroke or spinal cord injury Soundy 2014b To understand the importance of social identity and meaningful activities on well-being of individuals with Parkinson's disease, to identify factors and strategies that influence well-being and hope, and to establish a model that relates to an individual's hope and well-being van Mierlo 2014 To systematically examine the relationship between psychological factors and health-related quality of life after stroke (continued) To describe communication patterns in palliative care and discussing potential relations between communication patterns and upcoming telecare in the practice of palliative care Caboral 2012 To explore the construct of hope in elderly adults with chronic heart failure Connell 2012 To identify the domains of quality of life important to people with mental health problems Duggleby 2012 To report a meta-synthesis review of qualitative research studies exploring the hope experience of older persons with chronic illness Olver 2012 To describe the evolution of the definitions of hope in oncology Barclay 2011 To review the literature concerning conversations about end-of-life care between patients with heart failure and healthcare professionals, with respect to the prevalence of conversations, patients' and practitioners' preferences for their timing and content, and the facilitators and blockers to conversations Bright 2011 To clarify the concept of hope after stroke and to synthesize the findings to propose a working model of hope Leamy 2011 To synthesize published descriptions and models of personal recovery in mental illness into an empirically based conceptual framework Singh 2011 To provide a detailed overview of the literature to make an informed judgment on how teenage cancer services can be effectively delivered Stewart 2011 To conduct a systematic review of resilience and related concepts in the physically ill to determine factors associated with predicting or promoting resilience van Leeuwen 2011 To review the literature on relationships between psychological factors and quality of life of persons with spinal cord injury Duggleby 2010 To describe the hope experience of family caregivers of persons with chronic illness Livingston 2010 To provide a systematic review and meta-analysis of the extant research regarding the empirical relationship between internalized stigma and a range of sociodemographic, psychosocial, and psychiatric variables for people who live with mental illness Kylmä 2009 To describe the current status of research on hope in palliative care Todd 2009 To examine the literature on attitudes of patients with advanced cancer toward research and to define common themes Tutton 2009 To examine the perceptions of hope in health care with a particular focus on: the nature of hope in nursing, the relationship of hope to other related concepts, the experience of hope in some contexts, and the contribution of nursing Clayton 2008 To examine studies that have investigated sustaining hope during prognostic and end-of-life issues discussions with terminally ill patients and their families Schrank 2008 To define hope in psychiatry, review current approaches to assessment, and outline research evidence linking hope with effectiveness Wiles 2008 To explore how expectations and wants are distinguished in empirical research on hope and illness and the related issues of realistic hope and temporality (continued)  Chi 2007 To synthesize the literature, develop generalizations, and identify issues that should be evaluated in regard to hope and patients with cancer  To systematically review the literature on hope within interpersonal focused psychiatric/mental health nursing Davidson 2007 To explore the role of hope in heart disease and the potential utility of this construct in the development of nursing interventions  To systematically review the literature on hope within interpersonal focused psychiatric/mental health nursing, with a focus on the method used and the results Kylmä 2006 To describe the current status of research on hope and schizophrenia Lohne 2001 To review the literature on the concept of hope related to patients with spinal cord injury and its use in rehabilitation, and to explore the substantive areas of hope in the general and theoretical literature Baldacchino 2001 To identify those spiritual coping strategies used by the believers and nonbelievers followed by implications for holistic nursing care Kylmä 1997 To describe the ontological basis of hope and the epistemological solutions adopted in research on hope by reviewing research article concerned with the subject in the field of nursing science a In most instances the objective is a quotation derived from the abstract