QUALITATIVE

Eliott, Olver / DISCURSIVE

HEALTH RESEARCH
PROPERTIES
/ February
OF HOPE2002

The Discursive Properties of

“Hope”: A Qualitative Analysis
of Cancer Patients’ Speech

Jaklin Eliott
Ian Olver

The authors of this article question the usefulness of the empirico-realist search for a defini-
tive definition of hope. Semistructured interviews on “do-not-resuscitate” issues with 23
oncology clinic outpatients were tape-recorded, transcribed, and analyzed following
grounded-theory methodology and discursive analytical methodology. Twelve patients
spontaneously spoke about hope as objective or subjective, a burden or a resource. Hope rep-
resented an evaluation of empirical states of affairs or the wish for desired outcomes and was
a warrant for action or an excuse for inaction. It was attributed to both patient and caregiver,
to individuals or situations. Hope was present or future oriented, both vulnerable and
enduring. The variety of versions of hope has implications for interactions between health
care workers and patients. Recognizing a taxonomy of hope might prove more useful than
searching for definitions.

M edical research into hope has been set predominantly within an empirico-
realist paradigm. This presupposes that reality exists independently of the
observer, to be discovered by an objective researcher, unfettered by culturally or his-
torically situated subjectivity. Such an approach takes as a given that there is such a
thing as hope and attempts to define and operationalize it. In 1995, Farran, Herth,
and Popovich observed that there existed at least 11 different scales designed to
measure hope and 3 purporting to measure hopelessness. Snyder and colleagues
have since published 3 more (Snyder, Harris, et al., 1991; Snyder, Hoza, et al., 1997;
Snyder, Sympson, et al., 1996). The development of instruments to assess hope has
been viewed as a priority in medical research into hope, and the ability to identify
patients’ hope is considered a precursor to effective intervention in assisting them to
maintain or modify hope (Farran et al., 1995; Farran, Wilken, & Popovich, 1992;
Poncar, 1994). According to Dufault and Martocchio (1985), intervention is often
seen as the domain of nursing staff, who are assigned the role of “maintaining, sus-
taining . . . restoring” (p. 379), “assessing . . . and therapeutically influencing hope”
(p. 391), and presumably adjusting patients’ hope to what is considered appropriate
(Cutcliffe, 1995; Hall, 1990; Yates, 1993). The physician is similarly accredited with

AUTHORS’ NOTE: An earlier version of this article was presented at the Fifth World Congress of
Psycho-Oncology, held in Melbourne, Australia, in September 2000. The authors wish to thank Adelaide
University for partial funding for this project, Dr. Jane Blake-Mortimer for her assistance in interviewing,
Professor Ian John for his helpful observations, and four anonymous reviewers for their constructive
comments.
QUALITATIVE HEALTH RESEARCH, Vol. 12 No. 2, February 2002 173-193
© 2002 Sage Publications

173
174 QUALITATIVE HEALTH RESEARCH / February 2002

the ability and sometimes the responsibility to influence or adjust patients’ hope
(Kodish & Post, 1995; Menninger, 1987; Miyaji, 1993; Perakyla, 1991).
However, precisely what hope is remains problematic, with many definitions,
models, and conceptual frameworks proffered that are not always interchangeable.
Hope has been referred to as a multidimensional dynamic life force (Dufault &
Martocchio, 1985), a unique personal experience (Owen, 1989), an inner power
(Herth, 1990), a process of anticipation (Stephenson, 1991), the cognitive energy and
pathways for goals (Snyder, 1995), the most robust resource one can possess
(Ballard, Green, McCaa, & Logsdon, 1997), and a means of maintaining a fighting
spirit (Irving, Snyder, & Crowson, 1998). Somewhat justifiably, in a meta-analysis of
46 articles, Kylma and Vehvilainen-Julkunen (1997) concluded that there was a lack
of precision about hope, and Stephenson (1991) noted that hope as presented in the
literature is not a singular entity, being at once a part of human development, a pro-
cess, a theory, and a source of meaning in life.
Many researchers have acknowledged the complexity of meanings ascribed to
the concept of hope and have attempted various maneuvers to dissect and identify
its various components. Consensus is rare. Table 1 shows a selected review of recent
dissections of hope, said to be composed of between two and seven elements identi-
fied as subscales, factors, attributes, dimensions, components, and categories,
among others. There appears to be no single feature all authors identify as intrinsic.
Although most mention some kind of inner resource of the individual as well as an
interpersonal or relational aspect, some include a spiritual aspect, others a tempo-
ral, and so on. The suggested components seem to be variously describing a process,
a state, or a source. The diversity of definitions and conceptual frameworks has
been identified as causing confusion in terminology, hindering a consistent
approach to hope and limiting actual clinical application across populations (Farran
et al., 1995; Nekolaichuk, Jevne, & Maguire, 1999).
The origin of hope is similarly contested. Some identify the source as primarily
external to the individual. For example, Klenow (1991) named religion, medical sci-
ence, fallibilism, self-discipline and renewal, and deception by others. Salander,
Bergenheim, and Henriksson (1996), however, located it within the self, citing the
body, helpful relationships, cognitive schemata, and the handling of information as
sources of hope. Erikson (1968) identified hope as formed within the infant to
endure throughout life, and this, although compatible with the notion of hope as an
inner resource, might render attempts to alter its levels somewhat futile. More
recently, some (Averill, Catlin, & Chon, 1990; Dufault & Martocchio, 1985; Snyder
et al., 1991, 1996) have noted that hope is both a state and a trait and have claimed
that the former is amenable to influence.
Despite the lack of unanimity among researchers regarding hope, the number
of existing tools to assess it suggests certain features of the medical construction of
hope, specifically, the hope of interest to scale devisers and users. First, hope is per-
ceived as a valuable entity that can be measured and assessed objectively. Second, a
person can possess hope to varying degrees. Third, hope can be modified, even cre-
ated or destroyed. Finally, it is legitimately within the purview of the health care
profession to stipulate appropriate amounts of hope for an individual, determine a
patient’s hope, and then take action to reduce discrepancies between these two
amounts.
It has been suggested that hope remains elusive in part because the word itself
functions as a noun, a verb, and an adjective (hopeful) (Farran et al., 1995;
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 175

TABLE 1: Selected Review of Published Papers Delineating Elements of Hope

Number and
Author(s) (Date) Name of Elements Specific Elements

Snyder (1995) Two components Agency (goal-directed determination)

Pathways (planning of ways to meet goals)
Godfrey (1987) Two/three kinds Ultimate (focused)
(with three aspects) Fundamental (unfocused)
Absolute (an extreme form of fundamental)
(with three aspects: cognitional, conative,
and affective)
Herth (1991) Three subscales Temporality and future
Herth (1992) Three factors Positive readiness and expectancy
Interconnectedness
Jakobsson, Segesten, Three factors Satisfaction with self, others, and life
Nordholm, and Avoidance of hope threats
Oresland (1993) Ability and capacity to influence the outcome in life
Nekolaichuk, Jevne, Three factors (or Personal spirit (personal dimension)
and Maguire (1999) dimensions) Risk (situational dimension)
Authentic caring (interpersonal dimension)
Stephenson (1991) Four attributes A process involving thoughts, feelings, behaviors,
and relationships
The element of anticipation
A positive future orientation
An object that is meaningful to the individual
Farran, Herth, and Four attributes Experiential
Popovich (1995) A relational process
A rational thought process
Spiritual or transcendent
Cutcliffe (1996) Four themes Hope relative to help
Hope as coping resources
Hope interwoven with caring
The presence of hope as synonymous with a
personal future
Benzein and Five subthemes Inner strength and energy
Saveman (1998) Significant events
Support from relatives and/or a familiar environment
Confidence in treatment
Nursing actions and treatment
Owen (1989) Six subthemes Goal setting
Positive personal attributes
Future redefinition
Meaning in life
Peace
Energy
Dufault and Six dimensions Affective
Martocchio (1985) (within two spheres) Cognitive
Behavioral
Affiliative
Temporal
Contextual (within two spheres: generalized and
particular)

(continued)
176 QUALITATIVE HEALTH RESEARCH / February 2002

TABLE 1 Continued

Number and
Author(s) (Date) Name of Elements Specific Elements

Nowotny (1989) Six subscales Confidence

Relating to others
Spiritual beliefs
Belief that the future is possible
Active involvement
Hope from within the individual
Herth (1990) Seven categories Interconnectedness
Attainable aims
A spiritual base
Personal attributes
Light-heartedness
Uplifting memories
Affirmation
Morse and Seven components A realistic initial assessment of the predicament or
Doberneck (1995) threat
The envisioning of alternatives and the setting of goals
A bracing for negative outcomes
A realistic assessment of personal resources and of
external conditions and resources
The solicitation of mutually supportive relationships
The continuous evaluation for signs that reinforce the
selected goals
A determination to endure

Stephenson, 1991), to which we would add, as an adverb (hopefully). It seems curi-

ous, therefore, that in purporting to measure hope, scale devisers and users reify it,
focusing on its “noun-ness” and ignoring the verb aspect. Other writers have exam-
ined how hope is employed rhetorically to justify certain actions or beliefs within the
medical profession (Danforth, 1997; Delvecchio-Good, Good, Schaffer, & Lind,
1990; Kodish & Post, 1995; Miyaji, 1993), how it is informed by cultural myths
(Nekolaichuk & Bruera, 1998), and how it comprises part of a new discourse on can-
cer (Saillant, 1990). In doing so, they access another version of hope as constituted
by the medical profession, that is, the possibility, probability, or availability of treat-
ment resulting in cure or remission of disease. Although it is the prerogative of the
medical profession to determine this hope, attempts to define and measure hope are
confined to the hope defined in the previous paragraph.
In this article, we present an analysis of hope as perceived by a group of patients
with cancer as they spoke about end-of-life decision making, particularly focusing
on the “do-not-resuscitate” (DNR) decision. Other researchers into linguistic fea-
tures of hope have not examined hope “in action,” as it were, as part of spontaneous
speech; for example, Godfrey’s (1987) discriminating treatise considered the philo-
sophical and linguistic implications of hope, whereas Averill et al. (1990) analyzed
hope through its metaphors or their predetermined categories. Our analytical
approach was informed by the view that the language employed in discussing and
understanding experience is not a neutral, transparent description of an objective
world; it is used for a variety of purposes related to the intention of the speaker. Fur-
thermore, individuals’ everyday speech is shaped by the socially and culturally
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 177

TABLE 2: Demographic and Medical Details of Participants (N = 23)

Detail n

Primary cancer site

Colo-rectal 8
Breast 5
Lymph 2
Non-Hodgkins 6
Other 2
Stage of disease
I 2
II 5
III 2
IV 14
Current treatment
Chemotherapy 16
Radiation therapy 1
None 6
Treatment intent
Cure 12
Observe 2
Prolong life 3
Palliative 6
Male 14
Female 9
Mean age (SD) = 54.7 (15.3)

derived ideologies and assumptions that constitute their own particular cultural
milieu (Potter & Wetherell, 1987). We specifically considered whether medical con-
structions of hope were represented by patients, what other constructions were
manifest, the clinical implications of discrepancies between different versions, and
the context and implications of noun or verb usage. We conclude that hope can
incorporate, but is not limited to, the medical versions (or elements thereof), and we
present a preliminary taxonomy of hope.

METHOD

The study was approved by the Ethics Committee of the Royal Adelaide Hospital.
Participants comprised 23 patients (9 female, 14 male) attending the Royal Adelaide
Hospital oncology clinic at a specific time each week over a 9-month period.
Patients meeting inclusion criteria received an information sheet detailing the pro-
ject and were asked by their medical oncologist (IO) if they were willing to partici-
pate. None refused. Inclusion criteria were that they were capable of coherent dis-
cussion and had cancer but were unlikely to die in the near future.1, 2 Patients were
assessed as emotionally stable enough to suffer no undue effects due to the nature of
the topic.3 Follow-up counseling was offered, but no participants used this service.
Participants differed in regard to site and stage of cancer, length of time since diag-
nosis, current treatment, and treatment intent (Table 2). Their similarity lay in their
current relationship to the topic of interest, in that as death was assessed as not
imminent, DNR decision making was considered unlikely to be an immediate and
personal issue for these patients.
178 QUALITATIVE HEALTH RESEARCH / February 2002

A female clinical psychologist who was unfamiliar to the participants con-

ducted the interviews; all but one were on a one-on-one basis (Keith requested that
his female companion also attend).4 Signed consent was obtained prior to com-
mencement. Open-ended questions were intended to elicit speech on end-of-life
issues, with a primary focus on DNR decision making: for example, what patients
know about DNR, who should make a DNR decision, and factors influencing when
a discussion on DNR should take place. However, participants were encouraged to
raise and discuss any issue that they considered relevant. The interviews lasted
between 20 and 45 minutes and were taped, then transcribed (by JE), with all names
changed to preserve anonymity.
The transcribed data were entered into the qualitative computer software pack-
age NUD*IST 4 (Non-numerical Unstructured Data, Indexing, Search and Theo-
rizing, Version 4) (Qualitative Solutions & Research, 1997), then sorted into catego-
ries, some demographically based (e.g., gender) and some interview based (e.g., all
responses to a particular question). Further concept-based categories were estab-
lished guided by the grounded theory methodology (Glaser & Strauss, 1967) and
the process recommended by Glaser (1978). Through continual rereading of the
interviews, we sought to determine “what [was] actually happening with the data”
(Glaser, 1978, p. 57), and speech items exemplifying a particular concept or theme
were noted and examined through constant comparison for relevance across inter-
views. Within grounded theory methodology, the interview process is considered
to be complete on data saturation, or when subsequent interviews reveal no new
information. We stress, however, that participant speech about hope emerged
unprompted within the interview and was not the intended focus of the research.
Because the findings on hope were fortuitous, sample size was determined through
data saturation regarding DNR decision making.
During multiple readings of the interview transcripts, hope as part of the end-
of-life decision-making process appeared to be important, yet was characterized by
some variability of use. Therefore, a string-pattern search using the NUD*IST soft-
ware (Qualitative Solutions & Research, 1997) for hop[e|ed|es|eless|eful|efully|
ing] was performed. This collected all instances of the word hope (and derivatives
thereof) with surrounding context. Each item of speech was categorized to reflect
our emergent understanding of the processes and concepts encapsulated through
the use of the word hope. Further analysis focused on the discursive features of hope,
examining the consistency or diversity of use of hope within or between individual
speakers, the functions and consequences of hope for these patients, how its
employment and function varied with the aims of the speaker, and how hope was
constructed and shaped discursively (Potter & Wetherell, 1987). Conclusions were
regularly reviewed and discussed in consultation with health care workers and
qualitative researchers.

RESULTS AND DISCUSSION

1. Speaking of Hope
In the absence of specific prompting, when talking about DNR decision making, 12
patients used the word hope, or a derivative thereof, 64 times collectively.5 It was
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 179

employed as a noun or adjective (hope/s, hopeless, hopeful) 46 times, and as verb or

adverb (hope/d, hoping, hopefully) 18 times. Although hope as a noun (HN) and hope
as a verb (HV) are somewhat interchangeable in that “I have a hope that . . . ” and “I
am hoping that . . . ” are functionally equivalent, in practice, participants usually
employed them differently with associated differences in implications for the
patient.

2. Hope as a Noun

2.1 Hope Exists Independently

The most common rendering of HN was that hope represented an entity, with many
properties of an object; for example, some participants suggested that hope existed
independently—that there is or there isn’t hope—and that this was for the doctor to
determine:

If there is hope . . . is an open question which could be answered better by medical

professions than the patient. . . . [As] a patient, I would like to know that the doctors
would clearly state to me that there is no hope. (Alex6)
At the end of your life when you are past all medical help, and there’s not much that
can be done for you except for quality of life . . . [the patient] would want to know
how bad they are, and . . . if there’s no hope, not to be resuscitated. . . . [When] you
know there’s no hope, the doctor should talk to them about it. (Anne)

“No hope” emerged as a recurring phrase, but it appeared to be taken for

granted precisely what “no hope” meant. In common with much of the medical lit-
erature, our participants seemed to assume that hope (at least as a noun) just is.
However, hope must have an object—there has to be hope for, or of, something—
although this object may not be a “thing,” but rather a “state of affairs” (Godfrey,
1987, p. 11). Here, the object of hope is implied by Anne’s statement regarding the
limits of medical help. For participants, hope was usually directed toward the exis-
tence of treatment(s) that would ensure that they would not die (a cure) or, at the
very least, ensure long-term reasonable health. Anne and Alex expected doctors to
report on this, to relay an empirical fact, expressed in terms of the presence or
absence of an objective hope. This tendency to couple hope with a cure, even to
equate the two, reflects prevalent medical attitudes: Within the illness/disease par-
adigm, hope is often linked with curative treatment (Poncar, 1994), based on clinical
advances (Healy, 1998), but this practice can isolate the patient who has reached the
limits of medical help (Nekolaichuk & Bruera, 1998). Nuland (1994) suggested that
patients and physicians need to refocus the aim of hope to outcomes other than cure
or remission, but acknowledged that this is difficult in a high-tech biomedical era
that offers the possibility of attaining a cure. The effect of this hope is to maintain
both medical authority and patients’ reliance on and expectation of medical inter-
vention toward the end of their lives (Delvecchio-Good et al., 1990; Perakyla, 1991).
This construction of HN was also invoked as both a warrant for action and an
excuse for inaction, in that its presence or absence determined future outcomes and
current choices. As such, the function of this hope for participants was similar to
that observed within oncology (Delvecchio-Good et al., 1990), namely, as a
180 QUALITATIVE HEALTH RESEARCH / February 2002

rhetorical justification for various actions or beliefs. Participants represented hope

(or no hope) in terms of absolutes, with a sense of an inexorable predestined chain of
events that merely unfold with the progression of the illness or the passing of time:

At the beginning, there’s still hope, but at the end when you know there’s no hope,
then the doctor should talk to them about it. . . . As [the cancer] progresses and
there’s no hope, [DNR orders] should be discussed further then. (Anne)
If there was no hope of a productive life, just please do not resuscitate, and do not try
and prolong a life. (Elaine)
“Do not resuscitate” means . . . do not prolong my life . . . when it reaches the stage of
no hope. (Ingrid)
[If] I ever get to the stage where there is no hope, I would like somebody to put me to
sleep. . . . [If] it comes down to . . . no hope, finish it. (Mike)

These patients reified hope: The abstract concept of hope was perceived of and
dealt with as if it were a concrete entity, and this practice had associated conse-
quences. The absence of hope was equated with the imminent end of life, and this
was understood to legitimize a range of medical options, often centered on abstain-
ing from treatment. The reification of HN can act to obscure the facts that (a) hope, in
this instance, represents an evaluation by medical staff of how successfully medical
science can delay a death that is determined to be inappropriate and (b) any evalua-
tion is a probability based on statistical aggregates and therefore not inevitably pre-
dictive for a given individual. Reification of hope functions to obscure the subjective
component of the evaluation made and can operate to distance medical staff from
the evaluation, which can in turn act to reduce responsibility for any actions that fol-
low (Potter, 1996).

2.2 Hope Can Vary in Degree and Resilience

Although when speaking about DNR decision making, participants often pre-
sented HN as an all-or-nothing entity determined by the doctor, hope sometimes
appeared to fluctuate in amount. In such cases, hope was perceived as a possession
of the individual patient and as subjectively held, rather than objectively present.
Although not determined by the doctor, this subjective hope could be increased or
diminished through the doctor’s actions or, more specifically, by patients’ percep-
tions of these. This subjective hope also had varying degrees of resilience. It was fre-
quently construed as vulnerable and in need of protection, thus requiring some dis-
cretion on the part of the doctor when dealing with the patient:

[Doctors should raise DNR issues] when it appeared to be likely that there was . . . no
other outcome than death. I suppose it’s not a good idea while there’s still some
hope. . . . [If] there is felt to be some hope, it’s sort of premature. (Ben)
Some people . . . would literally go downhill with the mere suggestion of [DNR
orders. You need to be] very careful in those cases that you don’t take away a per-
son’s last thread of hope. . . . If they’re told, “look there is nothing more we can do,
it’s just a waiting game now,” some people really . . . go downhill very quickly.
(Delia)
For some people [a DNR discussion] would . . . bring it home to them that perhaps
they don’t have any hope, and they go down . . . quicker. (Gavin)
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 181

This version of hope can represent the focus of medical concern regarding the
impact of diagnostic and prognostic disclosure but is also accessible to justify prac-
tices of information control regarding these (Miyaji, 1993). Some participants sup-
ported this understanding, offering the possible loss of the patient’s hope as justifi-
cation for avoiding or delaying a DNR discussion, concluding that the patient
would be adversely affected if they knew there was “no hope”, that “there is noth-
ing more [medical science] can do.” Although this argument suggests that hope is
vulnerable, it represents two different medical constructions of hope, playing one
form against another: objective hope determined by medical science against subjec-
tive (vulnerable) hope held by the individual patient.
The logical inverse of an understanding that “no hope” (objective) means that
there is nothing more that doctors can provide, that death is imminent and inevita-
ble, and that the patient will lose hope (subjective) in these circumstances, is that the
mere fact of doctors’ doing something, the mere provision of treatment, can imply
the presence of hope (objective) and consequent delay of death. This certainly seems
to be implied by Harry and by Keith and his companion, who commented that a
visit to their doctor resulted in an increase of their (subjective) hope, arguably
because they saw treatment as demonstrating that there was (objective) hope:

I think the thing that I appreciated most with Dr. X . . . [is that] he explained things to
you in a positive way. You always felt walking out of . . . his room that there’s a next
challenge, that you can go ahead and there’s really some hope at the end. (Harry)
Keith: Up to the stage where [doctors] know that any further treatment is no longer doing
any good, they’re all hopeful that they’re going to control it.
Keith’s Companion: We always think of the worst, and then when . . . we see Dr. X, he puts
our hopes up again you know, because he’s seen so many patients and makes you feel
better.
Keith: Each time I come in for an interview, or an examination, he says “I’ll see you in a
month’s time” and I think, “Oh well, if he’s going to see me in a month’s time that’s a
month I’ve got to make sure I’m here,” do you see? If he came in one day and says,
“There’s nothing more we can do, don’t bother coming back,” that’s the time to
worry. . . . [If] we’re going to get in control, which is what he’s hoping to do, this [treat-
ment] is what’s going to do it.

What was important here is that for both Keith and Harry, the origin of hope
appeared to lie (in part) in something more than just treatment available—but in the
doctor’s positive manner, even his expertise in the field. Thus, patients can derive
hope from nonverbal aspects of the consultation, and possibly when it was not
intended; hope is engendered in the interaction, as doctors inadvertently communi-
cate hope to the patient. This supports the observation that patients can gain hope
from any aspect of any interaction with their health care workers (Cutcliffe, 1996),
legitimizing articles directed at advising health care workers regarding their (car-
ing, supportive) attitude to patients, but also indicating that patients’ hope cannot
be entirely amenable to professional control.
In using the words hopeful and hoping, Keith reveals another aspect of how hope
is construed by patients. Although patients can possess hope, it can also be attrib-
uted to their caregivers. This hope may not necessarily be identical with the objec-
tive evaluation of the probability of successful treatment, as medical staff are not
immune to the subjective desiring of a favorable outcome. This hope may also
182 QUALITATIVE HEALTH RESEARCH / February 2002

represent the expectation that some particular outcome will eventuate. Thus, medi-
cal staff might have the hope (subjective desire) that treatment will be successful,
and the hope (subjective expectation) that it will be, but believe that there is little
hope (objective evaluation) for their patient’s long-term survival.
Because subjective hope is the possession of the individual, it may be main-
tained independent of objective hope. Thus, although hope was identified as vul-
nerable, it could also be enduring. Some participants linked the presence of hope
with the occurrence of miracles:

In people’s minds, there’ll always be a glimmer of hope, and some have pulled
through it all. . . . I guess there’s always some hope. [It’s] difficult too, because the
patient will always be hoping and a miracle might occur. (Ben)
So many people say, “Where there’s life, there’s hope,” “Miracles do happen,” and
all that. (Ingrid)

If we take a patient’s knowledge of miracles to equate to knowledge of instances

wherein individuals have lived far beyond medical predictions, it follows that hope
may be sustained despite the most pessimistic of medical opinion. Certainly, media
interest ensures continued access to such anecdotal evidence of the power of hope.
Thus, aspects of hope lie beyond the domain of the rational, contradicting the claims
that hope should be rational and based on the possible (Godfrey, 1987, pp. 12, 23;
Snyder, 2000). Another implication behind Ingrid’s statement above is that hope is
rendered invincible up to the point of death, proving surprisingly resilient, with
doctors unable to remove patients’ hope, even if that hope does not concur with
medical opinion.
Hope has previously been identified as a coping resource (Ballard et al., 1997;
Cutcliffe, 1996; Owen, 1989) and was similarly perceived by these participants:

While there’s still hope, some people will cling on. (Gavin)
[Maybe raise DNR issues when] it’s obviously becoming more of a possibility that
[death] could be an outcome, but before all hope’s taken away, so at least the patient
can still realize the situation but feel like they can still go on, and there is something
left for them to hang on to. (Harry)

Far from a vulnerable burden, hope was understood to enable patients to cope
with present and anticipated difficulties associated with the experience of having
cancer. This appeared to apply regardless of the real or objective status of hope. The
enabling aspect of hope may also be perceived in cases wherein individuals hold a
belief in a life hereafter. For example, Debbie said,

As a Christian, [dying] wouldn’t hold any terror, it would be just moving to a better
life. . . . For me, the Christian hope is the all-important thing.

This “Christian hope,” though external to individuals, is presented as contributing

positively to their current and anticipated experiences and as enduring throughout
all circumstance, with its ontological status being a moot point given the benefits
associated with its presence. In this guise, hope equated with faith in a higher power
is also constituted as beyond the jurisdiction of medical control (Kodish & Post,
1995). Hope as a resource that endures, whether grounded in a specific religious
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 183

faith or not, may be similar in concept and function to the “generalized hope” postu-
lated by Dufault and Martocchio (1985), and the “fundamental hope” proposed by
Godfrey (1987).

2.3 Unrealistic (or False) Hope

Hope can vary both between and within individuals, so the potential exists for
incongruence and conflict between patients and health care workers with regard to
orientation to hope, a point that has been made elsewhere (Klenow, 1991; Perakyla,
1991). This affects medical perception and treatment of individual patients. For
example, although hope is usually perceived as a necessary positive quality for a
patient to possess, their hope that they will get better, in defiance of the majority of
medical opinion, is labeled false or unrealistic hope,7 and is decried by many medical
writers who suggest that it should be dismantled and replaced with realistic hope
(Herth, 1991; Hickey, 1986; Poncar, 1994). However, there are a number of factors
suggesting that this process is unnecessary and even counterproductive.
First, the distinction between realistic and unrealistic hope rests on an assump-
tion of shared and objective reality (Yates, 1993), which is itself problematic (Potter,
1996). Second, hope can only be proven to be false or unrealistic only after the fact,
that is, when the patient has died. Should they survive, their hope is unlikely to be
so labeled. This calls into question the merit of insisting that patients acquiesce with
medical opinion on whether or not their hope is realistic. Third, Hall (1990) noted
that the hope to continue living is common to all humans even though all will die
and asked why someone with a terminal illness should be expected to be different.
She further observed that patients usually die as they have lived, and if they have
tended to focus on the positive, even avoiding the negative, the dying process is no
time to try to change this. Finally, unrealistic hope is not the sole prerogative of the
dying, has not been proven to be detrimental to patient well-being, may have some
beneficial aspects, and often alters when the individual has the resources to cope
with the situation (Ersek, 1992; Yates, 1993).
The motivation behind efforts to alter a patient’s hope may be the societal pre-
eminence placed on autonomy (Goldberg, 1984; Miyaji, 1993; Tobias & Houghton,
1994). Patients and medical staff alike hold that individuals should possess all infor-
mation pertaining to their condition to make an autonomous and rational decision.
Yet, patients and doctors may differ in their perceptions of what is rational (Hall,
1990). Should a patient’s behavior following the provision of “bad news” not accord
with medical expectations, medical staff may conclude that he or she has failed to
understand the information provided, has unrealistic hopes regarding the disease,
and needs to have the information repeated. We do not suggest that doctors abdi-
cate their responsibility to inform patients of how or whether medical science can
benefit them, particularly because our participants considered this mandatory
(Eliott & Olver, 1999). However, it seems probable that the identification of unrealis-
tic hope in a patient may represent a mismatch of types of hope rather than the
patient’s failure to act rationally or comprehend given information. For example,
the patient’s hope may consist of his or her (not unreasonable) desire to survive, but
hope as employed by medical staff expresses their evaluation of the likelihood of
that occurring. It may, therefore, be useful for all health care professionals to con-
sider precisely the justification for acting to remove a patient’s false hope,
184 QUALITATIVE HEALTH RESEARCH / February 2002

particularly because there exists some debate regarding the ethical implications of
such a course of action (Ersek, 1992; Hockley, 1993).

3. Hope as a Verb

3.1 Hope Is Subjective

One consequence of using HV is that a subject is introduced: Someone hopes that

something will occur. HV is inherently subjective; one cannot objectively hope.
Hope is thus immediately personalized, and the object of hope is determined by the
individual (patient) requiring no legitimization by medical staff. This contrasts with
what can occur when HN is employed, where, as noted earlier, hope is more easily
perceived as objective, divorced from human volition, and merely assessed by the
doctor who then informs the patient of its presence or absence. Where HV is
employed, it is not for medical science to determine if there is or there is not hope.

3.2 Hope Is the Active Desiring of a

Possible Positive Future Outcome

Whereas HN was often associated with an inexorably predestined outcome beyond

the control of the patient, HV appeared to lend itself to the expression of a possible
positive outcome, with the patient engaged in his or her own circumstances, both
medical and social. This may be in part because to hope is to undertake an active
process of doing something, rather than being a helpless victim of circumstance.
Thus, even when anticipating death, Delia and Felicity were focused on something
associated with their lives, with the process of living:

What I do hope most sincerely is that the path leading up to [my death] is one of dig-
nity. . . . I hope it doesn’t get to [being a “write-off” and considering euthanasia] but I
believe in it. . . . [I] just think “well really you’re a tiny little speck and you’re here for
a while, and make the most of it and hope that when the time comes you can go out
with dignity, and maybe leave something behind.” (Delia)
Now [I’ve prepared a DNR document] I don’t have to worry about that, I can just go
ahead with my life. Hopefully, I won’t have to call on it for a long time but at least it’s
done, it’s there and it’s one less thing to have to worry about. (Felicity)

HV introduces both chance and positivity. Thus, it appeared that, in contrast to

the case with HN, participants were unlikely to define their situation as overwhelm-
ingly negative, as one requiring a definitive (often centered on ending their life)
response. HV facilitates the envisaging of a possible future outcome. Although this
may involve a cognitive, assessing component, it may reference the social, the emo-
tional, and the simply unknown. Because this hope is not limited to that which is
cognitively driven, as per Snyder’s (1995, 2000) theory of hope, we suggest that
hope in everyday speech is more akin to Morse and Doberneck’s (1995) conceptual-
ization, which emphasizes both the “doing” of hope and possible benefits to the
individual. Here, the active, positive voices of participants contrast markedly with
the absolute solutions demonstrated with the noun version (“if there’s no hope, fin-
ish it”):
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 185

So I’m [OK], and that’s after 8 weeks [of chemotherapy]. I think I’ve learnt to live
with it. I just hope I can live with it for a lot longer. And not deteriorate too rapidly.
(Keith)
After having this operation and recovering so well, the best I hoped for was a few
more years of a reasonable life. (Mike)
I would hope there’d be somebody to whom I’d communicated my wishes, who
would be able to carry [them] out. (Ingrid)
Hopefully [my family would] respect [my wishes] or if they were able to, carry them
out. (Gavin)

HV also reflected a desire for the future that might not be the patient’s own:

[Some] people will cling on ’til the bitter end, and hopefully they can make an
informed decision. (Gavin)
I would hope that [DNR orders] would be raised by medicos rather than patients
because I think some patients go into shock. (Ingrid)

As noted by many researchers (e.g., Dufault & Martocchio, 1985; Kylma &
Vehvilainen-Julkunen, 1997; Owen, 1989), HV implies an active occupation in the
present time, but the focus might be on another time or another life. Given that their
own current situations might be perceived as somewhat negative, this use of the
word hope might encourage a moment of positivity for the patient, ameliorating the
arduous vicissitudes of cancer and associated treatment.

4. The Consequences of (Multiple Versions of) Hope

Because hope encapsulates a number of different meanings, participants could
switch between different versions of hope, depending on the point they were
endeavoring to make. Although the tendency to exhibit variation about a particular
topic, even endorsing contradictory views, is common in unstructured speech
(Billig et al., 1988; Potter & Wetherell, 1987), interactions between particular ver-
sions of hope often carried with it specific consequences for the projected well-being
of the patient. Although some of these were noted in Section 2.2, the following dis-
cussion reveals how culturally specific notions of hope and the relationship
between mind and body informed these patients’ experience of cancer and its
treatment.

4.1 Hope and the Progression

of Cancer: The Discourse of Will

Our participants suggested that if doctors (perhaps through raising a discussion on

DNR issues) implied that there was no hope (noun, objective) for the patient, the
patient would lose hope (noun, subjective) and then cease to hope (verb, subjective)
for a positive outcome. Therefore, they would “drop their bundle” and “go down-
hill” or “go down . . . quicker.” The absence of hope (noun, objective) was under-
stood to negatively affect the physical well-being of the patient such that they
would move more quickly toward death, which would itself contribute to a poor
prognosis. Hope, patient health, and prognosis are locked within a reciprocal rela-
186 QUALITATIVE HEALTH RESEARCH / February 2002

FIGURE 1: Reciprocal Relationship Between Three Specific Versions of Hope and Patient Health:
Poor Prognosis

tionship (see Figure 1). The implication is that, conversely, the presence of hope
(noun, objective) would help the patient to maintain hope (noun, subjective) and
continue to hope (verb, subjective) for a positive outcome. This would enable them
not only to face the present and future with some degree of equanimity but also
would actually positively alter the physical progression of the disease within their
bodies, resulting in an improved prognosis (see Figure 2).
The perceived reciprocal relationship between these three versions of hope is
based on an assumption that the mind can influence the body. In making this
assumption, participants drew on what Delvecchio-Good and colleagues (1990)
identified as a discourse of will. This discourse incorporates Western concepts of the
individual as responsible for his or her own life and the relationship between psy-
che and soma, suggesting that “if one has enough hope, one may will a change in the
course of the disease in the body” (Delvecchio-Good et al., 1990, p. 61). As
Delvecchio-Good and colleagues do not define the precise nature of this hope, it is
difficult to discern its nature. Nonetheless, although the meaning of the word hope is
still contested within medical circles, it remains a fundamental principle in medical
practice that a primary duty of a doctor is to preserve hope, a view shared by our
participants. Doctors, however, may have other reasons for perceiving hope as a
valued possession for the patient, including the observation that a patient with
hope is less demanding and more compliant clinically than one without hope
(Delvecchio-Good et al., 1990; Gordon, 1990; Klenow, 1991).
Nevertheless, this understanding of the real effect of hope in influencing the
course of a disease may account in part for the medical emphasis on detecting and
increasing a patient’s hope. Certainly, some doctors appear to hold the view that the
presence of hope might enable a patient to “will” a change in the progression of their
disease, thus delaying their death (Delvecchio-Good et al., 1990; Klenow, 1991;
Lantos, 1994). Some have claimed that without hope, a patient will die (Nowotny,
1989; Stephenson, 1991), but it would seem indisputable that many patients with
cancer have died with or without hope. There are few conclusive studies regarding
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 187

FIGURE 2: Reciprocal Relationship Between Three Specific Versions of Hope and Patient Health:
Good Prognosis

the impact or mode of operation of hope on the body (Delvecchio-Good et al., 1990),
although hope has been positively linked to survival time in some patients with
cancer (Gottschalk, Kunkel, Wohl, Saenger, & Winget, 1969; Greer, Morris, &
Pettingale, 1979). More recently, in investigating the “cerebral neurobiology of hope
and hopelessness,” Gottschalk, Fronczek, and Buchsbaum (1993) attested to the real
effect of hope. Jenkins (1996) and Snyder, Michael, and Cheavens (1999) have sug-
gested that the positive (and well-documented) effect of the placebo is essentially
the effect of hope. It is somewhat surprising, therefore, that Snyder (2000) was
unconvinced by correlational studies indicating that greater hope is related to posi-
tive health outcomes. Regardless of the empirical evidence for the power of hope,
we suggest that its effect is real inasmuch as the presence or absence of hope is used
to justify or explain a range of behaviors and outcomes within the medical setting
for both patient and medical staff.

4.2 Implications for Doctor and Patient

The multiple employment of hope suggests that the term cannot be defined simply
as an entity to be operationalized and measured but can accommodate a plethora of
meanings. The versatility of hope influences communications between patients and
physicians in several ways. Indeed, the following points may pertain to patients’
interactions with all medical staff.
First, doctors (and other health care workers) may not be able to ensure an abso-
lute and enduring unanimity of interpretation of the word hope, as it may be used in
completely different ways. This is particularly true for patients with cancer, for
which the outcome is life threatening, the social consequences potentially devastat-
ing, and the degree of uncertainty for the patient regarding treatment and prognosis
extreme (Gordon, 1990; Kellehear & Fook, 1989; Saillant, 1990). In addition, for both
patient and staff, the word hope may signify different things at different times during
188 QUALITATIVE HEALTH RESEARCH / February 2002

a discussion or even over the course of an entire relationship, further increasing the
probability that some miscommunication may occur.
Second, a patient may take any aspect of the consultation, including the doc-
tor’s positive manner or proven expertise, to indicate that there is hope (noun,
objective; see Section 2.2). The patient’s perception of hope is thus beyond the con-
trol of medical staff, who may be unaware of factors or processes that engender
hope within the patient.
Third, regardless of how medical staff perceives treatment and prognosis,
patients may take treatment to indicate that there is hope (noun, objective). Accord-
ing to Kodish and Post (1995), any treatment carries an implication of hope. If this is
so, given the importance placed on sustaining hope, one might conclude that treat-
ment is always beneficial and can never be dismissed as futile if desired by the
patient. This understanding might, however, conflict with issues of resource alloca-
tion within the medical system (Lantos, 1994). This uneasy contradiction, which
must influence actual medical practice, contributes to a continuing debate within
medical circles (Callahan, 1994; Schneiderman, 1994; Veatch, 1994).
Fourth, although participants insisted that doctors should preserve hope, thus
implying its vulnerability, they also perceived hope as enduring and impervious to
any attempts to alter or remove it. Such endeavors may, therefore, be considered
futile. This consideration does not diminish the doctor’s obligation to provide
patients with available relevant medical information, but it might justify placing
less insistence on determining appropriate levels of hope for an individual patient
and acting to contrive conformity to this standard.
Fifth, these patients did not distinguish between realistic and unrealistic hope,
identifying hope as a probable source of strength and a means to withstand current
or anticipated hardships (see Section 2.3). Attempts to demolish unrealistic hope
might, therefore, conflict with the mandate that the actions of medical staff should
maximize patients’ well-being.
Finally, it appears that, for many participants, HN was commonly expressed as
“no hope.” This was considered to be within doctors’ jurisdiction to determine; it
often implied an unfavorable end for themselves and, in the guise of the objective
facts, left little room for perceiving or anticipating any positive outcome. It was,
therefore, employed to justify somewhat extreme courses of action (see Section 2.l).
In contrast, HV was usually used to express the patient’s positive desires either for
themselves or another person, either now or in the future; as inherently subjectively
determined, it positioned patients as actively engaged in their circumstances (social
and medical), fostering a degree of independence from the medical regime (see Sec-
tion 3.2). If patient autonomy remains a primary concern for medical staff, this may
be better served if when asked, “Is there any hope?”, they respond, “For what are
you hoping?” thus enabling the patient to express and engage in what is important
to them.
We recognize a number of factors that may limit generalizability from, or repre-
sentativeness of, our findings: Our selection procedure and subsequent sample
group may have led to the predominance of particular constructions of hope as the
speech of emotionally stable patients with cancer may differ from that of the emo-
tionally labile or those with another illness. Because patients were assessed as not
immediately dying, many suggested that the DNR issue was not personally rele-
vant at that time (Olver & Eliott, 2000; Oliver, Eliott, & Blake-Mortimer, in press),
which may also influence the role and employment of hope in their lives and
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 189

speech. Demographically, participants were somewhat homogenous with respect

to ethnic origin (Anglo-Australian) and religious persuasion (no non-Christian reli-
gions represented). To address some of these issues, a subsequent study will focus
on patients in the final stage of their illness of both Anglo-Australian, and non-
Anglo-Australian heritage within Australia, and a further study will feature
Tamil patients in southern India. In the present study, participant discussion on
hope was unprompted and therefore relatively infrequent. Although we consider
the spontaneous use of hope to have been beneficial in analyzing the discursive
properties of hope, planned studies will include a direct question about hope to
facilitate the examination of both the considered and spontaneous manifestation of
hope by patients with cancer. It may also be instructive to examine these within a
population of health care workers, including oncologists, physicians, and nurses, to
further explore potential problems in communication between these and patient
populations.

CONCLUSION: RECOGNIZING A TAXONOMY OF HOPE

Medical constructions of hope rendered it as independently existing, objectively

assessable, and either (a) representing the availability of treatment resulting in cure
or remission or (b) as an attribute of the individual, mutable and valuable. They fur-
ther stipulated that it was for the medical profession to determine appropriate lev-
els of hope, measure the level possessed by a patient, and attempt to reduce any dis-
crepancies between these two amounts. We suggest, rather, that hope is constituted
in the ways that individuals talk about it and that medical constructions coexist
amongst many potential others. Participants understood the word hope in a variety
of ways—sometimes, but not always, in accordance with aspects of the medical con-
structions. For example, when participants viewed hope as objectively determined
and measurable, measuring a patient’s hope was not focused on; hope was consid-
ered an attribute not of the patient but of the situation as assessed by medical staff.
Although participants often agreed that medical staff had the power to influence a
patient’s hope, they also considered that hope could endure regardless of medical
opinion. Finally, although some medical writers identify hope as realistic or unreal-
istic, true or false, our participants appeared to perceive hope as beneficial, consid-
ering that regardless of its ontological status, hope enabled the patient to endure a
trying situation.
The failure of many researchers of hope to recognize the variety of its versions
may explain the difficulties enumerated, difficulties both in devising the definitive
version and of achieving consensus regarding its meaning. Rather than continuing
a search for the “true” hope, we offer a preliminary taxonomy of hope, stressing that
it is unlikely that hope is limited to the constructs shown in Table 3. This notwith-
standing, it may be useful to acknowledge the possibility of combining a range of
meanings, rather than focusing on only one, and viewing hope as located within the
following sets of dualist constructs.
Although aspects of dualistic constructs can be found in other models, this
research is based solely on accidental elicitation of hope and, as such, represents
hope, as it were, “in action.” It affirms the multiplicity of hope, commented on by
many (e.g., Dufault & Martocchio, 1985; Farran et al., 1995; Morse & Doberneck,
1995; Nekolaichuk & Bruera, 1998; Nekolaichuk et al., 1999). We agree with Farran
190 QUALITATIVE HEALTH RESEARCH / February 2002

TABLE 3: Potential Dualistic Constructs Constituting Hope

Hope May Be . . .

Objective Subjective
An evaluation An expectation
An empirical fact An individual desire
A warrant for action An excuse for inaction
Present oriented Future oriented
Focused on the self Focused on another
A burden A resource
Vulnerable Impervious
A feature of the patient A feature of a caregiver
a
An attribute of the individual An attribute of the situation
Inherent within the individual Inspired by sources external to the individual

a. Some other individual, however, assesses the situation itself.

et al. (1995) that those measurements of hope that are unidimensional, focusing on a
single aspect (e.g., Snyder et al., 1991, 1997), cannot do justice to the complexity and
multiplicity of hope. To a lesser extent, this also applies to scales that tap into multi-
ple aspects of hope but then combine them in a single score (e.g., Gottschalk, 1974;
Herth, 1991, 1992). However, we observe that measurement per se tends to obscure
diversity, ignoring subtle yet important variation; furthermore, statistics, although
seductively reassuring in that they give the illusion of objectivity, may encourage
the production of “appropriate” norms and endorsement of standardized interven-
tion (Penrod & Morse, 1997). We have examined “hope-in-action” and suggest that,
in selecting aspects of hope that are amenable to measurement, scale devisers run
the risk of distancing hope from its context of use, from everyday parlance, thereby
decreasing relevance for patients themselves. As previously observed, measure-
ment also obscures the dynamic, multiple, and changing nature of hope
(Nekolaichuk et al., 1999; Penrod & Morse, 1997). Rather than attempting to mea-
sure (and therefore limit) hope, researchers should perhaps look at its function—
recognizing that this can vary, and asking to what degree a particular operation is
useful, and for whom. Rather than defining (delimiting) hope and then assessing
patients against this, we, with others (e.g., Averill et al., 1990; Farran et al., 1992;
Nekolaichuk & Bruera, 1998), recommend focusing on the specific meaning of hope
for specific patients at specific times and places. Furthermore, rather than label hope
true or false, medical professionals should recognize that individuals may differ in
their understanding of hope and of the relevance or meaning of any specific version
in any particular situation.
It seems likely that part of the importance that medical writers and our partici-
pants have placed on hope is based on its flexibility and ability to incorporate a
range of meanings. We do not wish to add to the array of competing models and
attempts to delineate hope, but we note that in 1969, Stotland suggested that hope
could be regarded as a “shorthand term for an expectation about goal attainment”
(p. 2). We suggest that as it emerges from the speech of these participants, hope rep-
resents a shorthand term representing a number of different constructs. If genuinely
concerned with patient well-being and the effect of hope on this, the role of medical
staff should be to determine precisely to what that shorthand term refers—most
effectively achieved through genuine communication with patients themselves. We
 Eliott, Olver / DISCURSIVE PROPERTIES OF HOPE 191

caution, however, that the chameleon-like nature of hope in everyday speech

ensures that medical staff can neither wisely nor ethically assume a shared or endur-
ing meaning of hope, as some patients may hold that “there is no hope” yet con-
clude that “one can always hope.”

NOTES

1. Medical assessments were carried out by IO, as the patients’ long-term attending medical
oncologist.
2. Nine patients have died since the interviews were conducted in late 1996/early 1997: 6 between 4
and 12 months later and 3 from that time to the time of the present analysis.
3. Determination of emotional state was carried out by IO, as the patients’ long-term attending med-
ical oncologist.
4. We acknowledge that the presence of another person during the interview changes both the
dynamic and content of what is said, but consider that this does not substantially affect the production
and our subsequent analysis of spontaneous speech about hope.
5. One patient used the word hopefully twice in a row.
6. Transcription protocol: Words included to make sense of the quoted sentence are presented
within square brackets, thus, [Like this]; Omission of some speech is indicated by an ellipsis, thus, “Some
people . . . would go downhill.”
7. Klenow (1991), however, defined false hope as generated through deception by (medical) others,
allowing that it may have beneficial aspects, but that, by his definition, false hope is based on the patient’s
relative lack of power.

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Jaklin Eliott, B.A. (Dance), B.A. (Hons Psych), is a research psychologist at the Royal Adelaide Hospi-
tal Cancer Center and is a Ph.D. candidate in the Department of Medicine, Adelaide University.

Ian Olver, M.D., Ph.D., FRACP, FAChPM, MRACMA, is a medical oncologist and the clinical direc-
tor of the Royal Adelaide Hospital Cancer Center and a clinical professor in the Department of Medi-
cine, Adelaide University.