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‘Hope as a lighthouse’ A meta- synthesis on hope and hoping in different nursing contexts

Background: Hope has a contextual dimension and experiences of hope seem to be an important part of everybody's life irrespective of changing and challenging health conditions. However, less focus has been placed on the similarities and differences in the experiences of hope among patients and family caregivers in different contexts of suffering and health, such as the nursing contexts of acute and critical care, rehabilitation and long- term care and prevention and health promotion. Aim: This paper focuses on experiences of hope and hoping in different clinical nursing contexts, based on a meta- synthesis of seventeen empirical studies on hope and hoping. These studies highlight experiences of hope and advance our theoretical and clinical understanding of the phenomenon. Methodological framework: This study on hope and hoping from seventeen empirical research studies was based on a meta- synthesis, by clarifying and modifying the essence of hope and hoping, aiming to identify


INTRODUCTION
This paper summarises 17 empirical studies on hope and hoping, based on patients' and family caregivers' experiences in different context of suffering. Hope has been regarded as a central nursing concern both clinically and scientifically (1)(2)(3)(4)(5)(6)(7)(8) as hope has a significant influence on patients and their families in suffering. Traditionally, hope is understood principally as a patient phenomenon (3). Although, the pursuit of hope can be challenging, depending on the context, hope still brings BACKGROUND According to research, hope is important and challenging for everyone irrespective of changing health conditions (3). According to Dufault and Martocchio (23), temporal as well as contextual hope reflects central dimensions of hope. As a comprehensive review of the literature on hope revealed, the essence of hope is defined as a positive future orientation (according to the hoping) and with a personal significant substance (10,13,20). Since hope by nature points to the future, time is an essential aspect of hope. A meta-synthesis of the meaning of hope produced six metaphors: living in hope, hoping for something, hope as a light on the horizon, hope as a human-to-human relationship, hope versus hopelessness and fear, and hope as weathering a storm (4). Further, Benzein et al. (24) found that patients with aggressive illnesses were 'hoping for something' and still 'living in hope' (after all). The researchers highlighted these experiences of hope by illuminating hope as a dynamic experience; the dynamism of hope is important both for maintaining hope and for living a meaningful life, even when struggling in the midst of great suffering.

The acute and critical nursing context
Patients suffering from acute spinal cord injury immediately face problems of mobility, uncertainty, helplessness, despair and vulnerability (10,(25)(26)(27). Patients suffering from acute head trauma experience long-term treatment in hospitals due to cognitive and physical impairments. Stigma, shame and uncertainty were common challenges among the participants (28). Patients hospitalised due to advanced chronic obstructive pulmonary disease (grade III-IV) experienced severe breathlessness and agony in combination with severe fatigue, often depression, despair and pain; these symptoms influence their lives. No treatment is available for the symptoms of breathlessness or the neural network, and the patients' condition and future perspectives are critical and frightening (29).

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HOPE AS A LIGHTHOUSE from multiple sclerosis for more than eight years experienced dizziness, fatigue, mobility and sensibility problems, invisibility, uneasiness, dependency and slowness (32). Since this disease advances gradually, common experiences among the participants were a challenging and frightening future (32). Immigrant women who were on sick leave due to chronic pain described their daily lives as lonely, and reported being excluded and not feeling sufficiently needed, wanted or valued by colleagues or even by family members (33). Residents in nursing homes experienced vulnerability, frailty, homelessness and loneliness due to complex health problems and extensive care needs (34). Common narratives among the elderly were fright, worthlessness and helplessness in a context of paternalism and stress (35).

The nursing context of prevention and health promotion
Human nature has a remarkable ability to adapt. The survivors of a spinal cord injury returned to a normal life 4 years post-injury. They had undergone major changes, such as having new partners, studies or jobs, new homes and new surroundings; they had established meaningful lives, though they were still struggling with vulnerability, depression and pain (36). Family members of and caregivers to seriously ill cancer patients faced emotional, spiritual, social, and physical strain and burden (37). Family members of patients in comas in serious condition in the Intensive Care Unit (ICU), experienced stressful and demanding daily 'ups and downs', deep despair, panic and helplessness on behalf of their loved ones (38). Family caregivers of residents in nursing homes experienced a continuous uneasiness on behalf of their relatives due to vulnerability and daily struggling (34). Families of individuals suffering from multiple sclerosis experienced a lonely and silent struggle day and night and reported experiences of feeling imprisoned and invisible while they suffered from fatigue and insomnia (39). Additionally, relatives also reported poor health status, although they were still healthy.

AIM
The aim of this study is to uncover essential and common aspects of hope and hoping to advance our clinical and theoretical understanding in the context of hope. The following research questions will be investigated: How are experiences of hope and hoping expressed by individuals in different nursing and health contexts? What characterises the substance of hope and the process of hoping in each nursing context? And, finally what is the reinterpreted and synthesised understanding of hope and hoping between and across these clinical nursing contexts?

METHODOLOGICAL FRAMEWORK
This process of reviewing and reinterpretation through a meta-synthesising aims to create more theoretically and broad contextual concepts, as well as to explore the different clinical and contextual attributes of hope and hoping. Based on our 17 previous published empirical studies, this explorative and interpretive meta-synthesis of qualitative studies of hope is inspired by Paterson et al. (40), Thorne et al. (41), Korhonen et al. (42), Beck (43) and Sandelowski (45). The included studies have a qualitative, descriptive and explorative design, all based on a phenomenological-hermeneutic approach (46,47), except for one randomised clinical trial with supportive comments. (37). The analytical focus was on experiences of hope and hoping that affected patients and their significant others.
According to Paterson et al. (40), a meta-synthesis involves a critical interpretation of existing qualitative research.
The key characteristic of a meta-synthesis is the transformation of this new conceptualisation (41) and contributes to a fuller understanding of the phenomenon. In this way, a metasynthesis functions as a translation, to grasp the particular within the whole according to Thorne et al. (41).
Before a meta-synthesis can take place, a new interpretation was carried out, based on different analytical phases, to provide a unique angle of vision from deconstruction and interpretation, to a new interpretation of the phenomenon. The goal was to achieve more, not less, and data were re-analysed with new questions, and ultimately transformed into a new conceptualisations. Extracted findings from the 17 original studies (See Table 1) were performed with sufficient accuracy and drawn up from the themes, categories and metaphors, and selected for a more careful analysis, interpretation and synthesis, in accordance with Korhonen et al. (43) and Thorne et al. and Sandelowki et al. (44,45).
In correspondence with Beck (43), a meta-synthesis helps us to accumulate new knowledge from individual studies. The first step of this analysis involved a re-analysis, based on our published empirical findings, from the 17 empirical included studies. Themes and metaphors emerged from the findings and were re-analysed and compared with those in other studies (43). New metaphors and themes arose from the text and were compared with other studies in each context. The next step involved clarifying and modifying the metaphors and themes in each nursing context, to identify a new synthesis of the unique and lived conditions of hope Sandelowski (45). Through this process, a new comprehensive understanding of hope and hoping arose from the text. Authors, year

SAMPLE
The results of this meta-synthesised study are based on findings from 17 empirical studies of hope and hoping in different patient groups and among family caregivers. One main study, upon which part of this study is based on, is a phenomenological hermeneutic (46,47), longitudinal and qualitative study of patients suffering from a spinal cord injury four years post-injury. Ten participants were followed, (one man died from cancer immediately before the last interview), through four years post-injury, with a focus on hope and hoping (10, 20, 25-27, 30, 3136). The different parts of the main study are presented in each of the three chosen nursing contexts to which they belong. The remaining nine empirical studies included in this analysis are single studies that explored hope and hoping retrospectively. Some of these studies had a main focus on dignity, although all participant were also asked about their experiences with hope and hoping. The context to which a patient or family caregiver belong is related to time and degree of their health and suffering.

The acute and critical nursing context
An interpretative and prospective design was used in the longitudinal study, which was based on qualitative interviews with ten participants suffering from acute spinal cord injury and which explored patients' experiences of hope and hoping during the first weeks following the injury (10,25,26,27). Findings revealed 'Images of the past and future', meaning that their hope was rooted in the past, though future oriented (25): Their hopes were 'to get well again', 'coming home soon' or 'to be as well as possible'. 'Hope will never disappear, although it may sometimes be experienced as strong and at other times as faint'. Their hope was constantly on their mind, and several were longing back to the past, before the injury.
The process of hoping was experienced as 'ups and down', metaphorically comprehended and illustrated as a 'balloon'-meaning that it can be stretched or cracked (25). At the same time, the participants experienced sudden and unexpected 'turning-points', and deep suffering was suddenly transformed into hope: 'One evening I was extremely depressed, nothing seemed to help, everything had gone to hell … suddenly a blue light started to shine… and it was like lightening when the sensations started in my legs and moved to my stomach, and then everything went on and on and the nurses wanted to check it out to see if it could be true, so I had to check it out again and then I had control, and I got everything back again'… Every turning-point increased their hope (20,26).
'The awakenings of hope' (26) were narrated through a metaphor as an 'image of the future', meaning that: Interviews with a research guide.
The text was analysed and interpreted by phenomenological-hermeneutical approach inspired by Ricoeur '… you gain a totally new perspective on life, and you do indeed appreciate life itself much more than before…. Experiences of hope make you feel a new energy that you were not previously aware of…without hope you would have given up'. They had survived in spite of everything (27) and were asking existential questions as: 'Is this a coincidence …. or is it a destiny'?.. as they pendulated between an understanding of a destiny or a miracle? The miracle was understood as the outermost hope.
However, the more serious the damage was, the less certain was the participants' hopes, and the uncertainty threw long shadows on their hope. Uncertain hopes, meaning in general a balance between hope and desperation (20,27): 'This is very hard for me…but He (God) gives us everything, even without prayer, so please do something to my legs, so I can just move a little, this is what I pray for all the time'.
Since the damage was primarily physical, the substance of hope was focused on 'walking and future independent living, without requiring help from others' (25)(26)(27). 'Walking' was understood as metaphor of freedom and mobility.
A qualitative, explorative and descriptive interview study of fourteen patients suffering from mild to moderate cognitive and functional incapacitation due to external head injuries that occurred six months to a year earlier (28) uncovered that all participants had hopes and dreams for the future, as 'to be able to do activities which you enjoy'. Their memories were strongly affected, and they had lost touch with time; nevertheless, the participants had 'hope for improvements and for a life worth living'. The substance of hope focused on regaining functions and returning to work. The participants' increased understanding of the extent of their injury gradually elicited hope for limited progress in the short term. Nevertheless, all the participants believed that 'hope was important' and 'hope continued to motivate' them.
Narratives from a qualitative interview study focusing on pain and hope among sixteen hospitalised patients suffering from chronic obstructive pulmonary disease (grade III-IV) (29), revealed that even when extreme fatigue confined them to bed, the participants experienced 'strong hope'. Their ultimate hope was obtaining 'new lungs' as a metaphor meaning breath and life, and they 'hoped for improvements -for better days and nights'. A general attitude was to try to be positive instead of focusing on the negative parts of their lives-meaning that hope was indispensable: On the other hand, periods of breathlessness threatened their hope and increased anxiety and despair: 'I have entered the circle where I lie down and listen to music… and then you escape from the anxiety-pain'. The constant uncertainty also caused some to 'hope for the release of death'. In this perspective, even despairing hopes were a part of life, irrespective of health and well-being.

The context of rehabilitation and longterm care
A year following the spinal cord injury, the ten participants' faith and will gave rise to their hopes comprehended as enduring hope, flexible hope and creative hopes (10,20). They were continually longing for their previous life. Nevertheless, the participants' longings that emanated from losses became their new sources of hope, reported as a 'longing back to the future' (30). Their longing created new hopes. 'Hope is like a comfort, in a way' according to the participants. The participants were tired of having to wait for assistance so they lived their hope through physical activities and daily exercises. 'Every new day express another chance. So there is hope, the colour of hope is light blue… and deep inside you, your will is strong, it is because of your willpower' (30,31).
Hope mainly manifested itself as an inner strength, which again provided energy that was necessary for their daily struggling and fighting: 'To me hope is an inner strength, it has something to do with your flame of life -it inspires me…. Without hope you loose the flame, you know… with no hope you would have given it all up…'. These narratives were understood as the power of hope (10,20,31).
Hope was expressed as necessary and invariable: 'I really have hope, you always have hope…. And to keep it you need the will as well as the belief that you will make it…'. 'You can never take hope away from somebody, right?..even if you say "oh I am about to give it up" I refuse to live on false hopes, but then the next day comes with a new morning, bringing another chance. So there is always hope'… (31) The substance of hope was related to independence, freedom and personal growth: 'They say that hardship makes you stronger, and I believe that…because you can grow a lot from struggling…you get more insight'. Nevertheless, their hopes were tested in many ways, and this developed their abilities to find new hopes, meaning flexible and creative hope. Finally, their hopes provided comfort and trust (10,20,30,31).
Narratives from a qualitative interview study focusing on experiences of hope and dignity among fifteen women at a rehabilitation hospital who were suffering from multiple sclerosis for more than eight years (32) revealed that the participants were living between hope and despair. Due to the participants' extreme fatigue, their hopes and prayers were concerned with 'not getting worse'. Everybody had fears for the future, such as experiencing new attacks, ending up in a wheelchair or having to leave home permanently. Therefore, their future hopes focused only on 'small possibilities', 8 | LOHNE created in the shadow of uncertainty and fear: 'I still have a sort of "inner me"…because I see it this way, even if I sit in a wheelchair, I am still the same person, right? It is only my legs that are not functioning'. Nevertheless, the participants were continually fighting against an invisible enemy, still 'hoping and praying for miracles' and the stagnation of the disease. Several also focused on the moment to keep the uncertainty at a distance.
A qualitative study of fourteen immigrant women on long-term sick leave due to physical pain revealed that their belief in Allah made them hopeful and peaceful: 'I pray. I trust my religion, I believe strongly, and therefore I live now'. Due to their belief in reincarnation, their faith and hope were also related to their next life, and their hopes were manifested through praying: 'If I die, I'd rather be a flower. I don't think flowers have so much pain'. Their spiritual comfort and faith in God increased their hopes. Their trust in God made them feel strong, confident and relaxed. Several women also reported that their 'faith in destiny' enabled them to maintain their own sense of value and personal worth, despite experiences of shame and despair (33).
A comprehensive qualitative interview study focusing on hope and dignity among 28 elderly residents in six different nursing homes in Scandinavia (35) revealed that the residents' hopes were related to enduring their final journey. They had arrived to remain for the rest of their lives, and they were more concerned about their families than with themselves. Several hoped for mutual and friendly relations at the nursing home; …'hoping something to happen that I care about' (35). Others hoped for participation in meaningful and enjoyable activities, such as singing, reading and dancing, while others hoped for death. 'I like to dance. I have danced for twenty years… the nursing home organize dancing in the afternoon for everyone. It's great because I like it so much'. Simultaneously, they were mostly living and longing for the past; nevertheless, they hoped for inner freedom and autonomy.

The nursing context of prevention and health promotion
Nine individuals experienced mainly universal hope and general hope four years after spinal cord injury (20,36). Universal hope was understood as a necessity of life, meaning that 'hope is always present' after all. Methaphorically, back to life again was based on life-related hopes and creative and expanding hopes. Creative hopes were metaphorically described as pushing limits, sprouting leaves, goals or a happy ending. Life-related hopes were comprehended as 'being in hope, and sometimes also existing in the future and longing back'. Their hope had become more general, as opposed to being specific or contextual, and the participants were living with more inner peace and harmony: 'There is a risk always looking ahead and life itself is put into a shadow, focusing only on hope ….because living in richness, wealth and activities.. and just enjoy it … and fulfilling your hope (36)'. The participants still experienced sudden turning points, meaning moments of improvement, which sometimes reached even beyond the patients' hopes and dreams. Additionally, all participants lived a fully adequate life, and they were more or less reconciled to the accident and grateful for having survived (20,36).
A descriptive and explorative qualitative study of twentyeight family caregivers to residents in six nursing homes in Scandinavia reported that family caregivers, due to their extended responsibility, experienced emptiness and loneliness when visiting the nursing home. Thus, their life had become busy and sad (35). However, 'hoping that the residents had a safe and meaningful life' was common among the family caregivers. Their family caregivers lived in constantly uneasiness on behalf of their dear ones, and their hope was closely related to the residents' daily experiences in the nursing home (35).
A qualitative, phenomenological in-depth interview study focused on experiences of hope and hoping among five family members of seriously ill patients in an intensive care unit at three different hospitals (38). This study revealed that although the family members' hope was weak, they hoped for the survival of their dear ones: 'You hoped of course, that when you came up here you would get some sign, a touch of the hand or a reaction in the eyes or something… I hoped for that every time I came… and if we got some form of reaction it was good'. Thus, the family members continually hoped for signs of improvements and, in the long run they hoped for a return to a normal life. Their hopes kept fears for the worst at bay: 'Yes, where there's life there's hope -and hope is all we've got'. The process of hoping was 'two steps forward and one back' and to have 'a slight hope' after all. They were continually 'hoping for recovery, for treatments and for good news'. Small improvements related to their hopes kept them continuing and enduring the suffering. In addition, hoping made them stronger, as well as contributed to a sense of direction (38). This finding is also in line with 134 family caregivers of patients with pain from bone metastasis (37), where the highest hope score was as follows: 'Recall happy, joyful times' and 'life has value and worth'.
A qualitative, descriptive and explorative interview study of nine family caregivers to patients suffering for years from multiple sclerosis (39) revealed hopes, from tiny hopes of treatments to the conviction that 'you get the help that you need, when you need it'. Additionally, the findings highlighted that the relatives continually focused on the sick one, and seldom on themselves. When their future worries grew, 'faith in God' was important to several, and this faith reduced their loneliness. They 'needed hope in the roughest time in their life… even small hopes'. At the same time, they hoped to be a resource and a support in a life that had become a balance between love and obligations (40).
A synthesised and contextual understanding of the empirical findings is presented below.

RESULTS
Findings from this meta-synthesis of the 17 included empirical studies in this study revealed several dimensions and metaphors on hope. Based on these findings, the presentation below was related to each clinical nursing context where they belong, according to this analysis.

Hope means transformation
Hope is related to time as rooted in the past, though pointing to the future (25). Additionally, hope was experienced as a 'balloon'-meaning that hope is creative, flexible and changeable (26). Being in hope means that the suffering give way for hope, and hope creates energy and pleasure (20). Some hopes origin from dreams (25,28) and some hopes were comprehended as miracles (27).

Hope is indispensable
Hope was important to everyone and was continually on their mind (20), balancing the images with the uncertainty (25,26). The battle between the hoping and the suffering (20) was a battle between freedom and desperation (27)(28)(29). Still, their hopes and dreams were mainly related to improvements, meaning towards a life worth living, as their hope were decisive for life and continually present in their minds (28,29). Conclusively, the essence of the contextual hope was understood as 'possibilities'.

The nursing context of rehabilitation and longterm care
Hope as an inner flame The flame of hope is the motor in hope, creating the energy and the power of hope (10,31). Additionally, hope is increasing the capacity of enduring, since hope is based on faith, will and power (20,30). The flame of hope was related to faith, praying for personal growth and safety (33), which was based on their daily struggling (32). And above all, the flame inspired their will to never give up and the act of hoping was experienced as a comfort (31).

Hope as a lighthouse
The lighthouse is symbolising the direction of hope, the hope of 'becoming'-literary comprehended as longing back to the future, since their losses became a new source of hope (30). Aspects of the lighthouse were illuminating not to get worse, to become independent (of help), for participation and autonomy (35), and for living a meaningful life, as well as to protect the vulnerable side of themselves (32,35). Additionally, having a hope provided inner peace and trust (31), as well as strength and endurance (33). Conclusively, the essence of the contextual hope was understood as 'expectations and destiny'.

The nursing context of prevention and health promotion
Expanding hope Expanding hopes were understood as life-related hopes, meaning being in hope. Some existential hopes were experienced as living beyond hopes and dreams, and becoming a deeper and better person (36). Hope was not specific contextual any longer, but more general with a focus on meaningful living, for safety and for being at peace and harmony (35,37).

Hope means pushing limits
Pushing limits is symbolically, meaning fulfilling your hope through sudden improvements and reconciliation to life and destiny (36), also meaning that where there is life there is hope, and hope is sometimes all we have got (37,38). Hope also contributed to strength and sometimes a new direction (36). Hope and faith, even in the roughest time, were also understood as pushing limits (39). Conclusively, the essence of the contextual hope was understood as 'vitality and freedom'.

Methodological issues
The aim of this study was to investigate essential and common aspects of hope through a meta-synthesis of 17 empirical studies to advance our clinical understanding of hope and hoping. The aims of a meta-synthesis may vary from theory development, increasing the abstraction level or towards generalisations of research findings, to a hermeneutic understanding of phenomena (45). According to Thorne et al. (44), a meta-synthesis may help explaining phenomenon through metaphors, as well as comparing and contrasting, and critically examining the thematic structures of results or findings from the included studies. Ricoeur (47) stated that real metaphors tell us something new about reality and that metaphors may say more than 1000 words. During the phase of determining the related studies in each context, it appeared that the synthesised dimensions and metaphors were both specific to each context, but may also open up for a more general comprehensive understanding of hope regardless of the contexts. This may also be due to the few amount of studies in each clinical context.
Another important question according to this weakness is whether each study belongs to the different contexts chosen for this study, since patients continually move between them. The study of the brain-injured patients, understood as belonging to the acute and critically nursing context, because the patients' injuries were the result of a sudden and serious accident. Since several had been in a long-lasting coma due to their brain injury, they were all in an early stage of gradual mental awakening, even though the accidents, for some participants, were in the past. In addition, patients suffering from more aggressive and progressive diseases were still understood as belonging to the context of rehabilitation and long-term care, due to the stage of their diseases at the time of the interviews. And further, an obvious weakness in this meta-synthesis is that the empirical studies used were different in methodological design and scope. However, each qualitative study reflects empirical experiences of hope, mainly through the participants own expressions. Since hope is a central nursing concern, the main point was to illuminate the dimensions and metaphors based on the chosen empirical studies, and beyond the empirical findings. Although considerable attention was paid to the concept of hope, there is no consensus on the definition of hope (48); this lack of consensus emphasises the importance of this study. Nevertheless, the concept of hope was based on the same comprehensive understanding in each study (13).

Discussion of the findings
Findings in this meta-synthesis were 'Hope means transformation' and 'Hope is indispensable' in the acute and critical nursing context. And further, 'Hope as an inner flame', as well as 'Hope as a lighthouse' was comprehended as central metaphors in the nursing context of rehabilitation and longterm care, and finally, 'Expanding hope', as well as 'Hope means pushing limits' arised form the nursing context of prevention and health promotion.
Compared to other meta-synthesis studies of hope, studies, we found several similarities: Based on a metasynthesis of 15 qualitative studies in three different nursing context nursing (among healthy people, chronic ill people and terminally ill people), the meta-synthesis collapsed the three contextual dimensions into six universal metaphors (4): Living in hope-a being dimension, hope as a light in the horizon-a becoming dimension, hope as a humanto-human relationship-a relational dimension, hope vs hopelessness and despair, two sides of the same coin-a dialectic dimension, and hope as weathering a storm-a situational and dynamic dimension (4). A central finding in this study was 'hope as a lighthouse' which has similarities to 'hope as a light in the horizon'. And likewise, 'expanding hope' in this study has an equal meaning and understanding to 'hope as weathering a storm' (meaning a dynamic dimension). And lastly, 'hope is indispensable' in this study is understood as similar to 'living in hope' (4). This study was also performed in three different nursing contexts, and possibly the meta-synthesis also collapsed these contextual dimensions. The fact that three of six dimensions on hope are overlapping in these two metasynthesised studies strengthen the findings of this metastudy. Accordingly, the authors argue that the usefulness of synthesising available qualitative studies related to a broad understanding of the meaning of hope justifies that the limitation from the contextual studies disappeared (4).
Duggleby et al. (1,2), has published two studies of metasynthesis of 20 studies of hope (1) and 14 studies of hope (2), based on different clinical context, such as older adults and chronic illness (1) and family caregivers of persons with chronic illness (2). Compared to our study, 'hope means pushing limits' is corresponding to 'hope as a dynamic experience of possibilities within uncertainty' (2). The results from to Duggleby et al. (1), uncovered hope as 'a dynamic or situational nature', 'multiple coexisting types', had 'objects that were desirable realistic possibilities', 'future focused' and 'integration of processes of transcendence' (1). And further, 'hope means transformation' is to a certain degree, corresponding with 'possibilities within uncertainty' which again strengthen the findings of this study. And likewise, 'expanding hope' in this study was clearly related to a 'dynamic hope', as well as 'hope means transformation' may correspond with 'integration' and 'transcendence' in that study. In both studies, the metaphors were understood as being contextual and therefore not universal (1,2).
Based on seventeen of our empirical studies, experiences of hope were highlighted as a dynamic process that is essential for life, health and well-being, in line with Bays (49), Forbes (50), and Dufault & Martocchio (23). Additionally, a central finding in this study was 'hope as an inner flame', as well as 'hope as a lighthouse' which is corresponding with Default & Martocchio (23), Marcel (14) and Stotland (55).
Findings also revealed contextual differences across the contexts. Synthesised characteristics of hope within the nursing context of acute and critical care uncovered experiences of hope as possibilities in accordance with Vaillot (51), Lynch (11), Nowotny (15), Hinds (12), Laskiwsi et al., (52), Kylma et al. (53) and Duggleby et al. (2). Typical patterns of hope within the context of rehabilitation and long-term care were illustrated through expectations in line with Marcel (54), Stotland (55), Cutcliffe and Herth (56) and fate in line with Raleigh (57) and Ross (58). In this context, the participants' hope was based on will and faith, in accordance with Eriksson (9). In the context of prevention and health promotion, experiences of hope were more universally based, according to Dufault and Martocchio (23), and illustrated as vitality and freedom, in accordance with Marcel (14), Lynch (11), Hinds (59) and Herth (5).
Kim et al. (61) uncovered individual patterns of hope based on individual personality traits among patients and healthcare personnel. Five patterns of different orientations towards hope emerged: external orientation, pragmatic orientation, realistic orientation, future orientation and internal orientation. These different patterns illustrate different individual ways of understanding and orientation towards sources of hope; meaning that different understanding and experiences of hope may be explained through both psychological patterns, as well as through patients' contextual situation. Individuals having an external orientation were hoping for help from significant others, such as God, family or friends, while individuals with an internal orientation looked to their own abilities, such as the ability to learn or to adapt. Additionally, such perspectives will create different experiences of hope in different individuals, together with different contextual patterns. According to Chopra (60), the essence of life is uncertainty, and the way to peace and freedom is through accepting the wisdom of uncertainty. Furthermore, uncertainty was understood as an inner contrasted core of hope. Therefore, health personnel's hope is extremely important, according to Valle and Lohne (38). The shifting perspective model, derived from a metasynthesis of 292 qualitative research reports on chronic illness (18), illuminates shifting perspectives based on beliefs, perceptions, experiences and expectations about what it means to suffer. This model also illustrates how either illness or wellness takes precedence in peoples' minds: people's perspective shifts to which illness or wellness is in the foreground or background of their 'world'. In this way, the perception of reality, not reality itself, is the essence of how people interpret and respond to illness. Similarly, experiences of hope allow people to shift from being a victim of circumstances to being a creator. Threats that require courage also cause people in suffering to learn courage, according to Paterson (18). Likewise, people experiencing suffering may learn to hope. In this synthesised study of hope, hope and hoping shifted between having a hope and being in hope in accordance with Benzien (62).

CONCLUSIONS
Patients and their family caregivers are in great need of hope, regardless of nursing context. This study reveals that hope is indispensable, expanding and methaphorically is symbolised as an inner flame as well as a lighthouse. According to research, dimensions and metaphores of hope are surrounded by losses, uncertainty, independency, abilities and relationships. The context of losses is the essence of suffering, while the context of hope is the essence of courage as well as faith and trust. The same life situations may be occasions for either hope or suffering, depending upon the interpretation and response of the person involved. From this perspective, some dimensions of hope are always present, which is the ultimate hope in life.

IMPLICATIONS FOR PRACTICE
Based on this meta-synthesis, hope was metaphorically understood as a lighthouse, independent of the different nursing contexts. A lighthouse was comprehended as a bright and shining centre, which is illuminating the horizon as well as pointing forward towards safety and security. A lighthouse is making hidden things visible. Clinical implications from these perspectives mean that nurses are obliged to point out desired targets and future possibilities, and protect, encourage and promote hope and hoping when patients are struggling in suffering and despair. In this way, nurses may bring comfort, light and confidence in patients and their families in spite of their suffering.

CONFLICT OF INTEREST
This article involves no conflict of interest.

AUTHOR CONTRIBUTIONS
V.L performed this synthesis and wrote the manuscript.