According to the World Health Organization (WHO), palliative care (PC) provides a systematic and humanistic approach in improving the quality of life of patients and their families who are facing incurable and/or severe disease and limited prognosis.1 Important components of PC are the interdisciplinary approach, the control of pain and other symptoms, and attending to the physical, psychological, social and spiritual needs of patients and their families.2 Palliative care is built on the holistic bio-psychosocial-spiritual model of care, and underpinning this is the critical role of spirituality in patient care, particularly those with complex, serious and chronic illness.3
Notwithstanding the development of symptom control and psycho-social models of care, addressing spirituality is often defined as complex, as this dimension comprises all aspects of meaning in life, transcendence and connectedness.4 Nevertheless, there is a consensual understanding of the importance of spirituality in palliative care research and also among palliative care providers.5 In the WHO definition of palliative care, spirituality is mentioned as one of the main dimensions to be addressed by palliative care teams.1 The use of tools to measure spiritual needs and to assess spirituality may be helpful in supporting healthcare providers and in improving the quality of care.6
Spiritual interventions require the healthcare provider's presence to effectively connect with the patient through a healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, client centeredness and the creation of a spiritually nurturing environment in addressing spiritual needs.7,8 In a holistic paradigm of health, spiritual needs should be afforded the same level of importance level as other patient and family needs.3,4 Spiritual needs include the need for love and being loved, beliefs, meaning in life, creativity and forgiveness.9 Patients and families facing a serious illness often express regret about life events or the need for forgiveness. The characteristics and intensity of the relationship in palliative care settings, particularly, the nurse-patient relationship, may provide the opportunity of expressing regret and the need for forgiveness.10
Forgiveness is described as a process or journey aiming to release or reduce the bitterness, anger, resentment or hatred against another or others;11 a means of freeing oneself from previous judgments, misconceptions or false ideas about others;12 or a learned response to certain situations.13 Enrigh has argued that forgiveness encompasses the interaction between cognition, emotion and behavioral responses to an offender.14 Forgiveness is defined as “willingness to give up resentment of law, the negative judgment and indifferent behaviour towards those who unjustly hurt us, while fostering undeserved qualities of compassion, generosity and even love”.14(p.46) This is quite important in palliative care settings, because the need for forgiveness has been described as an antecedent to suffering in cancer patients.15
Research on forgiveness is dispersed in the literature, and has been conducted in different clinical settings but mainly in palliative care contexts.16 Some outcomes have been related to forgiveness, such as better life satisfaction,17 increased blood pressure,18 positive mental health, physical and emotional well-being,10 and lower levels of depression and anxiety.19 Also, forgiving (others or self) is important in reducing the sense of guilt, which has been suggested as an indicator of spiritual distress in patients with acute renal failure20 or cancer patients undergoing chemotherapy.6,21 Forgiving is also associated with a greater sense of hope and optimism in the future, and the willingness to forgive relieves negative self-esteem.22 Forgiveness may be associated with better spiritual health, as the experience of forgiving facilitates the act of letting go and brings about inner peace, even for those who are not religious.23 Researchers agree that forgiveness is a complex phenomenon, but further systematization is needed.18 Regardless of the knowledge about forgiveness in health, it is not clear in the literature which healthcare team members usually provide forgiveness facilitation and neither are the outcomes related to that intervention in the context of palliative care. The forgiveness facilitation intervention seems to be a multidisciplinary and non-pharmacological intervention, and the Nursing Interventions Classification (NIC) defines it as “assisting an individual's willingness to replace feelings of anger and resentment toward another, self, or higher power, with beneficence, empathy, and humility”.24(p. 608) Interestingly, the International Classification for Nursing Practice does not include this concept as a focus.25
The knowledge about this intervention lacks completeness and a scoping review will facilitate the required mapping of the knowledge concerning, in particular, the healthcare providers involved, the activities and resources that comprise this intervention, and also the outcomes after the intervention, particularly in PC. This scoping review will be based on the methodology proposed by Joanna Briggs Institute for the conduct of scoping reviews.26 This scoping review aims to analyze and map the intervention of forgiveness facilitation as implemented in the multidisciplinary palliative care context, which may lead to a systematic review focusing on the best evidence on the effects of this intervention, considering that “scoping reviews undertaken with the objective of providing a map of the range of the available evidence can be undertaken as a preliminary exercise prior to the conduct of a systematic review”.27(p.6)
An initial search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, MEDLINE and CINAHL revealed that currently there is no scoping review (published or in progress) on this topic.
Types of participants
This scoping review will consider all studies that focus on palliative care patients (having a chronic, incurable and advanced disease, regardless of the medical diagnosis), 18 years or over, assisted by palliative care teams, that include all health professionals (physicians, registered nurses, physiotherapists, psychologists, social workers, occupational therapists), chaplains and volunteers.
This scoping review will consider the forgiveness facilitation intervention provided in a multidisciplinary palliative care team. The NIC will be used as a framework as the intervention is described in several activities that would be helpful in the analysis of the results, but other activities might be included, particularly those provided by other healthcare professionals.24 The activities listed in NIC for this intervention are:
- Identify patient's beliefs that may hinder/help in “letting go” of an issue.
- Acknowledge when anger and resentment are justifiable.
- Identify source of anger and resentment, when possible.
- Listen empathetically without moralizing or offering platitudes.
- Explore forgiveness as a process.
- Help the patient explore feelings of anger, bitterness and resentment.
- Use presence, touch and empathy, as appropriate, to facilitate the process.
- Explore possibilities of making amends and reconciliation with self, others, and/or higher power.
- Assist the patient to examine the health and healing dimensions of forgiveness.
- Assist patient to overcome blocks to healing by using spiritual practices (e.g. prayers of praise, guidance and discernment; healing, touch, visualization of healing and thanksgiving), as appropriate.
- Teach the art of emotional release and relaxation.
- Assist client to seek out arbitrator (objective party) to facilitate process of individual or group concern.
- Invite use of faith traditional rituals, as appropriate (e.g. anointing, confession, reconciliation).
- Communicate God's/higher power's on inner self's forgiveness through prayer, scripture, other readings, as appropriate.
- Communicate acceptance for the individual's level of progress.
This scoping review will consider studies in the context of palliative care, specifically, hospices and palliative care units.
Types of sources
This scoping review will consider quantitative, qualitative and mixed method studies.
Quantitative designs include any experimental study designs (including randomized controlled trials, non-randomized controlled trials, or other quasi-experimental studies, including before and after studies), and observational designs (descriptive studies, cohort studies, cross sectional studies, case studies and case series studies).
Qualitative designs include any studies that focus on qualitative data such as, but not limited to, phenomenology, grounded theory, ethnography designs or discursive analysis.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Spanish, German, Italian and Portuguese will be included. Studies published in any year will be considered for inclusion in this review to capture how interventions implemented to provide forgiveness facilitation in palliative care has been addressed in research and in practice over time. Also, the authors of primary studies will be contacted for clarification or missing information whenever necessary.
The databases to be searched include:
- CINAHL complete (by EBSCO)
- Nursing and Allied Health Collection (by EBSCO)
- Cochrane Library, including Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE)
- Mediclatina (by EBSCO)
- SciELO – Scientific Electronic Library Online
- PROSPERO- International prospective register of systematic reviews.
The search for unpublished studies will include:
- Open Grey
- RCAAP – Repositório Científico de Acesso Aberto de Portugal
- Banco de teses da CAPES (Brasil).
Initial English language keywords to be used will be: “forgiveness facilitation”, “palliative care”, “end of life care”
Articles searched will then be assessed for relevance to the review, based on the information provided in the title and abstract, by two independent reviewers. The full article will be retrieved for all studies that meet the inclusion criteria of the review. In case of disagreements or uncertainties between the two reviewers about the relevance of a study from the abstract, the full article will be retrieved.
Two reviewers will examine the full texts independently and analyze the inclusion criteria. Any disagreements that arise between the reviewers will be resolved through discussion based on the objectives of the review, or with an independent third reviewer.
Studies identified from the reference list of previous searches will be assessed for relevance based on title and abstract.
Data will be extracted from included papers using a charting table in a Microsoft Excel sheet, which comprises the elements to respond to the objective of this review (Appendix I). This instrument was developed according to the preliminary search and the review questions, but further refinement may occur. For this, the two reviewers will chart the first five studies and decide whether the instrument is adequate to the objectives of this review.26,27
Two reviewers will extract the data independently and discussion or a third reviewer will solve disagreements.
In case the search find the same study published in different formats (example: thesis and paper) only the original paper will be taken into account.
The overview of the reviewed material will, where possible and appropriate, be synthesized and presented in a tabular summary (Appendix II) with the aid of narrative and figures.
For question 1 (What activities have been implemented and evaluated to provide the forgiveness facilitation in palliative care?), the tables and charts may include data indicated in Appendix III.
For question 2 (What are the characteristics [single or/and related activities, name, resources, frequency, duration, cultural or spiritual background] of these interventions?), the tables and charts may include data indicated in Appendix IV.
For question 3 (What are the healthcare team members involved in providing forgiveness facilitation?), the tables and charts may include data indicated in Appendix V.
For question 4 (What are the outcomes [topics] that were assessed after the intervention?), the tables and charts may include data indicated in Appendix VI.
The authors gratefully acknowledge the support of the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC), and Foundation for Science and Technology (FCT).
Appendix I: Data extraction instrument
Appendix II: Summary of results form
Appendix III: Data presentation template for question 1
Appendix IV: Data presentation template for question 2
Appendix V: Data presentation template for question 3
Appendix VI: Data presentation template for question 4
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