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Supportive Care

Valerie Burger, RN, MA, MS, OCN®—Associate Editor

Fostering Hope in the Patient With Cancer Rebecca Lichwala, RN, BSN, OCN®

When a patient is diagnosed with cancer, feelings such as fear, anxiety, and hopelessness can negatively affect a person’s frame of mind. Hope can help a patient decrease anxiety and increase quality of life. Nurses should assess hope, provide interventions, be empathetic, listen, and treat patients with dignity to help improve hope and quality of life. This article features how hope can have a positive impact and provides specific information about how nurses can promote and foster hope in patients with cancer. Rebecca Lichwala, RN, BSN, OCN®, is an RN in the medical oncology unit at St. Joseph’s Hospital in Tampa, FL. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Lichwala can be reached at [email protected], with copy to editor at [email protected] Key words: hope; patients with cancer; quality of life Digital Object Identifier: 10.1188/14.CJON.267-269

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ancer can invoke fear and devastation, as well as cause physical and emotional changes to the person diagnosed with cancer (Mattioli, Repinski, & Chappy, 2008). Hope can be defined as a feeling of desire that something can be had or will happen (Cambridge Dictionaries Online, 2013). In nursing, hope is defined as a power that helps a person adapt to a situation, such as during suffering. Hope is an aspiration that an individual looks for in the future and an effective coping strategy in individuals diagnosed with cancer (Chi, 2007). Hope also provides individuals with a reason for living, maintaining high selfesteem, and helping to discover a meaning to their cancer diagnosis (Mattioli et al., 2008). Studies have suggested that people who have hope are more likely to develop meaningful coping strategies during cancer treatment, improving quality of life (QOL) (McLean, 2011).

The Cancer Diagnosis A cancer diagnosis is scary for patients and their families. Patients may become

hopeless when faced with a cancer diagnosis, its treatment and side effects, and the possibility of dying. Hopelessness can lead to detachment, depression, and even giving up (Sachs, Kolva, Pessin, Rosenfeld, & Breitbart, 2013). A new diagnosis of cancer puts patients at risk for unstable mood, anxiety, depression, and anger (Landmark, Bøhler, Loberg, & Wahl, 2008). Hopelessness can be a symptom of depression, and without hope, psychological symptoms may present and mental well-being may decline (Herth, 1995; Sachs et al., 2013). Patients reported that when they experienced pain or other poorly controlled side effects, they felt a sense of hopelessness and depression (Sachs et al., 2013). However, when pain is controlled, patients reported feeling a better sense of hope. Even when patients were referred to hospice for pain control, feelings of hopelessness improved and an increased sense of hope was reported (Sachs et al., 2013). Increased fatigue also has a negative impact on a patient’s level of hope. Patients who reported persistent fatigue

Clinical Journal of Oncology Nursing • Volume 18, Number 3 • Supportive Care

that interfered with their daily life also reported lower levels of hope (Shun, Hsiao, & Lai, 2011). Hope can help patients cope with a cancer diagnosis. Hope in patients with cancer provides an increased sense of well-being, a positive outlook on a cancer diagnosis, and a reason for living (Saleh & Brockopp, 2001). Hope can allow a person to adapt during a period in their life when they may be suffering (Kavradim, Özer, & Bozcuk, 2013). Hopelessness has been associated with an eagerness for accelerated death and a lower QOL (Sachs et al., 2013). However, hope can provide patients with a positive sense of physical and mental well-being (Herth, 2000).

Assessment of Hope The Herth Hope Index (HHI) assesses the levels of hope in patients. Although the HHI is not the only scale created to assess hope, it has been widely used in the literature and is designed for patients who are critically ill. The HHI consists of 12 questions and uses a four-point Likerttype scale. Scores range from 12–48, with higher scores indicating higher levels of hope (Herth, 2000; Rustøen, Cooper, & Miaskowski, 2011). Using the HHI, nurses can evaluate patients at various points in their cancer journeys. The HHI is an easy, consistent assessment tool used all over the world, and it has been translated into five languages (Herth, 2000). QOL also may be assessed with patients’ hope levels. QOL and hope have been linked together and are shown to be part of an important coping strategy (Rustøen, Wiklund, Hanestad, & Moum, 1998). Many tools exist that assess a patient’s QOL, including the Quality of Life Index and the Cancer Rehabilitation 267

TABLE 1. Support Programs for Patients With Cancer Program

Description

Look Good Feel Better®

Cosmetologists teach patients how to use cosmetic products specific to their skin and hair changes caused by their cancer treatments.

Online communities and support groups

Three online support groups, WhatNext™, Circle of Sharing™, and Cancer Survivors Network, offer a support program for patients with cancer to discuss what they are going through.

Online educational classes

I Can Cope® is an educational class providing online education to patients and family members about the cancer diagnosis, treatment, and managing side effects such as emotional changes.

Patient Navigator Program

Provided by the American Cancer Society, this program matches patients with a patient navigator to give one-on-one guidance specific to each patient.

Reach to Recovery®

This program pairs patients with breast cancer with volunteers to help guide the patient through their diagnosis and treatment.

Tell your story

Patients are allowed the opportunity to tell their story, helping other patients with cancer to cope with their diagnoses.

Note. Based on information from the American Cancer Society, 2013.

and Evaluation Systems questionnaire (Herth, 2000).

Positive Effects of Hope Many things can have a positive effect on a patient’s level of hope, including having a strong family relationship and family support that helps patients cope with their diagnoses and treatments (Mattioli et al., 2008; Sachs et al., 2013). Spirituality also has a positive effect on hope levels. However, patients with cancer can develop spiritual distress because of their cancer diagnoses, which can cause physical suffering; therefore, nurses should provide the appropriate patient resources to address spiritual needs (McClement & Chochinov, 2008). Patients reported that they felt anxious when experiencing negative interactions with their healthcare provider (Reb, 2007). Healthcare providers should recognize patients with high levels of stress and be sensitive to their psychosocial needs. After recognizing a patient at risk of stress and anxiety, the healthcare provider should individualize appointments and schedule follow-up at regular intervals to help enhance communication (Reb, 2007). The nursing staff and other healthcare providers can become a support system and a positive influence for patients. Patients reported feeling an increase in hope when they felt that their 268

healthcare providers provided emotional support and education, as well as listened and responded to questions and concerns empathetically and without judgment. (Koopmeiners et al., 1997).

During End of Life Advanced-stage cancer may challenge a person to change their focus and personal definition of hope. Patients may develop new goals in life, such as having hope for dignity, comfort, and close relationships (Sachs et al., 2013). Patients with a serious and potentially life-threatening diagnosis may use hope as a way to obtain realistic goals, not necessarily hope for a cure or more years of life (Herth, 2000). Patients may develop fears related to inadequate symptom management. Therefore, nurses should put their primary focus on managing patients’ symptoms to reduce stress and increase hope. Nurses can help guide patients to find a sense of meaning in their life by remembering positive moments in their lives, called dignity therapy (McClement, & Chochinov, 2008). Having hope can increase QOL in patients who have an advanced-stage cancer.

Interventions Many intervention studies have been performed using specific interventions to help enhance hope. The results of

those studies revealed that providing interventions to enhance hope improves hope levels (Chi, 2007). Those results demonstrated that nurses should take action to help enhance patients’ level of hope. Intervention studies can be patient guided, such as using multimedia, or they can be nurse guided. Nurse-guided interventions involve multiple counseling sessions, which develop coping skills and increase hope.

Patient-Guided Interventions Multimedia can increase a patient’s level of hope. Cancer centers can incorporate CD-ROMs (or web-based programs that a patient can use at home on their own time. A nurse can call after a defined period of time to follow-up with the patient, or an interview can be done at his or her next appointment to evaluate levels of hope. Oh and Kim (2010) used multimedia in a study, providing patients with a CD-ROM, a booklet, and a telephone counseling session. This intervention showed high scores in fighting spirit and self-care behaviors (Oh & Kim, 2010). A video also could be created by nursing staff. The main foci of the video should be related to developing coping skills, symptom and stress management, increasing fighting spirit, strengthening social relationships, overcoming negativity, achieving functional wellness, and setting goals (Oh & Kim, 2010). The video would focus on a patient (one of the staff nurses) and their course of treatment, showing coping techniques that decrease anxiety and stress, maintain a healthy lifestyle, and improve social relationships (Oh & Kim, 2010). An activity can be completed after the video to see if the intervention was helpful for patients (Duggleby et al., 2007). A benefit of patient-guided interventions is the ease of delivering the intervention and the cost effectiveness of the intervention (Oh & Kim, 2010).

Nurse-Guided Interventions Studies have shown that providing guided counseling sessions within a group increased patient hope levels (Rustøen et al., 2011). Nurses would need special training in counseling to conduct the sessions (Rustøen et al., 1998). However, if the cancer center has a designated counselor, he or she can lead the guided session, and the nurse would refer the patient to the

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counselor. The guided sessions should focus on developing coping strategies, with discussion topics such as searching for hope, connecting with others, spirituality, and building up hope (Herth, 2000). Other discussion topics can include emotional reactions, relationships with others, belief in one’s self, active involvement in health care, and acknowledging that a future exists (Rustøen et al., 2011). An overview of the sessions should include establishing trust within the group and background information about each participant. During these sessions, participants’ fears and questions should be answered, and participants should identify things in their life that either threaten their hope or raise their hope levels (Herth, 2000). Family and friends should be invited to one of the group sessions. Information about support groups can be given to patients, and the importance of family and friends can be discussed. Baseline hope levels are gathered prior to the initiation of therapy and after the sessions are complete.

Barriers to Fostering Hope Nurses may find it hard to adequately assess patients and implement a hope intervention in a particular timeframe. They also may not have time to get training in counseling patients. The importance of this article is to not only provide information on hope interventions, but also to educate nurses. If the nurse is not able to provide a hope intervention to the patient, they can provide the patient and family with resources on how to increase hope (see Table 1).

Nursing Implications The identified gap between the literature and bedside nursing is that hope is not assessed and interventions are not routinely initiated on patients. The literature explains the importance of hope and interventions (Herth, 2000). However, hope should be assessed with all patients when they are diagnosed with cancer and at different stages of their cancer treatment. Nurses can implement a hope assessment scale, such as the HHI, so that patients with low levels of hope can be identified and an intervention can be implemented. Some patients experience negative side effects that lower hope

scores, including mouth ulcers, anxiety, fear, and pain (Kavradim et al., 2013). Therefore, nurses can improve hope levels by identifying and appropriately treating side effects early. Nurses should build relationships with their patients, providing positive interactions that decrease patient anxiety and increase hope. Finding, recommending, and educating patients about support groups is a task that nurses can undertake to help their patients. This can, in turn, increase a patient’s level of hope. Nurses also can initiate a hope intervention in their facility for patients with cancer. In addition, nurses can develop several characteristics to enhance hope levels, such as caring, listening, giving respect, being present, being honest, and showing compassion (Mattioli et al., 2008). By enhancing patient hope, nurses can increase patient QOL, foster patient acceptance of the diagnosis, and decrease patient anxiety, depression, and stress (McClement & Chochinov, 2008).

References American Cancer Society. (2013). Find support programs and services in your area. Retrieved from http://www.cancer.org/ treatment/supportprogramsservices/ index Cambridge Dictionaries Online. (2013). Hope. Retrieved from http://dictionary .cambridge.org/us/dictionary/american -english/hope_1?q=hope Chi, G.C. (2007). The role of hope in patients with cancer. Oncology Nursing Forum, 34, 415–424. doi:10.1188/07.ONF.415-424 Duggleby, W.D., Degner, L., Williams, A., Wright, K., Cooper, D., Popkin, D., & Holtslander, L. (2007). Living with hope: Initial evaluation of a psychosocial hope intervention for older palliative home care patients. Journal of Pain and Symptom Management, 33, 247–257. Herth, K. (1995). Engendering hope in the chronically and terminally ill: Nursing interventions. American Journal Of Hospice and Palliative Care, 12, 31–39. Herth, K. (2000). Enhancing hope in people with a first recurrence of cancer. Journal of Advanced Nursing, 32, 1431–1441. Kavradim, S.T., Özer, Z.C., & Bozcuk, H. (2013). Hope in people with cancer: A multivariate analysis from Turkey. Journal of Advanced Nursing, 69, 1183–1196. Koopmeiners, L., Post-White, J., Gutknecht, S., Ceronsky, C., Nickelson, K., Drew, D., . . . Kreitzer, M.J. (1997). How health-

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care professionals contribute to hope in patients with cancer. Oncology Nursing Forum, 24, 1507–1513. Landmark, B., Bøhler, A., Loberg, K., & Wahl, A. (2008). Women with newly diagnosed breast cancer and their perceptions of needs in a health-care context. Journal Of Nursing and Healthcare Of Chronic Illnesses, 17, 192–200. Mattioli, J.L., Repinski, R., & Chappy, S.L. (2008). The meaning of hope and social support in patients receiving chemotherapy. Oncology Nursing Forum, 35, 822–829. doi:10.1188/08.ONF.822-829 McClean, P. (2011). Balancing hope and hopelessness in family therapy for people affected by cancer. Australian and New Zealand Journal of Family Therapy, 32, 329–342. McClement, S.E., & Chochinov, H.M. (2008). Hope in advanced cancer patients. European Journal of Cancer, 44, 1169–1174. Oh, P.J., & Kim, S.H. (2010). Effects of a brief psychosocial intervention in patients with cancer receiving adjuvant therapy [Online exclusive]. Oncology Nursing Forum, 37, E98–E104. doi:10.1188/10.ONF.E98-E104 Reb, A.M. (2007). Transforming the death sentence: Elements of hope in women with advanced ovarian cancer [Online exclusive]. Oncology Nursing Forum, 34, E70–E81. doi:10.1188/07.ONF.E70-E81 Rustøen, T., Cooper, B.A., & Miaskowski, C. (2011). A longitudinal study of the effects of a hope intervention on levels of hope and psychological distress in a communitybased sample of oncology patients. European Journal of Oncology Nursing, 15, 351–357. doi:10.1016/j.ejon.2010.09.001 Rustøen, T., Wiklund, I., Hanestad, B., & Moum, T. (1998). Nursing intervention to increase hope and quality of life in newly diagnosed cancer patients. Cancer Nursing, 21, 235–245. Sachs, E., Kolva, E., Pessin, H., Rosenfeld, B., & Breitbart, W. (2013). On sinking and swimming: The dialectic of hope, hopelessness, and acceptance in terminal cancer. American Journal of Hospice and Palliative Medicine, 30, 121–127. doi:10.1177/1049909112445371 Saleh, U., & Brockopp, D. (2001). Hope among patients with cancer hospitalized for bone marrow transplantation: A phenomenologic study. Cancer Nursing, 24, 308–314 Shun, S.C., Hsiao, F.H., & Lai, Y.H. (2011). Relationship between hope and fatigue characteristics in newly diagnosed outpatients with cancer [Online exclusive]. Oncology Nursing Forum, 38, E81–E86. doi:10.1188/11.ONF.E81-E86 269

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Fostering hope in the patient with cancer.

When a patient is diagnosed with cancer, feelings such as fear, anxiety, and hopelessness can negatively affect a person's frame of mind. Hope can hel...
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