Research for Evidence Based Practice

1/17/24, 10:11 AM How People Forgive: A Systematic Review of Nurse-Authored Qualitative Research

https://journals.sagepub.com/doi/epub/10.1177/0898010119828080 1/22

Journal of Holistic Nursing Volume 38, Issue 2, June 2020, Pages 233-251 © The Author(s) 2019, Article Reuse Guidelines https://doi.org/10.1177/0898010119828080

Critical Reviews

How People Forgive: A Systematic Review of Nurse-Authored Qualitative Research

Ann Gentry Recine, DNP, RN, AGPCNP-C 1,2, Louis Recine, OFS3, and Tenzin Paldon4

Abstract Purpose: The aim of this systematic review of qualitative forgiveness studies by nurse authors is to contribute to the body of holistic nursing knowledge by discovering answers to the following research questions: (a) where/how does a person get the power to forgive? and (b) what are the people who forgive like? Method: We conducted a systematic search of the English language, peer-reviewed literature for nurse-authored, primary qualitative research that answered our research questions. A total of 188 potential studies were found, and 11 studies met the inclusion criteria. Results: Study participants used interpersonal, intrapersonal, and transpersonal sources of power to forgive, including prayer, meditation, and support from family, friends, and nurses. The findings also revealed the cognitive, emotional, and spiritual traits of forgiving people, including being faith oriented, empathetic, and understanding the meaning of forgiveness as letting go of negative emotions. The findings confirm activities listed under “Forgiveness Facilitation” (2018) in Nursing Interventions Classification (NIC) and suggest additions. Conclusion: This literature review adds to nursing knowledge by synthesizing the findings of the review in a way that provides guidance to nurses to help facilitate forgiveness with patients who want that.

Keywords forgiveness, forgiveness model, forgiveness process, forgiveness intervention, forgiveness facilitation, qualitative research, nurse author, spirituality, common themes, meditation/mindfulness, stress management/relaxation, healing modalities

Introduction

Defining Forgiveness and Its Relevance to Holistic Nursing

1University of Wisconsin–Eau Claire 2Holistic Therapy, LLC 3Lou Recine Coaching, LLC 4University of Wisconsin–Eau Claire

Corresponding author(s): Ann Gentry Recine, DNP, RN, AGPCNP-C, Assistant Professor, College of Nursing and Health Sciences, University of Wisconsin–Eau Claire, 5 Roosevelt Avenue, Eau Claire, WI 54701, USA; e-mail: [email protected]

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Phenomenological research has demonstrated that patients want nurses to address their spiritual needs by (a) caring genuinely, (b) connecting with patients, (c) talking about spiritual matters, and (d) facilitating the use of spiritual resources (Tanyi, Werner, Recine, & Sperstad, 2006). Holistic nurses understand that the patient or client in front of them presents with a mental state, emotional affect, beliefs, values, personal strengths and weaknesses, and chronic or acute mental, emotional, or spiritual stressors, which may pose obstacles to their overall physical health (Slavich, 2016). The stress that comes from a patient’s mental state of unforgiveness can be mitigated through forgiveness, which is negatively related to stress (Tuck & Anderson, 2014); thus, failure to cope with being wronged by an intimate partner, with betrayal from a friend, or injurious treatment from a stranger joins a possible host of other stressors in one’s life. Previous research has established the correlation between reducing stress through forgiveness and human health (Lawler et al., 2005; Lawler-Row, Karremans, Scott, Edlis-Matityahou, & Edwards, 2008; Toussaint, Owen, & Cheadle, 2012).

To respond holistically to the spiritual and emotional needs of patients, nurses are using spiritual nursing interventions such as Forgiveness Facilitation. This is defined in Nursing Interventions Classification (NIC) (Butcher, Bulechek, Dochterman, & Wagner, 2018), the research-based taxonomy of nursing interventions, as “assisting an individual’s willingness to replace feelings of anger and resentment toward another, self, or a higher power, with beneficence, empathy, and humility” (p. 195). Using this as a springboard, holistic nurses need to understand the definition of forgiveness itself in order to assist patients to forgive. Though some variations in forgiveness definitions exist, most scholars agree that there are three essential elements. Recine, Werner, and Recine (2007) incorporate these elements when they define forgiveness in their concept analysis as “letting go of, or relinquishing a negative response following an offense and changing to a positive response toward the offender, within a process that occurs over time” (p. 312). This is the definition of forgiveness we used for the evaluative judgments in this systematic literature review.

Exploring the Forgiveness Process

In addition to understanding the definition of forgiveness, holistic nurses need to understand forgiveness as a process. A key component of “Forgiveness Facilitation” is to “explore forgiveness as a process” (2018, p. 195). To that end, Figure 1 shows a model of the process based in the scholarly literature, originally developed by the first author (Recine, 2006) for use in private practice. This model was developed as a result of a literature review for a forgiveness concept analysis (Recine et al., 2007) and based on the borrowed nursing theory of meaning (Frankl, 1959; Starck, 2003). Since the time when it was first referred to as an unpublished manuscript (Recine, Werner, & Recine, 2009), the model has gone through many iterations based on feedback from focus groups—use with individual patients, dyads, and groups. It illustrates that in the midst of the suffering that comes from personal hurt, the spirit can defy the mind and the body in making a choice to forgive. The attitudes of forgiveness are also the attitudes of forbearance; the difference is that in forgiveness the person first starts at unforgiveness and over time makes a shift to forgiveness attitudes (Recine et al., 2007). See Figure 1.

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The downward arrow in the model in Figure 1 illustrates that if the personal hurt results in a choice to stay in a state of rumination on the offense, unforgiveness will result (Worthington, 2003). It shows that the necessary components of unforgiveness are (a) to take the offense personally, (b) to judge the other, and (c) a resultant mixture of negative emotions such as anger, fear, and hatred. What is the negative life purpose of unforgiveness that is being chosen? It is chronic self-protection or getting retribution. In the forgiveness process, over time, there is a shift from the negative to the positive that results in the attitudes of forgiveness: (a) not taking the offense personally; (b) judging the action, not the person; and (c) positive emotions such as peace, love, humility, and empathy. What is the life purpose of forgiveness that is being chosen? It is to give an altruistic gift to self, others, or God. This altruistic response is one which does not place conditions on the offer of forgiveness.

Holistic nurses understand the process of forgiveness in the context of the health of their patients. In their study on forgiveness and health, Toussaint et al. (2012), while noting that responses from a wrongdoer such as apologizing or changing behavior can make the process of forgiving easier, found that “conditional forgiveness of others was associated with increased mortality risk” (p. 382). Thus, a failure to arrive at such an unconditional offering of forgiveness appears to have a negative health impact. In contrast, Toussaint et al. (2012) note,

An unconditional perspective on forgiveness allows the process to begin whenever the offended party chooses, without the necessity of waiting for particular responses from others. Placing conditions on offering forgiveness to others adds barriers that can translate into extended duration of unforgiveness and/or decreased frequency of forgiveness, both of which may ultimately yield poorer health and greater mortality risk. (p. 383)

The Background of Our Research Questions and Choice of Review Type

The main purpose of this study was to discover how people forgive—particularly, where they get the power to forgive and what kind of people are able to forgive. Clinically, the model in Figure 1 has been useful and yet a question that patients have is “Where does one get the power that enables the shift from the negative to the positive?” Patients have also found that to learn to forgive they need exemplars who have been successful in this process. They need to be able to see what a forgiving person looks like, which is in keeping with the social learning theory (Bandura, 1977). Therefore, we undertook this systematic literature review to help answer the following questions, which formed the research focus of the review:

Figure 1. “Forgiveness: Understanding the process,” 2006

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• Where do people get the power to forgive? • What are the people who forgive like?

We chose to do a systematic review for this study because we wanted to find out whether the extant nurse- authored primary qualitative research addressed our research questions or whether there were significant gaps that would justify a new qualitative study. A systematic review involves doing a search for all relevant primary studies that answer the research questions in a particular clinical area (Rebar & Gersch, 2015). It includes a “summary of research findings categorized and synthesized under clinically meaningful topics” (Rebar & Gersch, 2015, p. 43). It also includes “specific identification of practice implications, derived from the synthesis of the literature” (Rebar & Gersch, 2015, p. 43).

The Value of Qualitative Forgiveness Research to This Inquiry

“Historically, quantitative studies have significantly outnumbered qualitative studies of forgiveness . . .” (Mihalache, 2012, p. 115). We chose to conduct a systematic review of the qualitative forgiveness literature to help make the qualitative research contributions more accessible and to add to the overall picture of the forgiveness process. Nursing has contributed significantly to the body of qualitative studies on forgiveness. This is not surprising, due to the holistic culture of nursing, which is a culture of reverently listening to the lived experience of the patient. Yet we are not aware of any systematic reviews of the qualitative nursing literature on forgiveness. Qualitative forgiveness research can enrich quantitative research by discovering and adding the how or why to the what, of forgiveness, perhaps even sometimes adding new manifestations of what. This systematic review of nurse-authored qualitative forgiveness studies addresses this gap in the hope that nurse researchers can tell a story of the human response of forgiving in a way that honors those who were interviewed, confirms or adds to the work of quantitative researchers, and elucidates new knowledge about how and why people forgive. Our research questions are embedded in the needs of people seeking answers from nurses, and the answers to those questions can be found in the qualitative studies of nurses who reverently listened to the stories of people who have found the power to forgive and have told us about the how, why, and what behind their forgiveness experience.

Method

After consulting with a research librarian, we conducted a systematic search of the English-language, peer- reviewed literature for nurse-authored, primary qualitative research that answered our research questions. No date limit was set on the search.

The databases we searched were PsycINFO, Cochrane, CINAHL Complete, Medline, PubMed, and Google Scholar. Using the search terms forgiv* and nurs* and qualitative, we found 169 articles. A total of 188 potential articles were found because of the addition of 19 potential articles that we found through the references of the full-text article reviews we later did. Before choosing which abstracts of these 188 potential articles to read, we eliminated 139 articles if they did not meet the following criteria: (a) have at least one nurse author, (b) were primary research, or (c) were qualitative research. Through review of the abstracts of the remaining 49 articles, we were able to further eliminate articles in which the abstract clearly indicated that the study was not substantially about forgiveness of others. We then reviewed the full text of the remaining 29 potential articles and were able to further eliminate articles that did not have enough useful data to answer our research questions. Through this process, we found 11 nurse-authored qualitative, primary studies that substantially addressed forgiveness of others and answered our research questions. See Figure 2.

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After identifying the 11 studies, our method of analyzing the data in the studies was similar to the process of qualitative data analysis in primary qualitative research in that it involved a “spiraling” process (Rebar & Gersch, 2015, p. 75). This process of qualitative data analysis is not circular, returning to where it began, but evolves to eventually identify key themes or concepts. Each of the investigators completed an initial round in the spiral by individually identifying the themes in the qualitative studies that we reviewed. The spiral of data analysis continued to broaden and grow as we met together weekly and continued the process of discovering and categorizing themes and revising the placement of themes into the categories. When needed, we reread the material together out loud. This spiraling process continued until we reached the point of saturation, which in this case meant until we as a group were satisfied that we had identified all the themes in the studies that answered our research questions and no more new information was being collected through further analysis. The results are seen in Tables 2 and 3.

Results

Theoretical Frameworks of the Reviewed Studies

To best understand the results of the spiraling process that we used in our analysis method, it can be helpful to understand the various theoretical frameworks that underlie the qualitative research in the 11 included studies, which helped produce the data that we analyzed. One qualitative method used by nurse authors in these studies (Mickley & Cowles, 2001) was based on grounded theory. In this qualitative interview and analysis method,

Figure 2. Search and Selection Process

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there are “simultaneous collection, analysis, and interpretation of data” (Mickley & Cowles, 2001, p. 32), which result in evolving categories that are constantly compared with one another. The coding process generally involves multiple reviewers, and member checks to validate the findings. Bracketing of the researcher’s own experience and pre-understandings is valued in this method to see the participants’ perceptions without bias.

In five of the qualitative studies, the investigators had the philosophical underpinning of phenomenology (Arpanantikul, 2011; Chao, Chen, & Yen, 2002; Laughon, Steeves, Parker, Knopp, & Sawin, 2008; Parker, Steeves, Anderson, & Moran, 2004; Steeves & Parker, 2007). These studies took a Heideggerian (interpretive)- based approach to phenomenology in which the researcher’s involvement in the interpretation of the participants’ world is an integral part of the interview and evaluation of data (Reiners, 2012). Chao et al. (2002) explained that the Heideggerian (interpretive)-based approach positively values the investigator having a pre- understanding of the phenomena to be explored. Rather than emphasizing bracketing one’s own prejudice, the nurse investigators sought a healing dialogical interaction with patients in which both the nurses’ and the patients’ human experience was part of the holistic process of discovery of the present and the future in light of the past.

Other rigorous qualitative approaches were used in the studies we analyzed that positively valued the experience of the researcher as key to the study. For example, one study (Taylor, 2014) was an ethnographic qualitative research study with an emphasis on framing the interpretation of the narratives in light of how race, class, and gender produce social consequences in the lives of the subjects. Similarly, another qualitative study was based in participatory action research (PAR) (Mill, Edwards, Jackson, MacLean, & Chaw-Kant, 2010). PAR is a type of research in which the researcher focuses on consciousness raising and promoting critical thinking, exploring the root cause of situations (Schoepf, in Mill et al., 2010). Two studies framed their understanding of the qualitative approach from a womanist/feminist approach (Arpanantikul, 2011; Taylor, 2004). In another study (Ferrell, Otis-Green, Baird, & Garcia, 2014), the researchers analyzed the participants’ responses in light of communication theory. See Table 1 under the “Qualitative Design Type and Study Background” column for a description of each study’s qualitative design type as well as a summary of the background of each study.

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Participants and the Offenses They Forgave

The compiled data that arose from the aforementioned qualitative research, based on a variety of theoretical frameworks, revealed a rich variety in the participants’ race, gender, religion, culture, and ages as well as the type of offenses they forgave. Hence, the qualities and strengths of the participants in these 11 studies could be instructive to a wide, multicultural population of people who are looking for answers from nurses on how to forgive. Many of the participants were patients, such as women with breast cancer (Liu et al., 2008). We readily see that patients can be our greatest teachers. From American terminally ill cancer patients (Mickley & Cowles, 2001), to Taiwanese hospice patients (Chao et al., 2002), to HIV positive patients who were stigmatized by the staff (Mill et al., 2010), each group offers a contribution to our understanding of how to forgive. Often, people in the studies were examples of those who forgave what might be considered unforgiveable. For example, the African American women who forgave intimate partner violence (Taylor, 2004), the adults who forgave their one parent for murdering their other parent (Laughon et al., 2008; Parker et al., 2004; Steeves & Parker, 2007), parents who forgave the murder of their child (Mickley & Cowles, 2001), and the Vietnamese men who forgave dehumanizing treatment by their captors (Nguyen et al., 2014), all teach us about what kind of people forgive and where they get the power to go on to lead peaceful lives. See Table 1 under the “Description of Sample” and “Type of Offense Forgiven” columns.

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Findings That Answered the Research Questions

We analyzed the content of the qualitative studies based on our research questions. Thus, we reviewed them for the cognitive, emotional, and spiritual characteristics (traits or qualities) of people who forgive. What are the people who forgive like? See Table 2. We also reviewed the studies for answers to the question “Where/how does a person get the power (sources and strategies) to choose to forgive?” We divided these sources of power or strategies into the following domains: (a) interpersonal, (b) intrapersonal, and (c) transpersonal, building on the example of Mickley and Cowles (2001). See Table 3.

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Cognitions of the Forgiving Person (Table 2). The findings demonstrated that the kind of people who forgive are people who take time to think, to introspect, to look inside, and work on themselves (Parker et al., 2004). As they introspect, they are able to not take the offense personally and examine if they had a part in the situation (Arpanantikul, 2011; Mickley & Cowles, 2001). They think about forgiving as a “personal victory” (Taylor, 2004, p. 41). As one participant said, “I also triumphed by not hating men” (p. 41).

Forgiving people also think about forgiveness in a particular way and understand what forgiveness means and what it does not mean. For example, forgiving people understand that forgiveness is letting go of negative feelings rather than condoning, pardoning, or absolving (Mickley & Cowles, 2001; Taylor, 2004). “‘It’s a letting go.’ . . . Bitterness, anger, guilt, and jealousy are ‘put to rest.’” (Mickley & Cowles, 2001, p. 33). They understand that forgiveness can include boundaries and detachment from the perpetrator and holding the

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perpetrator accountable (Laughon et al., 2008; Taylor, 2004). They also understand that forgiveness is a choice (Taylor, 2004).

A prominent finding about the cognitions of persons who decide to forgive is that they have insight that the anger they carry about the offense is harmful to them and letting go of that anger will bring healing and reduce suffering (Arpanantikul, 2011; Steeves & Parker, 2007; Taylor, 2004). “If I do not forgive them, I will have stress forever. Stress will be stuck in my mind. My life will be unhappy” (Arpanantikul, 2011, p. 326). “One individual wondered, ‘Is this [anger] keeping me from getting well as fast as I should, or is it keeping me from never getting better?’” (Mickley & Cowles, 2001, p. 33).

Another prominent finding is that they are willing to see things differently by looking back at the situation and analyzing what happened in order to gain perspective and understanding (Arpanantikul, 2011; Laughon et al., 2008; Mickley & Cowles, 2001; Mill et al., 2010; Nguyen et al., 2014; Parker et al., 2004; Steeves & Parker, 2007). One woman said: “Somehow you have to figure a way of having peace around that person . . . [I knew] I would be able to forgive my father on the basis that he was mentally ill and that was a logical reason for me” (Laughon et al., 2008, p. 158).

Importantly, they are able to understand that there were mitigating factors in the perpetrator, such as mental illness, addiction, or fear (Laughon et al., 2008; Mill et al., 2010; Parker et al., 2004; Steeves & Parker, 2007). Some were able to gain perspective because they understood the brevity of life, and this helped them identify what is truly important to them (Ferrell et al., 2014; Mickley & Cowles, 2001). After the diagnosis of cancer, one study participant stated, “What is really important if I die? What do you want to leave to your children?” (Mickley & Cowles, 2001, p. 33). Others gained perspective from being willing to open up to trusted, caring people, and share their feelings about the offense (Chao et al., 2002; Taylor, 2004). Some of the participants’ cognitions reflected the practice of mindfulness, such as staying in the present (Nguyen et al., 2014), as well as re-focusing their attention to pleasant experiences and pleasant memories. As one study participant expressed it (Arpanantikul, 2011): “When I feel stressed or angry, I create my happiness by thinking about past good memories. . . . I realize I am of value. . . . Memories of good past events help reduce my anger” (pp. 329-330). In addition, they employed the mindful outlook of acceptance of one’s unpleasant experiences and letting go of all comparisons with other people’s lives in order to gain happiness (Arpanantikul, 2011).

The Emotions of the Forgiving Person (Table 2). The participants’ forgiving perspectives resulted in feelings of humility (Arpanantikul, 2011; Mickley & Cowles, 2001) and empathy for the perpetrator (Arpanantikul, 2011; Mill et al., 2010; Taylor, 2004). In addition, for some, it resulted in a longing for restored intimacy with the offender (Mickley & Cowles, 2001).

The Spiritual Qualities of the Forgiving Person (Table 2). A prominent finding in the spiritual domain was that the forgiving person wanted to be at peace (Arpanantikul, 2011; Ferrell et al., 2014; Laughon et al., 2008; Mickley & Cowles, 2001; Steeves & Parker, 2007). They valued loving other people (Mickley & Cowles, 2001). This connection to other people helped them be in touch with a sense of common humanity with the offender (Mickley & Cowles, 2001). Notably, many were also connected to God and wanted to live according to God’s will and moral principles (Arpanantikul, 2011; Ferrell et al., 2014; Laughon et al., 2008; Mickley & Cowles, 2001; Steeves & Parker, 2007).

The subjects in these studies who succeeded in forgiving, in spite of the serious offenses against them, also have something to teach us about where people get the power to forgive. They found interpersonal, intrapersonal, and transpersonal sources of power and strategies to let go of their anger and choose to forgive.

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Interpersonal Sources of Power and Strategies (Table 3). Participants found a variety of rich interpersonal sources of power. Notably, having a nurse or other professional, or a trusted confidant who showed an active interest and was a nonjudgmental listener, was an important source of inspiration and strength to forgive (Arpanantikul, 2011; Chao et al., 2002; Ferrell et al., 2014; Mickley & Cowles, 2001). Having support from clergy and one’s church congregation can also be a source of power (Mickley & Cowles, 2001; Taylor, 2004). Discussion with family and friends and being influenced by their values is another important source of power (Chao et al., 2002; Mickley & Cowles, 2001). Having strong figures in one’s life to rely on also can be key to the stability that is needed for a person to forgive (Parker et al., 2004; Steeves & Parker, 2007). For a brother and sister in one of the studies (Parker et al., 2004), this was an aunt. The authors (Parker et al., 2004) noted, “They said that no matter what, she was available to them and loved them. She was a constant presence for them” (p. 143). Even the perpetrators can be a source of inspiration to forgive if they are able to give a sincere apology (Laughon et al., 2008).

Intrapersonal Sources of Power and Strategies (Table 3). There are also intrapersonal sources of power within each person that can give a person the power to respond to an offense with forgiveness. Within the inner sanctuary of the heart, there are strategies that the participants used that can serve as a model to us as sources of inner strength in the face of the realities of living in a world where offenses occur every day, some of which seem unforgiveable. The sources of inner power included private contemplation (Mickley & Cowles, 2001), remembering forgiveness principles learned during childhood (Mickley & Cowles, 2001; Steeves & Parker, 2007), and pondering the words of family, friends, clergy members, and counselors (Mickley & Cowles, 2001). In particular, the inner work of the Buddhist women in Bangkok is a model of a way to mature intrapersonally and find the power to overcome stress and anger (Arpanantikul, 2011). Their practice of calming themselves, accepting life as it is, and looking at the positives, even the positives that can come as a result of the troubling situation and positives in the perpetrator, were a great source of power to them as they lived their daily lives.

They . . . engaged in positive thinking . . . to find good things from bad situations. “Things in the world are not entirely good or bad. If I focus on the bad side of a situation, instead of the good side, I will lose a valuable learning opportunity.” (Arpanantikul, 2011, pp. 328-329)

Transpersonal Sources of Power and Strategies (Table 3). Transpersonal sources of power to forgive, based in something beyond oneself, were found in prayer and meditation (Arpanantikul, 2011; Mickley & Cowles, 2001; Taylor, 2004) and spiritual reading (Liu et al., 2008; Parker et al., 2004; Taylor, 2004). Many participants found strength to forgive by choosing to rely on God (Ferrell et al., 2014; Liu et al., 2008; Mickley & Cowles, 2001; Parker et al., 2004; Steeves & Parker, 2007). “When I choose to rely on God, I feel God can help me more” (Liu et al., 2008, p. 2545). A prominent finding was that people found power to forgive by practicing the teaching of their faith/religion (Arpanantikul, 2011; Laughon et al., 2008; Mickley & Cowles, 2001; Parker et al., 2004; Steeves & Parker, 2007; Taylor, 2004). For example, in one study (Arpanantikul, 2011), some of the participants: “focused on Buddhist doctrine and, as a result, they felt peaceful. . . . “When I am angry, I pray for 1- 2 hours. . . . I begin to feel calm and merciful. It works very well. My anger is reduced after praying” (Arpanantikul, 2011, p. 327).

In addition, some were able to transcend the feelings of unforgiveness by finding meaning in their suffering and in the experience of being wronged (Mickley & Cowles, 2001; Parker et al., 2004; Steeves & Parker, 2007). For example, in one of the studies (Mickley & Cowles, 2001), “one participant stated that a ‘silver thread’ through the cancer experience is that ‘now I know what I want.’” (p. 35).

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Discussion

It is worth noting that the studies were conducted in diverse cultural contexts. The research represents the forgiveness experiences of a wide variety of people—from Black women in the United States, to male Vietnamese ex-prisoners of war, to middle-aged Buddhist women in Thailand. The subjects varied also in the developmental stage in which they struggled to forgive—from children who experienced the murder of their parents, to young men who were imprisoned, to patients at the end of life. This wide cultural and developmental breadth of experience in the subjects adds richness and depth to these findings. The findings of this systematic review of nurse-authored qualitative forgiveness literature builds on the foundation laid by Festa and Tuck (2000). In their classic work, they challenged nurses to begin scholarly investigation of forgiveness as a clinically promising field of inquiry to add to the scholarship conducted on this area by other disciplines. Since then, to our knowledge, there have been two forgiveness concept analyses by nurse authors (Brush, McGee, Cavanagh, & Woodward, 2001; Recine, et al., 2007), mostly based in the theoretical and quantitative empirical literature. These laid the foundation for nurses in our understanding of forgiveness. This systematic literature review does not stand alone but is situated in the historical context of nurse scholarship. Importantly, it confirms the knowledge in the two concept analyses as well as adds knowledge to help us assist our patients.

For example, the findings of this systematic review of nurse-authored qualitative forgiveness studies confirm the following forgiveness concepts from Brush et al.’s (2001) forgiveness concept analysis.

• It is important to understand the definition of forgiveness (what it is and is not) (Mickley & Cowles, 2001). • The internal motivation of the victim (Mickley & Cowles, 2001; Parker et al., 2004; Taylor, 2004), as well as

apology (Laughon et al., 2008) from the perpetrator, can be important antecedents of forgiveness. • An important consequence of forgiveness is that it can result in healing from past trauma and lead to personal

transformation (Mickley & Cowles, 2001; Steeves & Parker, 2007; Taylor, 2004).

In addition to confirming the above concepts, the findings of this systematic review of nurse-authored qualitative forgiveness studies also confirm the following forgiveness concepts gleaned from scholarly literature by Recine, et al. (2007) in their multicultural forgiveness concept analysis.

• Forgiveness takes time (Mickley & Cowles, 2001; Nguyen et al., 2014; Taylor, 2004). • Viewing the personal relationship with the perpetrator as important is a key motivation to forgive (Laughon et

al., 2008). • Empathy is an important antecedent to forgiving (Arpanantikul, 2011; Mickley & Cowles, 2001; Taylor,

2004).

• Forgiveness does not mean letting go of justice and can be a form of self-respect (Laughon et al., 2008; Taylor, 2004).

• Religious principles and a religious community help give a person power to forgive (Laughon et al., 2008; Mickley & Cowles, 2001; Steeves & Parker, 2007; Taylor, 2004).

• Parents and family are important influences on a person’s attitude about forgiveness (Chao et al., 2002; Laughon et al., 2008; Mickley & Cowles, 2001; Parker et al., 2004).

• Counseling and therapeutic interventions can help a person forgive (Ferrell et al., 2014; Steeves & Parker, 2007).

• Forgiveness can bring about a state of personal peace (Arpanantikul, 2011; Ferrell et al., 2014; Laughon et al., 2008; Mickley & Cowles, 2001; Steeves & Parker, 2007).

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What This Article Adds to Holistic Nursing Knowledge

This systematic review of nurse-authored qualitative forgiveness research adds to nursing knowledge by synthesizing the data in the reviewed articles in a way that provide guidance to our patients on how they can find the power to forgive and helps them see what spiritual traits a forgiving person has, how they think, and what they feel. To our knowledge, this has not been done in the systematic nursing forgiveness scholarship to date. The data from this systematic review gives the new insight to nurses that in addition to assisting a patient to find interpersonal (social) and transpersonal (spiritual) sources of power, they may also assist patients to build intrapersonal sources of strength to help them forgive and find peace. The following self-reflective intrapersonal strategies were used by the participants in the studies we reviewed and can be instructive to nurses in guiding our forgiveness interventions to address the inner sanctum of the person.

• Through quieting oneself (Arpanantikul, 2011) and private contemplation (Mickley & Cowles, 2001), forgiveness can be more easily attained.

• Time is needed for personal reflection in which the values of forgiveness learned earlier in life can be remembered and pondered (Mickley & Cowles, 2001; Steeves & Parker, 2007).

• Calming oneself by doing good things for others can be an aid to forgiveness (Arpanantikul, 2011).

In addition, the following intrapersonal principles of mindfulness practiced by the participants give helpful new insights for learning to forgive.

• Living in the present helps minimize the impact of past wrongs (Nguyen et al., 2014).

• Acceptance of the troubles and negative emotions one experiences helps one more easily attain forgiveness (Arpanantikul, 2011).

• Strengthening one’s ability to refocus the mind on enjoyable activities and positives in life, even the positives within the troubling situation and the perpetrator, is an aid to forgiveness (Arpanantikul, 2011).

• Learning to accept oneself and letting go of comparing oneself with others to feel happier helps in letting go of anger and stress (Arpanantikul, 2011).

Thus, this article adds to holistic nursing knowledge by helping us answer the question of how people find the power to forgive. As a result, we have been able to add to the process model in Figure 1 the ways to describe what is happening over time to gain the power to move from unforgiveness to forgiveness. Over time, people change their perspective by self-reflection, support of others, and/or connection to a higher power. This is seen in Figure 3.

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Implications for Research and Practice

Clinical Application to Holistic Nursing Practice

Nursing has a history of understanding the value of forgiveness facilitation as a means of health promotion. There is a connection between forgiving attitudes and long-term health benefits such as better sleep, less use of medication, better mental health, and better cardiovascular status to mention just a few (Recine et al., 2009). As our nursing knowledge of the best ways to facilitate forgiveness evolves over time, we need to review and update our approaches. For example, though all of the activities listed under “Forgiveness Facilitation” in NIC (Butcher et al., 2018) are supported by this review of qualitative studies (see Table 4), the data from these studies suggest that there are possible additional activities that might be considered for being added. See Table 4.

Figure 3. Forgiveness: Understanding the Process, 2018

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Ivory Tower to Bedside/Clinic

Confirming existing findings on forgiveness and the forgiveness process and adding to the body of holistic nursing knowledge of forgiveness is not enough. These findings must reach our patients in such a way as to improve clinical outcomes. Because of the frequency of their contact with patients, nurses may find opportunities to help facilitate forgiveness. Yet, as Ferrell et al. (2014) note,

Research and clinical experience would suggest that nurses in the position of witnessing the intense need for forgiveness from or to the patient may not be well prepared to adequately address the complex dynamics or processes of how to appropriately respond. (p. 633)

This systematic literature review contributes toward meeting this need. For instance, the varied, multicultural sources of power identified in the study provide nurses with an assortment of options to suggest to a patient who may want, or be open to, assistance with forgiveness. Recine et al. (2009) note that patients “need to be listened to and learn to forgive according to their own needs and consistent with their own values and life situations” (p. 121). Knowing the patient will help the nurse choose from the sources of power or strategies for forgiveness that would be most acceptable and helpful to the patient.

The challenge for nurses and other clinicians is to translate findings from scholarly research into effective patient education, using language that patients will not only understand but which will move them toward

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healthy change. Guidance from the U.S. Department of Health and Human Services’ National Institute on Aging (2014, para. 7) for communicating scientific research findings to lay people include (a) focusing on what’s important; (b) summarizing research findings in a way that account for the details and nuances in the research but use the least amount of detail; (c) using “common, everyday words”; (d) using “active voice”; and (e) using the shortest sentences possible. In a literature review of verbal patient education (Marcus, 2014), one of the findings was that verbal education combined with written was more effective than verbal alone. To this end, the first and second authors have created a handout to use with patients and clients (Guideposts to Forgiveness, 2018) in their private practices, which attempts to communicate some of the findings of this study in a way that may easily be grasped and remembered by patients or clients (see the appendix). To help ensure clarity and effective writing style, we solicited feedback from a number of individuals, including nurses and professional writers. We hope that it will be a useful tool for nurses to ideally go over with patients verbally and also to give it to the patient to help reinforce what was discussed in person. While with the patient, and based on their knowledge of the patient, nurses can present, repeat, and emphasize the information that is most important to that specific patient (Marcus, 2014). Research shows that the number of interactions and the amount of time with a patient regarding forgiveness matter (Lundahl, Taylor, Stevenson, & Roberts, 2008). Though this is true, whether nurses have repeated interaction with a patient to guide the forgiveness process or are only able to briefly interact with the patient regarding forgiveness, it is worth noting that the effect of the nurse–patient interaction depends on the level of distress that unforgiveness is causing the patient (Lundahl et al., 2008). A nurse may feel that a brief nurse-patient interaction is not as effective as referring the patient to a forgiveness group or seminar, but research shows that individually delivered forgiveness information is more effective (Lundahl et al., 2008). The Guideposts to Forgiveness (2018) are not a delineation of steps that we hope to bring a patient through in a linear fashion, but they are insights from people who have forgiven that can light the way to forgiveness. Just as a very small seed cast into fertile soil can grow into a very large tree, if a patient is distressed and looking for a solution to unforgiveness, these insights, shared in the nurse-patient interaction, may grow in the patient’s heart over time into a freeing forgiveness experience.

Gaps and Implications for Further Research/Scholarship

While all the studies have some valuable findings to enrich our understanding of how and why people forgive, and what forgiving people are like, only two nurse-authored qualitative studies were found in which the main goal of the research was to explore the lived experience of the patient in forgiving and letting go of anger (Ferrell et al., 2014; Mickley & Cowles, 2001). Thus, one implication for future research is seen in the paucity of qualitative nurse-authored research on the characteristics of the forgiving person and how a person finds the power to forgive. This would be a fertile area to explore and add to the inquiry of forgiveness. Holistic nurses are uniquely positioned to fill in this gap in forgiveness scholarship because of their respect for the value of qualitative research and their understanding of the connection between the body, mind, and soul.

In addition, a systematic review of what nurse researchers have contributed to the quantitative research on the forgiveness process would also help us get a fuller picture of nurses’ contribution to this important area of inquiry and guide us for further research. Scholarship to explore the role of nursing grand theory and middle range theory as it applies to forgiveness as well as possible exploration of a middle range theory of forgiveness is also needed.

Limitations of the Review

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A small limitation of this review is that while each study gave rich examples of forgiveness by one or more participants, we were unable to determine how many of the participants discussed the forgiveness process with the interviewer. This is because the main objectives of some of the studies was broader than discussing forgiveness. Therefore, in Table 1, the n in the “Description of Sample” column does not necessarily refer to the participants who discussed their forgiveness process with the interviewers. For example, in the study conducted by Taylor (2004), the n of 21 represents the total amount of study participants, not necessarily the total number of people who focused on discussing forgiveness with the interviewer. Notwithstanding this, we were able to derive substantial insights into how people forgive through the descriptions offered in the studies. Also, three of the studies had overlap in some of the authors and content. To account for this, we strove to not repeat content that was similar in the three studies. Finally, limiting articles to those published in English, as well as to those including at least one nurse author, could have resulted in the exclusion of important work.

Conclusion

The main purpose of this study was to discover how people forgive; particularly, where they get the power and what kind of people are able to forgive. The findings enable nurses to facilitate forgiveness by helping patients find answers to their questions about the forgiveness process. Listening to the voices of the people interviewed in the qualitative nursing literature on forgiveness adds to the findings of quantitative forgiveness literature. It enriches quantitative research and fills in the gaps by adding the how or why to the what of forgiveness. This will enable nurses to understand the lived experience of their patients better as well as to facilitate forgiveness by helping patients find the power to forgive and heal.

ORCID iD

Ann Gentry Recine https://orcid.org/0000-0003-0406-8064

Note

Authors’ Note:

We would like to acknowledge that support for this project came from Student Blugold Commitment Differential Tuition funds through the University of Wisconsin–Eau Claire Summer Research Experiences for Undergraduates program. We would also like to thank Dr. Susan Moch, Dr. Rita Sperstad, and Dr. Hans F. Kishel for their invaluable guidance.

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Biographies

Ann Gentry Recine, DNP, RN, AGPCNP-C, is an Assistant Professor of Nursing at University of Wisconsin-Eau Claire, College of Nursing and Health Sciences. She is the owner of Holistic Therapy LLC and speaks and writes on forgiveness and health.

Lou Recine, OFS, owns Lou Recine Coaching LLC. He works with individuals and groups on forgiveness. He is also a member of the Secular Franciscan Order.

Tenzin Paldon is a graduate nurse from University of Wisconsin- Eau Claire, College of Nursing and Health Science. She was a co-researcher and co-writer during her senior year.

Appendix

Guideposts to Forgiveness

Holistic Therapy LLC (Dr. Ann Recine) & Lou Recine Coaching LLC, 2018 Where the forgiveness guideposts come from: The guideposts below come from interviews by nurses with many

people who changed their lives through forgiveness. These people were hurt by what often would seem unforgivable. They were justifiably angry but found the power to let go of that anger. The words below express the ideas and example of these people who found a way to live lives of peace and joy in spite of being hurt.

Begin with knowledge: Know the definition of forgiveness. Forgiveness is letting go of your anger and resentment (even though justified) and choosing to have a positive intention toward the person who hurt you. It is not letting the person off the hook legally, nor is it forgetting or pretending that it didn’t happen, nor deciding you’re going to hang out and be friends. Forgiving does not mean giving up safety or personal boundaries.

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Press pause: There are ways to learn how to gently stop the noisy circles of angry, painful thoughts in your mind. You can find a quiet place and time to calm yourself. Take time to figure out how you want to respond instead of reacting.

Put your health first: Know that the health of your body is connected to the health of your mind. Your health is more important than your hurt. Give yourself the gifts of health, peace of mind, and happiness that come from letting go of anger.

Take baby steps: Know that forgiveness and feeling better takes time. It starts with being willing to be willing to forgive. It begins with wanting to get your life back—with wanting to be at peace.

Change channels: We might not be in control of our thoughts initially, but we can learn to shift our focus. When you are angry or upset, you have the option to pick a more peaceful channel. You can think of what you are grateful for today. You can notice the pleasant and beautiful things in your life. You can focus on lifting someone else up today.

Power-up: When your mind slips back into focusing on the hurt and hurtful person and you feel powerless over your angry feelings, reach out to a power greater than yourself. Notice what gives you strength and inspires hope that you can lead a happier, peaceful life in spite of having been hurt. Develop a practice of meditation, prayer, spiritual reading, religious services, or anything else that connects you to that source of power.

Lean on somebody: Don’t be afraid to ask a strong, trustworthy person in your life for help. Choose to lean on people who care about you and are forgiving.

See both sides: Think about a time when you have hurt someone in a way that was against your values. Deeply understand what was going through your mind and the pressures you were under. Seek to understand the kinds of pressures and struggles the person who hurt you was experiencing.

Look for meaning: There will come a day when you will be able to find the good that has come to you as a result of growing from the hurtful experience and even find the good in the other human being who hurt you. Let the virtues that you value help you make sense of the hurtful experience and achieve forgiveness as a personal victory.

Realize life is short: We don’t know how many days we have left. Is there an attitude you would be willing to give up in order to have peace inside? It’s empowering to take charge of a relationship by deciding to forgive. By choosing to forgive, you are showing people what you value and how you’d like to be remembered.