Hope in Cancer Patients with Depression

Hope is a highly valued concept in nursing. According to the North American Nursing Diagnosis Association, hope drives individuals to act, move and achieve goals with the aim of reaching their objectives in regards to treatment (Keenan, Falan, Heath, & Treder, 2003). Recent studies reveal that in the process of treatments, particularly chemotherapy, hope has a tendency of cancer patients to boost their energy and wellness (Lin & Bauer, 2003). In the taxonomy of the North American Nursing Diagnosis Association, this kind of expectation is referred to as the ‘readiness for hope’. It is also worth noting that the enhanced hope for nursing diagnosis is divided into two spheres which include generalized and particularized. The latter has the aim of achieving a particular objective regarding treatment in cancer patients. The objective of this paper is to study the concept of hope in cancer patients with depression. Recently it has garnered attention due to various studies, theories developed, and assessment tools used to measure it. 

At its core, hope is the ability to produce pathways for achieving desired goals and motivating oneself using those pathways (Snyder, Rand & Sigmon, 2002). It is described as the ability of cancer patients to stay motivated to achieve the goal of healing. The patient’s ability to remain hopeful is beneficial when it comes to life-threatening diseases such as cancer. Recent studies reveal that in both oncology and palliative care of cancer patients, hope plays a critical role in the quality of life the patients are likely to lead (El Nawawi, Balboni,&Balboni, 2012). Hopelessness may be mismatched with other features like depression, leaving cancer patients with other issues such as dealing with existential concerns andfeeling uncomfortable despite regularly takinganti-depressants. 

Particularly, hope is of great benefit to cancer patients because of the disruptive nature of the illness that has to involve considerable resources either for healing to be achieved or in the entire treatment process. According to Herth (1990), the ability of nurses among other health care professionals to understand the concept of hope is critical to not only individual experiences of treatment and recovery but also to supportive mechanisms. Furthermore, nurses and health professionals, in generalhave an ethical obligation of giving hope and being consistent sources of hope for those experiencing life-threatening diseases, such as cancer. Though an invisible experience, hope is critical particularly for cancer patients that have mental illnesses such as depression. 

Depression is a common form of psychological distress faced by the majority of cancer patients. With the ever-increasing number of cancer cases across the world, demands have been placed on the healthcare system to address this issue of depression. Recent studies reveal that the treatment of cancer is not determined by the state of becoming cancer-free, but the ability to achieve psychosocial well-being and qualityof life (Zebrack&Zeltzar, 2003). That is why the concept of hope combined with optimism has received great attention in oncology. In regards to cancer,hope has been associated with the ability of patients to cope with the illness, thus increasing their well-being as well as the quality of life they lead, and lowering symptoms of mental illnesses such as depression. (Ho et al., 2011) define hope as a positive motivational state that comprises the components of pathways and agency. The latter initiates and sustains movement in achieving a goal while the former generates routes deemed successful to achieve an objective. 

Saracino, Rosenfield,and Nelson (2018) indicate that there is the presumption that all people with cancer should be depressed. On the contrary, this is not usually the case. There is a likelihood that health professionals may underestimate the morbidity caused by depression among cancer patients due to presumption. Nurses and health professionals should use screening tools and also raise awareness about depression. Furthermore, research reveals that there is a tendency of nurses to recognize the levels of depressive symptoms particularly in patients living with cancer (Fische, Cripe,& Rand, 2018). 

Regardless of nurses being sources of hope for such patients, it is worth noting that hope is associated with various aspects of psychological distress such as depression in patients that have either been diagnosed with, are undergoing treatment for cancer, or are in the advanced stages of cancer. Often, psychological distress in the form of depression arises from hardships and uncertainties associated with cancer. Research reveals that the potential predictors and mediators of depression among cancer patients include the fear of death, high costs of treatment associated, and treatment decisions that could destabilize their lives (Williams, 2019). Giving hope to cancer patients is thus important as it has implications on decisions regarding treatment as well as the outcomes. In his study (Reinkeet al., 2010) concluded that hope reduces the likelihood of cancer patients making treatment decisions in reaction to psychological distress such as depression and increases the likelihood of making decisions that are in alignment with stable life values. 

Herth (1990) reveals that within the domain of nursing the concept of hope has been defined differently under various studies. For instance, Korner in his studies defines hope as a health and well-being precursor that buffers psychological distress such as depression through serving as a coping strategy and enabling self-transcendence (Herth, 1990). On the other hand, Beck et al., (1974) highlighted hope in cancer patients in the relation to life expectancy, level of hope, and coping which confirms Herth’s study of measuring hope and coping response among cancer patients using scales. How hope has been conceptualized and defined by previous studies underpins individual opinions and views about strategies that can be used in various stages of cancer in order for hope to be manifested. There has to be a definite goal to be achieved at the end of the hoping process, which in the case of cancer patients is either to recover or survive many years despite the terminal disease. Generally, the assertions given in these studies in a bid to define hope is the implication that psychological distress such as depressiontakes place among individuals experiencing terminal illnesswhich can then force them to make changes to their personal beliefs enabling them to move forward. 

Theories 

Snyder’s Hope Theory 

Coined by an American psychologist Charles Richard Snyder, hope theory is inclusive of goals, paths, and the freedom of choice. Snyder defines hope as the perceived ability to walk certain paths leading to the desired destination (Snyder et al, 2000). He adds that to remain on these paths, people ought to stay motivated. Based on Snyder’s hope theory, more research has been conducted to increase levels of hope for physical health and well-being in cancer patients that have mental issues such as depression. According to Snyder, Lopez, Shorey, Rand,and Feldman (2018), there are three components that people need to relate to in order to be termed as being hopeful. These include having focused thoughts, development of strategies to achieve these thoughts, and being motivated to achieve these thoughts. 

Furthermore, Snyder’s theory is characterized by three main features or rather characteristics: goals, pathways thinking, and agency thinking (Nweze, Agom, Agom & Nwankwo, 2015). Goals are targets of mental actions and provide the cognitive element in which hope theory is anchored. According to Snyder, human actions are goal-oriented, regardless of being long-term or short-term. In the case of depressed cancer patients, there is uncertainty for recovery as well as long life due to the life-threatening nature of the disease. However, cancer patients are able to be hopeful if they have an objective or goal of recovery. Snyder further reveals that in order for people to attain their goals, they have to generate pathways (Snyder, Ilardi, Cheavens, Michael, Yamhure & Sympson, 2000). 

Similarly, for cancer patients with depression, they have to have perceived capabilities of achieving recovery or a long life. When encountering psychological distress and impediments such as cancer, patients can remain hopeful through the generation of numerous pathways to achieve the desired goal. 

Agency thinking, on the other hand, as a feature of Snyder’s hope theory is the capacity to use the generated pathways to achieve the desired goal (Lopez, Snyder,& Pedrotti, 2003). At its core, agentic thinking reflects personal thoughts about moving along a particular pathway and remaining on that path in order to achieve progress and eventually the desired objective. 

In a recent study that sought to elaborate Snyder’s hope theory in the context of lung cancer, authors reveal that it is one of the leading causes of cancer deaths in the United States (Steffen, Vowles, Smith, Gan & Eldeman, 2018). The prognosis of lung cancer is poor with low survival rates of approximately 15 and 41 percent for not more than five years following diagnosis and the onset of treatment (Berendes et al., 2010). Notably, patients diagnosed with cancer often undergo aggressive treatments that are likely to cause pain and fatigue. The uncertainty in diagnosis and treatment can increase psychological distress such as depression. Despite the challenges of living under depression with cancer, some patients are capable of maintaining hope for the future while others are not. Snyder’s theory of hope has received great attention particularly among cancer patients living with depression. This is because patients that have high levels of hope characterized by Snyder’s three key features have been associated with a positive mood, ability to cope with distress, and lower depression symptoms (Snyder et al., 2003). 

With its lethality, associated stigma, and patient burden, the diagnosis of lung cancer becomes a challenge for patients. A recently conducted study reveals that daily hope (commonly defined as goal-oriented and having strategies and plans to meet those goals) is critical to the proper function and reduction of depressive symptoms in patients receiving cancer treatment (Snyder et al., 2003). Based on this study, results reveal that hope is associated with the proper psychological functioning of lung cancer patients. Hope may, therefore be an appropriate intervention that targets supporting the psychological well-functioning of cancer patients as well A 

Immanuel Kant and Hope 

Besides Snyder, philosopher Immanuel Kant also gives significance to the concept of hope. Kant defines hope as an unexpected offering of the prospect of immeasurable good fortune. From the standpoint of the psychology of individual humans, Kant suggests that hope occupies a central place in human beings by focusing on the concept that allows human beings to relate with issues they have no control over. For instance, in the case with cancer patients, from a Kantian perspective, hope is connected with the ability to have a belief in God. Kant’s theory of hope is characterized by three main features which include one’s happiness, progress, and improvement (Paley, 2002). Therefore, for depressed cancer patients, the aim is to achieve happiness amidst the pain and fatigue, improve in areas such as treatment decisions, and sequentially make progress to achieve the desired goal of long life or full recovery. 

Florence Nightingale and Hope 

A famous theorist of nursing practice, Florence Nightingale also touched on hope. Though an environmental theory, it applies canons and concepts that are a guide for patients and nurses. One of these canons is shattering hope. According to Nightingale,shattering hope is the attempts made by friends and attendants to cheer the patients but end up doing the opposite (Hudson, 2006). The theorist is keen to warn against giving false hope particularly to terminally ill patients. Such false hope exaggerates the probabilities of their recovery (Ladwig, Ackley & Makic, 2019). 

For instance, in the process of diagnosing breast cancer, a study reveals that health care workers should avoid giving false hope. Health professionals and nurses can break the news to the patient in such a way without having to impact the patient’s optimism. False hope is likely to increase depressive symptoms among cancer patients. Another study reveals that terminally ill patients are often depressed and need intrinsic hope which is more realistic in oncology. In another study, palliative patients who have strong hope may be misunderstood by health professionals. However, false hope should not be given to patients because it ultimately has a negative impact on their psychological well-being. 

Nursing Assessments 

De Groot, Triemstra, Paans & Franke (2019) indicate that nursing assessment is the first step of the nursing process that involves the systematic and continuous collection of data (analyzing, sorting, and organizing), and the documentation and communication of said data. The oncology nurse is expected to be an expert in assessing both physical and emotional health statuses, the health history of the patient, and the knowledge of both the patient and the family. It is also essential for the oncology nurse to be aware of the test results and general implications from pathology, the laboratory, and imaging. Also, the assessment of the patient’s knowledge of the disease is critical in reducing symptoms of anxiety and depression. Thorough assessment and preparation of the patient are also deemed necessary because it improves compliance with the treatment, increases hope among cancer patients, and reduces symptoms of depression. 

Assessment for hope in cancer patients, however is based on the expression of believing in possibilities, the setting of achievable goals that are in line with their values, designing strategies to achieve goals, and exhibition of zest for life (Ladwig, Ackley & Makic, 2019). Therefore, before assessing for hope, it is important for the oncology nurse to have a thorough medical history of the patient including psychological well-being. Recent studies reveal that there are numerous reliable and valid tools used for assessing hope in cancer patients. These include the Herth Hope Scale (HHS), Herth Hope Index (HHI), Miller Hope Scale, and the Nowotny Hope Scale, among others. 

The HHI’s assessment tools are based on the conceptualization of hope; a life force that is characterized by confidence yet uncertainty in the achievement of a goal whereby an individual’s hope for something is realistically possible and significant (Alidina &Tettero, 2010). The HHI is extensively used for cancer patients and is based on three main factors. The first factor measures cognitive-temporal dimension with an outlook of goals.The second indicates the confidence of achieving the desired outcomes, and the third factor looks at measurement of interdependence between self and others (Rustoen, Lerdal, Gay,& Kottorp, 2018). The reliability and validity of the HHI are good. The HHI has been translated into various languages. Additionally, the Chinese version of HHI has been used to investigate hope and pain in cancer patients (Lin, Lai, & Ward, 2003). In another study, the HHI has been used for hope and health locus of control among cancer patients (Lin & Tsay, 2005). 

In order to classify cancer patients as hopeless, at risk of hopelessness, or hopeful using the HHI, it is necessary that the 12 items are answered correctly and the procedure runs as required. Usually, the total possible score points is 48. Scoring information for the patient is achieved by adding points from the subscale to those of the total scale. Cancer patients with lower scores on the HHI are diagnosed with lower levels of hope. 

Nowotny Hope Scale 

At its core, the Nowotny Hope Scale (NHS) is based on the definition that hope is the multidimensional attribute of an individual. Made up of 29 items, the NHS has six factors all of which are supported by Snyder’s hope theory. The use of this scale in assessing hope in cancer patients has not been dominant in literature. However, studies reveal it is important in the measurement of spirituality which is an important intervention plan for cancer patients with depression. The study found out that hope is significant in wellbeing and helps patients find meaning amidst the terminal illness and the painful process of treatment. In another study, the Norwegian version of the Nowotny Hope Scale was applied to cancer and results revealed its validity and reliability in the measure of hope among cancer patients in Norway (Wahl et al., 2004). 

Miller Hope Scale 

The Miller Hope Scale consists of 40 items and is reliant on the definition of hope as an anticipation of the continued good state, an improved state, or the release from the perception of feeling trapped. Factor analysis of the Miller Hope Scale is based on satisfaction with self, avoidance of feeling trapped and lacking future plans, and having expectations for the future (Miller, 1986). Previous studies reveal that the Miller Hope Scale is widely used as a tool to assess hope among cancer patients with depression. Using the Miller Hope Scale, if the patient does not meet the required score in the three factors of analysis, they are diagnosed as either hopeless or at risk of hopelessness. 

Application 

In recent years, studies have given more attention to the role of hope in cancer patients suffering from depression. While most of the knowledge is theoretical, the development of assessment tools to analyze for hope has been ongoing. Based on the above hope assessment tools, it is worth noting that cancer patients that have low scores are correlated to psychological distress such as depression and anxiety. These tools have also been used in various evidence-based research in numerous countries to assess hope. Based on the findings in the nursing diagnosis, it is important for nurses and health care providers to intervene using various strategies to increase hope among depressed cancer patients. 

Nursing Intervention 

It is well known that the process of diagnosis, treatment, and challenges of surviving increases psychological distress among cancer patients. Therefore, increasing hope is critical for the process of treatment and psychological wellbeing of patients. This nursing intervention has proven to increase and improve hope by promoting psychological wellbeing and decreasing psychological problems such as depression (Jacobsen & Jim, 2008). Based on the score of the patients in the area of assessment tools, the nurse will plan for intervention. Nurses can develop an open and empathetic relationship, as well as create an environment that encourages the client to discuss hope. Based on the previous study, results reveal that time spent with patients can inspire hope. 

Nurses should also focus on the positive aspects of remaining hopeful rather than on hopelessness. This is because hope as a multidimensional construct has been regarded as a fundamental human need particularly among terminally ill patients. Research reveals that cancer patients that are hopeless are likely to have increased symptoms of depression and despair (Abbey, Rosenfeld, Pessin & Breitbart, 2006). This can sequentially affect the outcome as well as the treatment decisions. Also, with the help of nurses, patients can learn to have positive anticipations and recognize the necessary pathways through which to achieve desired outcomes. 

Notably, helping the patient develop realistic goals for their recovery is also critical in nursing intervention for cases of hopelessness among depressed cancer patients. Furthermore, realistic goals give a realistic sense of hope. They also avoid false hopes that could worsen hope in a patient if they had set unrealistic goals and failed to achieve them (Ladwig, Ackley & Makic, 2019). Not only should goals be developed but also set and written down. Additionally, the steps taken to achieve that goal should be discussed by both the patient and the nurse. For instance, if a cancer patient sets a goal of adding realistic weight, they can come up with a nutrition plan for achieving that goal. Research reveals that having structured goals improves hope which sequentially reduces the symptoms of depression among cancer patients (Rustoen et al., 1998). 

The provision of emotional support and encouragement of hope is also an important intervention plan among cancer patients. At its core, emotional support is the summation of messages and actions that assure an individual that they are cared for, loved, and valued (Mansano-Schlosser, Ceolin & Valerio, 2017). Emotional support is centered on comfort and security during times of psychological distress such as depression while undergoing cancer treatment or even upon diagnosis. 

Emotional support plays a critical role in the mental wellbeing of cancer patients. Studies reveal that emotional support and encouragement of hope is linked with a better quality of life and decreased rates of morbidity and mortality. Encouragement of hope and being emotionally supportive can be done through family members, friends, and health professionals. Solano da Silva, Soares, Ashmawi and Vieira (2016) believe that the holistic and personalized approach in the treatment and care of cancer patients requires attention to be given to their spirituality and hope. They are deemed as resources for coping with cancer as well as improving wellbeing. 

In conclusion, nurses play a major role in improving hope among cancer patients that are faced with psychological distress such as depression. Hope as a concept in nursing has been defined by various researchers based on the population of the study. The HHI scale which has been extensively used in the measurement of hope among cancer patients, has defined hope as the ability to have self-motivation of achieving set goals. In addition, various theorists such as Snyder, Nightingale, and Kant have defined hope in different ways. Snyder’s definition of hope is the perceived ability to achieve desired goals and to motivate oneself to use those pathways is the most eligible for cancer patients. This is because cancer patients often experience hopelessness due to the fact that they are suffering from a life-threatening disease. Therefore, nurses should be keen to assess for hope using valid and reliable tools such as the HHI scale, Miller Hope Scale, and the Nowotny Hope Scale. Based on the score of the patient they can then intervene in various ways such as encouraging emotional support, helping patients to not only develop but also set realistic goals, establishing a relationship and environment in which empathy is shown to the patient and they are allowed to talk about hope. Improving hope among cancer patients is key to the reduction of psychological symptoms such as depression. This is where the role of nurses in oncology is critical. 

References 

Abbey, J. G., Rosenfeld, B., Pessin, H., & Breitbart, W. (2006). Hopelessness at the end of life: The utility of the hopelessness scale with terminally ill cancer patients.  British Journal of Health Psychology ,  11 (2), 173-183. 

Alidina, K., & Tettero, I. (2010). Exploring the therapeutic value of hope in palliative nursing.  Palliative & Supportive Care ,  8 (3), 353-358. 

Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The hopelessness scale.  Journal of Consulting and Clinical Psychology ,  42 (6), 861. 

Berendes, D., Keefe, F. J., Somers, T. J., Kothadia, S. M., Porter, L. S., & Cheavens, J. S. (2010). Hope in the context of lung cancer: Relationships of hope to symptoms and psychological distress.  Journal of Pain and Symptom Management ,  40 (2), 174-182. 

De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews.  Journal of advanced nursing ,  75 (7), 1379-1393. 

El Nawawi, N. M., Balboni, M. J., & Balboni, T. A. (2012). Palliative care and spiritual care: The crucial role of spiritual care in the care of patients with advanced illness.  Current Opinion in Supportive and Palliative Care ,  6 (2), 269-274. 

Fischer, I. C., Cripe, L. D., & Rand, K. L. (2018). Predicting symptoms of anxiety and depression in patients living with advanced cancer: The differential roles of hope and optimism.  Supportive Care in Cancer ,  26 (10), 3471-3477. 

Herth, K. (1990). Fostering hope in terminally ‐ ill people.  Journal of Advanced Nursing ,  15 (11), 1250-1259. 

Ho, S., Rajandram, R. K., Chan, N., Samman, N., McGrath, C., & Zwahlen, R. A. (2011). The roles of hope and optimism on posttraumatic growth in oral cavity cancer patients.  Oral Oncology ,  47 (2), 121-124. 

Jacobsen, P. B., & Jim, H. S. (2008). Psychosocial interventions for anxiety and depression in adult cancer patients: Achievements and challenges.  CA: A Cancer Journal for Clinicians ,  58 (4), 214-230. 

Keenan, G., Falan, S., Heath, C., & Treder, M. (2003). Establishing competency in the use of the North American Nursing Diagnosis Association, nursing outcomes classification, and nursing interventions classification terminology.  Journal of Nursing Measurement ,  11 (2), 183-198. 

Ladwig, G. B., Ackley, B. J., & Makic, M. B. F. (2019).  Mosby's Guide to Nursing Diagnosis E-Book . Elsevier Health Sciences. 

Lin, C. C., & Tsay, H. F. (2005). Relationships among perceived diagnostic disclosure, health locus of control, and levels of hope in Taiwanese cancer patients.  Psycho ‐ Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer ,  14 (5), 376-385. 

Lin, C. C., Lai, Y. L., & Ward, S. E. (2003). Effect of cancer pain on performance status, mood states, and level of hope among Taiwanese cancer patients.  Journal of Pain and Symptom Management ,  25 (1), 29-37. 

Lopez, S. J., Snyder, C. R., & Pedrotti, J. T. (2003). Hope: Many definitions, many measures. 

Mansano-Schlosser, T. C., Ceolim, M. F., & Valerio, T. D. (2017). Poor sleep quality, depression and hope before breast cancer surgery.  Applied Nursing Research ,  34 , 7-11. 

Miller, J. F. (1986).  Development of an instrument to measure hope  (Doctoral dissertation). 

Nweze, O. J., Agom, A. D., Agom, J. D., & Nwankwo, A. (2015). A critical analysis of the concept of hope: The nursing perspective.  International Journal of Science and Research ,  4 (3), 1027-1030. 

Paley, J. (2002). Virtues of autonomy: the Kantian ethics of care.  Nursing philosophy ,  3 (2), 133-143. 

Reinke, L. F., Shannon, S. E., Engelberg, R. A., Young, J. P., & Curtis, J. R. (2010). Supporting hope and prognostic information: Nurses' perspectives on their role when patients have life-limiting prognoses.  Journal of Pain and Symptom Management ,  39 (6), 982-992. 

Rustøen, T., Lerdal, A., Gay, C., & Kottorp, A. (2018). Rasch analysis of the Herth Hope Index in cancer patients.  Health and Quality of Life Outcomes ,  16 (1), 196. 

Saracino, R. M., Rosenfeld, B., & Nelson, C. J. (2018). Performance of four diagnostic approaches to depression in adults with cancer.  General Hospital Psychiatry ,  51 , 90-95. 

Smith, H. R. (2015). Depression in cancer patients: Pathogenesis, implications, and treatment.  Oncology Letters ,  9 (4), 1509-1514. 

Solano, J. P., da Silva, A. G., Soares, I. A., Ashmawi, H. A., & Vieira, J. E. (2016). Resilience and hope during advanced disease: A pilot study with metastatic colorectal cancer patients.  BMC Palliative Care ,  15 (1), 70. 

Steffen, L. E., Vowles, K. E., Smith, B. W., Gan, G. N., & Edelman, M. J. (2018). A daily diary study of hope, stigma, and functioning in lung cancer patients.  Health Psychology, 37 (3), 218–227. Retrieved from https://doi.org/10.1037/hea0000570 

Snyder, C. R., Feldman, D. B., Taylor, J. D., Schroeder, L. L., & Adams III, V. H. (2000). The roles of hopeful thinking in preventing problems and enhancing strengths.  Applied and Preventive Psychology ,  9 (4), 249-269. 

Snyder, C. R., Ilardi, S. S., Cheavens, J., Michael, S. T., Yamhure, L., & Sympson, S. (2000). The role of hope in cognitive-behavior therapies.  Cognitive therapy and Research ,  24 (6), 747-762.to 

Snyder, C. R., Lopez, S. J., Shorey, H. S., Rand, K. L., & Feldman, D. B. (2003). Hope theory, measurements, and applications to school psychology.  School Psychology Quarterly ,  18 (2), 122. 

Wahl, A. K., Rustøen, T., Lerdal, A., Hanestad, B. R., KNUDSEN JR, Øistein, & Moum, T. (2004). The Norwegian version of the Herth Hope Index (HHI-N): A psychometric study.  Palliative & Supportive Care ,  2 (3), 255-263. 

Zebrack, B. J., & Zeltzar, L. K. (2003). Quality of life issues and cancer survivorship.  Current Problems in Cancer ,  27 (4), 198-211.