Giving Hope as a High Reliability Function of Health Care

Abstract

We believe that reliably offering Hope should be one of the goals of the therapeutic relationship between clinician and patient. Establishing Hope as a target outcome creates opportunities for both patients and clinicians to find meaning in their journeys.

This article defines Hope in a new way by quantifying Hope as the delta or increase in one's belief that a future positive state can be achieved.

Though prior conceptual models of Hope have focused nearly exclusively on an individual's own agency and competence to achieve goals, we particularly emphasize the role of Other—specifically, that of the clinician—in promoting Hope for patients.

We recommend a Hope Checklist for clinicians that incorporates (1) the process of eliciting and clarifying patient goals, (2) conveying the intent and ability to help, and (3) identifying realistic pathways forward with the specific intent to maximize patient confidence in the potential to achieve meaningful positive outcomes.

Introduction to the Issue

Can the “softer” skills so greatly prized in health care be delivered with high reliability? How physicians address issues related to hope in their patients provides a good test case. Our belief is that physicians should use a structured approach to help them give hope to every patient in every context. Doing so offers clinicians the rewarding opportunity to see the emotional impact of their work in real time.

Our recommended approach is inspired by conversations with clinical colleagues regarding how they respond when patients say they feel hopeless. “There's always hope,” they often say. “The question is what we are hoping for?”

“Early on, we hope for a cure,” they continue. “And when that is impossible, we hope for as much good time as possible. And then, at a later point, we hope for relief from suffering. And then, in everyone's life, we reach a time when we are hoping for a death with dignity.”

Then clinicians hasten to add, “We are nowhere near that phase—but let's focus on today, and what we should be hoping for right now.”

Direct conversations about hope mean a lot to patients, and they mean a lot to clinicians, too. After all, patients come to health care seeking relief of suffering, and that relief is incomplete if they feel hopeless. Even in dire circumstances there can be positive things to hope for. And for clinicians, few interactions are as satisfying as helping patients identify goals that are meaningful, and then helping attain them.

For these interactions to go well reliably—that is, for all patients, not just the ones with whom physicians “connect”—physicians should understand that being brokers of hope is one of their core functions. They should think clearly about the nature of hope and take steps in patient interactions that create a shared vision of what can realistically be hoped for and how to pursue it. They should not just do this when the spirit moves them; they should function as if they have a Hope Checklist.

This stepwise approach requires recognition that hope is not the same thing as optimism (the belief that generally things will get better), and that false hope is destructive to trust. Real hope blends attributes of desired outcomes, expectations, and confidence.

Key Factors for Consideration

In the early1990s, the psychologist Charles R. Snyder established Hope Theory, which defined hope as reciprocally reinforcing perceptions of a person's own ability to create Pathways (Ways) and their own Agency (Will) related to thoughts about attainment of goals. ¹ Although this definition might be more accurately described as confidence in one's own ability to achieve goals, this model has been used to create interventions to raise hope in within clinical groups including cancer patients. ²

But health care would benefit from modifications of the Hope Theory model. Hope Theory predominantly focused on perceptions that individuals have about their own ability to optimize their future. In health care, no patient should hope alone; instead, hope should be a group activity, with shared understandings among patients, clinicians, and families about what is being hoped for and how it might be attained. Indeed, most patients seek healthcare because they cannot solve their medical problems alone. The impact of clinicians’ Agency and Pathways into creating hope for patients should not be ignored. Another element of the model that bears refinement is the quantification of Hope itself. Hope Theory measures Hope at the individual level by summing across positive perceptions about the individual's Agency and expectation of successfully navigating Pathways. This model equates Hope with general confidence in achieving a positive outcome, whereas we define Hope specifically as the delta—the change or lift in one's belief that a meaningful positive outcome is attainable. By focusing on this delta, clinicians have the opportunity to specifically create Hope, and to literally watch it happen.

Even when patients have unrelenting conditions, clinicians should help patients seek something positive in their future whether it be the reduction of suffering or the enhancement of quality of life. Indeed, the notion of Hope encompasses both the belief that what is dreaded may be avoided as well as the belief that what is desired may occur. What patients and their clinicians hope for may change with time, but the interactions between them that cultivate hope should stay the same. Rather than thinking of hope as reserved for only the best possible outcome—such as cure—clinicians should help patients seek incremental improvements in their expectations about their future.

Recommendations

For clinicians, the first step in creating hope is to understand the patient's current goals. This involves gaining an understanding of how the patient views their probable future state and exploring the possible ways the future could be better than expected, even if an initially stated goal cannot be achieved. In any situation, there is always something to hope for, and an important role for the physician is to help patients identify what a good future could look like—then concentrate attention on what is required to realize hopes.

The second step for the clinician involves demonstrating Agency, both their will (intent) and skill (ability) to help the patient to achieve the array of goals that have been discussed. Explicitly verbalizing a commitment to partner with the patient on their individual journey reassures patients that they have an experienced guide who will walk alongside them.

The third step is making sure that the plan is clear to patients and other caregivers, including family. These discussions make the Pathways to be pursued explicit and tangible. Creating Pathways also involves discussing the time frames in which the effectiveness of interventions should be assessed. This step is important because sustaining hope requires periodic recalculation of both goals and actions.

Table 1 offers a more in-depth checklist of these overarching steps. The checklist links the model to actions that clinicians often already engage to optimize clinical care and patient experience. The framework ensures that key attributes needed to support Hope are not missed. It brings attention to the process so that clinicians can be highly reliable at delivering on these elements and are aware of their role in creating Hope. Patients value these attributes of their care as evidenced by the verbatim comments from experience surveys fielded across Press Ganey clients in 2022.

Table 1.

The Hope Framework Checklist: Major Steps, Actions, and Patient Voices.

Steps to support hope	Clinician actions	How patients describe this
Clarify or modify goals of what a positive future could look like: Understand the patient's current goal. Provide supportive and realistic feedback. Identify additional goals that are meaningful to the patient.	☑ Be direct in asking patients what they currently hope for ☑ Probe both for what is desired and what is dreaded ☑ Share realistic feedback in a supportive way, describing what can be accomplished ☑ Offer additional goals for consideration ☑ Discuss and prioritize actions to maximize wellness and minimize burden of condition	I think her finest quality is that she is a listener. Dr <X> listens to your fears, hopes and goals. He tells you the truth about your situation. He works with the patient to put a plan together to get better. He sets short and long term goals with the patient's “buy in.” She took the time to ask appropriate questions, listened to me and worked with me to set a goal and plan.
Increase belief in clinician agency (will & skill): Convey intention and ability to help the patient achieve their goals.	Will ☑ Listen for understanding of the patient as an individual ☑ Convey intention to help and commitment to the patient's journey Skill ☑ Create confidence in overall ability ☑ Demonstrate knowledge, experience, professionalism	I always leave his office feeling like we’re a team with my cardio health as a common goal. Very impressed with overall. Well organized very professional, I could tell ALL staff members very concerned for patients needs. All my nurses were FANTASTIC! They truly cared about my health, healing, and comfort. I LOVE Dr. <Y> I feel so blessed she is taking care of me. I appreciate that she keeps up with current data and formulates my care plan with evidence-based medicine in mind. … She is honest which I also appreciate. She doesn't paint a perfect picture but gives facts. I feel safe with her because she paints the whole picture and gives me info to keep me safe. As you can imagine, cancer patients are terrified of recurrence or new cancers developing. With her guidance I feel safe we are minimizing recurrences and staying vigilant for signs. I just love her because she is a good doctor and she helped save my life …
Increase awareness of pathways: Help the patient see the path or paths available to them to progress toward their goals.	☑ Describe path(s) ☑ Explain next steps ☑ Elicit and answer questions about the care plan ☑ Describe how and when you will together evaluate the progress being made or alternatives to be explored ☑ Communicate prior experience with patients on a similar journey ☑ Connect to patient communities	Doctor was informative without being overwhelming, and outlined clearly what steps to take next, as well as her assessment of where I am at currently. He takes his time explaining everything, patient to answer my questions, open to discussion of care, possible future treatments, etc. He has not only provided the tools, education, treatment plan, and continued adjustments according to the fluctuations within my treatment plan, symptoms, and ever-changing diagnoses. But, he has also continued to support my life goals and helping to creating a treatment plan that supports it. She is caring, informative, listens and has multiple solutions to my physical problems in complete alignment with my health goals.

Conclusion

This checklist requires clinicians think through with patients what is probable, what is possible, and what steps might close that gap. And it also requires clinicians to have conversations with patients and families with the specific intent of creating shared understanding. Giving hope is a successful when all parties share the same hopes and adjust their hopes together.

Patients want peace of mind that things are as good as they can be given the cards they’ve been dealt. This requires knowing their clinician has heard what is important to them, is committed to their journey, and can show them the path forward. They essentially want the confidence that their odds of success have been maximized—by that definition, what they are looking for is Hope. By being attentive to the process, clinicians can not only become more reliable in creating hope, they can witness its creation.