Why health expectations and hopes are different: the development of a conceptual model

Abstract

Background  In the literature, ‘hope’ has often been thought of as an ideal expectation. However, we believe the classification of hope as a type of expectation is problematic. Although both hopes and expectations are future‐oriented cognitions, expectations are distinct in that they are an individual’s probability‐driven assessment of the most likely outcomes, while hopes are an assessment of the most desirable – but not necessarily the most probable – outcomes.

Aim  This paper presents a conceptual model of the factors that may serve as common antecedents of hopes and expectations, and a mechanism that may mediate their differentiation.

Method  Ovid Healthstar and PsycINFO database searches from January 1967 to October 2008 were conducted. An integrative literature review, synthesis and conceptual model development were carried out.

Outcome  Our model envisages the differentiation of hope from expectation as a dynamic, longitudinal process consisting of three phases: appraisal of possible outcomes, cognitive analysis for achieving hopes and goal pursuit. Key variables such as temporal proximity, controllability, external resources, goals, affect, agency and pathways may moderate the extent of divergence by influencing the perceived probability of achieving desired outcomes.

Conclusion  Hopes and expectations are distinct, but linked, constructs. This preliminary conceptual model presents how hopes and expectations develop, become differentiated and how social‐cognitive factors may moderate this relationship. A better understanding of hopes and expectations may assist health professionals in communicating illness‐related expectations while maintaining the integrity of patient hopes.

Introduction

Hope is considered to be a universal human phenomenon that is essential to overcoming adversity and fostering resilience. ¹ In the context of Western medical care, hope is regarded as being positively correlated with health and wellness, ² and strength of will and determination are seen as having the potential to alter the experience of illness. ³ , ⁴ Research examining health and positive psychology has found that hope, when in conjunction with emotional expression, is related to reduced incidents of emotional distress ⁵ and fatigue. ⁶ In relation to coping, hope may enable patients and their families to endure rigorous medical treatments, ⁷ and to actively engage in rehabilitation and recovery. ⁸

Dufault and Martocchio provide a useful approach for understanding the multifaceted nature of hope, ⁹ and distinguish between particularized and generalized hope. ¹⁰ Particularized hope describes the belief in the possibility of achieving a specific, valued and realistically‐possible outcome (e.g. ‘I hope to recover from cancer’), ¹¹ while generalized hope describes the non‐specific sense of a favourable tomorrow that can be intrinsically meaningful and a buffer against despair (e.g. ‘All I can do now is hope’). ¹⁰ , ¹² Thus, hope is motivational, and may be defined as the anticipation of achieving a personally significant future good ¹⁰ which is potentially possible (i.e. could happen) but not necessarily probable (i.e. will happen).

Because hopes are beliefs concerning future outcomes, attempts have been made to examine them under the tenets of expectancy theory. Expectancies are postulated to be the mechanism through which past experience and knowledge are used to predict future outcomes. ¹³ The ability to assess causal relationships and to anticipate outcomes, in part, drives key processes such as goal‐directed behaviour, motivation and self‐regulation. ¹⁴ As situation‐specific applications of expectancy theory, ¹⁵ ‘expectations’ are defined as cognitions about future events and experiences, and derive from subjective assessments of probability that range from the ‘unlikely but possible’ to the ‘virtually certain’. ¹³

Considerable attention has been paid to understanding how patient beliefs about the future influence attitudes and behaviours. ¹⁶ Within health care, unmet expectations are associated with recurrent visits for unresolved symptoms, ¹⁷ poorer adherence with treatment, ¹⁸ and lower satisfaction with care. ¹⁹ These outcomes are based on a diversity of expectations, leading various researchers to develop typologies of expectations. ²⁰ , ²¹ , ²² Although the labels vary, two categories of expectation are usually identified. The first is often termed ‘predicted expectations’. This type identifies an individual’s probability‐driven assessment of what outcomes will most likely occur based on experience and current circumstances. ¹⁵ , ²¹ , ²² The second category is termed ‘ideal expectations’, which identifies desired outcomes stemming from a person’s beliefs about an idealized future. ²² Hope is typically incorporated into the latter class.

However, we believe the classification of hope as a type of expectation is problematic. ¹⁵ Although many preferred outcomes typically converge well with personal estimates of their probability of occurrence, others persist or even intensify despite evidence indicating a poor likelihood for achievement. ²³ For instance, patients and health professionals have argued that given the numerous anecdotal accounts of people making remarkable recoveries or exceeding life expectancies, maintaining hope is reasonable even in situations with seemingly low probabilities. ²⁴ , ²⁵ Unlike predicted expectations, ideal expectations by definition are assessments of preferred outcomes, which may or may not be likely to be realized. While we accept that hopes and expectations are closely related, we believe that they are more usefully understood as independent constructs, with hopes being driven primarily by a sense of preference and expectations being driven primarily by a sense of probability.

This distinction is highly relevant in clinical contexts. Health professionals must maintain a delicate balance between encouraging reasonable hope and creating unrealistic expectations of health outcomes. ²⁶ At times, the desire to fulfil patients’ psychosocial and existential needs by fostering hope and tempering unfavourable prognoses ²⁷ may be diametrically opposed to obligations of ensuring that individuals fully understand their condition, discussing pragmatic treatment options and encouraging informed decision making. ²⁸ , ²⁹ From the patient’s perspective, failure by physicians to instill at least a minimal sense of hope may result in anxiety and distress. ³⁰ , ³¹ However, inadequately addressing patient expectations concerning the normative experiences of the illness and treatment side‐effects may lower satisfaction and increase distrust. ²⁶ , ³²

Health professionals are similarly compelled to manage excessive optimism in patients. ²⁷ Inflated or so‐called ‘false’ hopes may lead to a desire of the unfeasible, and result in the rejection of more modest yet achievable goals. ³³ At the heart of this concern is the assumption that hopes expressed by patients may not simply be self‐affirming beliefs about possible positive outcomes, but rather be unreasonable assessments of what will happen to their future health. Consequently, unattainable hopes may be perceived as unrealistic expectations, which may increase psychosocial vulnerability. ²⁷ , ³⁴ For instance, concerns have been raised that individuals with terminal illnesses and their families who have disproportionately high hopes for recovery may not receive adequate psychosocial support ³⁵ or timely palliative care. ⁷

In research, the terms ‘hope’ and ‘expectations’ are often used interchangeably. ¹⁰ , ³⁴ Ironically perhaps, little research has examined how to conceptually differentiate between them despite the extensive, albeit independent, literatures that exist on hope theory and expectancy theory. Yet researchers have identified the conflation of these constructs as a key limitation, and have advocated for the need to disentangle hopes from expectations. ¹⁵ , ³⁶

Montgomery and colleagues attempted to determine whether people actually distinguish between the two by asking participants about their hopes and expectations regarding non‐volitional outcomes (i.e. automatic responses that are beyond conscious control), such as pain following surgery and craving cigarettes. ³⁶ The researchers found that while hopes and expectations were moderately correlated with each other and that previous experiences and personality traits such as optimism influenced both constructs, statistically significant differences were found between how participants hoped to feel vs. how they expected to feel. ³⁶ This research suggested that hopes and expectations are related but independent constructs. However, uncertainty remains as to how previous experiences and personality traits interact to produce distinct hopes and expectations, and how the favourability of outcomes affects their divergence.

Hopes and expectations have also been differentiated using the parameters of interest in a study. In a qualitative study of the hopes and expectations of caregivers of palliative cancer patients, Wennman–Larsen and Tishelman viewed the distinction of the two constructs as being fluid, and differentiated them by referring to expectations as prerequisites for satisfaction with care and referring to hopes as wishes or desires but not necessities. ³⁷ While it is reasonable to define concepts operationally, this approach does not necessarily inform about the theoretical underpinnings of constructs, and the underlying mechanisms that govern how people cognitively distinguish between a hope vs. an expectation remain largely unclear.

Aim

This paper seeks to synthesize a preliminary conceptual model of the relationship between hopes and expectations that is grounded in theory and existing empirical evidence, to conceptualize factors that may serve as their antecedents, and to suggest a mechanism that mediates the differentiation between them.

Method

An integrative literature review was conducted in lieu of a systematic review whose highly‐delineated focus is incompatible with the exploratory nature of conceptual model development. ³⁸ The goal of an integrative review is to appraise and synthesize the literature so that new frameworks and perspectives are generated inductively. ³⁹ , ⁴⁰ Traditional systematic reviews require the comprehensive identification of a relevant canon of literature using precise inclusion criteria. ⁴¹ But, specifying a priori search boundaries is inherently difficult when the goal is theory exploration and generation. ³⁸ Under such circumstances, adopting an iterative, dialectic process to the literature search is more useful because the objective is to approach the literature as a starting‐point for model development and not to produce an exhaustive summary of its content. ³⁸ , ⁴²

Because our interest lay in exploring constructs, a broad range of study designs including qualitative and quantitative empirical research as well as theoretical papers were eligible for inclusion in the review. To anchor the emergent conceptual model in current hope and expectancies theories, Ovid Healthstar and PsycINFO database searches from January 1967 to October 2008 were performed using the terms ‘expectancy or expectation’ and ‘hope’ combined individually with ‘health’. These searches returned 6929 articles. Using the titles and abstracts to identify English‐language citations that expressly examined or validated the dimensions of these constructs produced 141 articles.

Although consensus remains elusive on how to review and amalgamate studies with epistemological and ontological differences, ⁴⁰ , ⁴² integrative methods suggest that qualitative and quantitative studies may be synthesized together when findings address common phenomena, ⁴⁰ and when the analytic emphasis is on transforming findings to a common platform, such as by extracting the central findings or ‘themes’ from quantitative results to enable comparison, corroboration and refutation with qualitative findings. ³⁸ , ⁴⁰ Hence articles were critically reviewed and thematically synthesized first to uncover the key antecedents and features of expectations and hopes which formed the foundation of the conceptual model, and then to identify for further exploration other constructs that might affect the relationship.

A second search of the same databases using the exploratory terms ‘goals, affect, optimism, optimistic bias, probability, motivation, locus of control, desirability’ combined individually with ‘future, hope, expectancy or expectation’ was performed to elaborate on and refine the conceptual model. In total, 357 citations were returned. Using the titles and abstracts, 67 English‐language articles were found, critically reviewed and thematically synthesized to identify potential moderating relationships between hopes and expectations.

To situate our conceptual model, a brief description of the key antecedents and features of expectations and hopes is presented first. Then, the proposed conceptual model of how expectations and hopes may become differentiated is presented.

Findings

Characterizing expectations and hopes

Expectancies have been examined extensively using social‐cognitive theory, which describes the learned associations between stimulus events, behaviours, self‐efficacy, non‐volitional responses and outcomes. ¹⁴ , ⁴³ , ⁴⁴ These classes of expectancies form the basis from which specific, probability‐driven expectations develop. ¹³ , ¹⁵ , Figure 1 presents a simplified view of how these expectancies are related. ⁴⁵ , ⁴⁶ Event or stimulus‐outcome expectancies are beliefs that certain events will result in particular outcomes. ¹⁴ For instance, a person who smokes might expect that cigarettes will increase the probability of cancer. Behaviour‐outcome expectancies are beliefs that engaging in a certain action will lead to a given outcome, ¹⁴ while self‐efficacy expectancies are a person’s assessment of how successful one will be in carrying‐out a behaviour for achieving that outcome. ⁴⁷ For instance, the person mentioned above might expect that by quitting she will reduce her chances of cancer, but in order to successfully quit, she expects that she will need the help of nicotine patches. Lastly, response expectancies are a person’s predicted non‐volitional or unconscious responses to situations, including emotional reactions and pain. ⁴⁷ , ⁴⁸ Thus, one might further expect to experience withdrawal symptoms during the quitting process. Overall, a person’s expectations are informed by beliefs, knowledge, cultural norms and situational factors. ¹³ , ¹⁵ , ⁴⁹

Figure 1.

 The relationship between various types of expectancies.

Within the hope literature, a number of theories have been suggested, with Snyder’s hope theory being the predominant model. ⁵⁰ , ⁵¹ Rooted in a motivational, goal‐setting framework, ⁵² , ⁵³ , ⁵⁴ hope is conceptualized as a cognitive set that is based on the perceived availability of pathways (which is the ability to formulate ways for achieving outcomes) and agency (which is the ability to successfully execute those pathways). ⁵⁰ This theory suggests that individuals with high levels of hope are more effective at generating a tenable pathway to their goal, formulating alterative pathways when confronted by obstacles and feeling confident about achieving their preferred outcomes. ⁵⁵ Thus, hope is shaped by a person’s perceived capacity to produce the requisite pathways and agency to achieve preferred outcomes. ⁵⁶

Most theories agree that hope requires and motivates personal investment, ¹⁰ , ⁵⁷ , ⁵⁸ such as generating pathways and agency, ²⁵ seeking the support of others, ¹² , ⁵⁹ or turning to intrinsic resources such as spirituality. Research has found that hopeful individuals have a greater likelihood of achieving specific outcomes, such as better adjustment after major burns, adherence to medical regimens and adopting preventative health measures. ⁵⁵ Such individuals are also able to maintain their ‘hopefulness’ when preferred outcomes are tenuous or eventually become unattainable. Drawing from the palliative care literature, many researchers have suggested that when the ultimate hope of regaining health is no longer possible, fostering alternative hopes (e.g. leaving a legacy) may help ameliorate distress and facilitate coping. ⁶⁰ , ⁶¹

Other perspectives also emphasize the importance of the emotions evoked by hoping. The emotional sequelae associated with hope, such as the absence of despair, are often more salient as defining features of hope than the cognitive processes that produce it. ²³ Emotional states are a powerful heuristic that can determine what outcomes are personally important ¹⁰ and guide decision‐making. ⁶² Furthermore, affect not only signals the likelihood of goal attainment, ²⁵ but positive affect in particular may increase the thoroughness, efficiency and flexibility of problem solving, ⁶³ which will positively influence the perceived likelihood of hope realization. ⁶⁴

Developing a conceptual model

To enable comparisons with situation‐specific expectations, we focused on particularized hopes rather than generalized hope. ¹⁰ Generalized hope may reflect more intrinsic traits such as optimism, which influence people’s overall perspective and beliefs, including their particularized hopes. Our model views the divergence of hope and expectations as a dynamic longitudinal and cyclical process consisting of three phases: appraisal of possible outcomes, cognitive analysis for maintaining and achieving hopes, and goal pursuit (Fig. 2). Each phase contains one or more aspects, which are largely encountered in a sequential manner.

Figure 2.

 A theorectical model of how hopes may become differentiated from expectations.

During the appraisal phase, a precipitating phenomenon initiates thinking about various potential outcomes. Prior knowledge informs a person of what outcomes are possible and the probability and desirability of those ends. The product of appraisal is the identification of a specific hope (the preferred outcome) and an expectation (the most probable outcome), with ‘θ’ symbolizing their divergence along a one‐dimensional axis of perceived probability. Marginal divergence occurs when the preferred outcome has a high probability of happening relative to the perceived probable outcome, and maximal divergence occurs when the former has relatively little probability of happening.

Within the cognitive analysis phase, a number of moderating variables including Snyder’s agency and pathways are identified, which may influence the perceived probability of hoped‐for outcomes. ²⁵ Because the defining characteristic of hope is its motivational capacity, ¹⁰ , ⁵⁷ this model suggests that individuals will contemplate strategies that will either maintain or increase the subjective probability of realizing hopes, thereby halting or reducing the divergence between hopes and expectations, respectively.

The goal pursuit phase dynamically involves performing the strategies identified in the cognitive analysis phase while reflecting on their relative usefulness. Unfavourable feedback encourages further cognitive analysis about other ways to achieve, or at least to maintain the possibility of achieving, preferred outcomes as well as re‐evaluations of their subjective probabilities, while the experiences gained during goal pursuit will become a part of one’s future knowledge. The occurrence of the actual outcome terminates this phase. In instances where the preferred outcome remains unattained, alternative hopes may be conceived and the process of hoping begins again.

While considering the model, at least three underlying assumptions bear mentioning. Although expectations are defined as probability driven assessments of outcomes, this is not to suggest that expectations are epistemologically more ‘real’ than hopes; rather, they are both subjectively determined representations of possible outcomes constructed from one’s knowledge and beliefs about what is likely or preferred to occur. Second, hopes and expectations are subject to individual differences, and how optimistic or pessimistic one is will influence what is hoped for and expected. ⁶⁵ Third, the discrepancy between hopes and expectations may lead to cognitive dissonance, ⁶⁶ an aversive state exemplified by psychological discomfort due to inconsistencies in cognitions. ⁶⁷ For example, contemplating expectations of disability or death is highly dissonant to hopes of a long and healthy life. A person may become motivated to increase the probability that preferred outcomes will occur, resulting in reduced dissonance.

Appraisal of possible outcomes

Optimistic bias

In the absence of specific stressors or challenges to well being, hopes and expectations are often difficult to differentiate (e.g. ‘I hope and expect to be in good health’). This describes the ‘optimistic bias’ and is well documented. ⁶⁸ People tend to overestimate the probability of experiencing positive life events, and underestimate their risk of experiencing negative ones, such as heart disease, ⁶⁹ cancer, vehicular accidents and becoming victims of crime. ⁶⁸ , ⁷⁰

The effect of optimistic bias is to suggest that personal expectations typically converge with ideal outcomes. This bias may be strengthened when individuals perceive a high level of controllability for a negative event, ⁶⁸ and a sense of efficacy in being able to avoid it (e.g. drug addiction). However, hopes and expectations are unlikely to converge completely even in an idealized state, and experiences that contradict optimistic bias often result in more realistic expectations. For instance, previous studies with students in financial need have found that they were more realistic in their assessments of potential financial losses than other students. ⁷¹ However, this expectation was domain‐specific, and did not appear to influence the level of optimism in other spheres of their lives, such as health. ⁷¹ Therefore, this general convergence between these two domains may explain why people generally tend to believe that hopes and expectations are very similar experiences.

Precipitating phenomenon

A precipitating phenomenon is envisaged as being the critical incident or incidents that initiate the differentiation of hopes from expectations by directly challenging an individual’s optimistic bias; this in turn, engenders more critical appraisals of probabilistic outcomes or expectations. ⁶⁸ , ⁷¹ Although an event with significant negative valence such as receiving a diagnosis of cancer will undoubtedly challenge an individual’s optimistic bias regarding good health, events with relatively less negative valence, such as ill health impacting on holiday arrangements, will also test it. A given event may act as a precipitating phenomenon if it entails some level of subjective risk to a specific aspect of an individual’s optimistic cognition.

Prior knowledge

Prior knowledge includes an individual’s informational knowledge, past experiences, spiritual beliefs and socio‐cultural norms and values. ¹⁵ , ⁷² This knowledge may be provided by or sought from others, ¹³ and collectively, these factors form the lens through which an individual interprets his or her situation. ⁷³ A person’s knowledge, perception of causal relationships and beliefs will inform the variety and types of outcomes that are considered possible, as well as the likelihood and desirability ascribed to them.

Possible outcomes

When confronted by a precipitating phenomenon, individuals consider the myriad of possible outcomes. Thoughts of the future may include what they would ideally experience, are likely to experience, or are afraid to experience. For example, a caregiver who is struggling to support a person with dementia may ideally believe that she might receive substantial 24 h homecare support if she makes a strong case to her family doctor, but may more realistically expect to receive daycare support, while the worst‐case scenario may be anticipating receiving no help whatsoever.

Desirability

A person’s appraisal of outcome desirability is also influenced by his or her beliefs and values. In the above example, receiving substantial homecare is usually more desirable than receiving periodic respite, and both are generally more desirable than receiving nothing. Furthermore, when contemplating health outcomes, desirability may also be influenced by the perceived severity of the event. For instance, a person with symptoms of coughing, chest congestion and chest pain, may consider the diagnosis that their doctor is about to give them. The patient may have identified three possible outcomes of cold, bronchitis, or pneumonia. In this case, a diagnosis of a cold is more desirable in that it is less severe.

Subjective probability

Some potential outcomes may be perceived as more probable than others. The perceived likelihood of an outcome reflects the subjective degree of belief in the occurrence of an event attributed at a given instant with a given amount of information. ⁷⁴ Estimates of subjective probability may be termed partial beliefs because of inherent uncertainties about the future; as a result, probability is fluid and may change with circumstances. ⁷⁴ However, acknowledging the probability of an event does not necessarily mean endorsing the deductive consequences of such assessments. ⁷⁴ For instance, an individual who has been diagnosed with late stage cancer may acknowledge that the probability of a full recovery is slight, but this does not necessarily mean that he or she has accepted that death is certain.

Identification of a principal hope and expectation

Weighing the desirability and probability associated with each perceived possible outcome culminates in the identification of a ‘principal’ hope and a ‘principal’ expectation, identified from a set of ‘reasonable possibilities’, which themselves represent the more likely futures out of the complete set of all possible ones. From this perspective, the principal expectation is based primarily on what outcome is considered the most probable, while the principal hope, which must realistically have some probability of occurring, ⁵⁷ is based on the outcome which is most preferred. We also suggest that hopes can be held concurrently with expectations even when their content is significantly divergent. For instance, qualitative work on hope in cancer care has found that while patients may have less optimistic expectations for the future, they continue to maintain hope for a cure and improved quality of life. ²⁷

Divergence of hope and expectation

In this model, the divergence between a hope and an expectation, and the extent of this divergence (θ), are related to the perceived probability of their occurrence. The best‐case scenario would be when a hope has a high probability of achievement, creating a strong convergence between the preferred and probable outcomes. In contrast, hopes and expectations may differ considerably, and are maximally divergent when a hope has a low perceived probability of achievement (e.g. ‘I hope to make a full recovery after my stroke’ but ‘I expect to experience little or no recovery at all’).

Cognitive analysis for maintaining and achieving hopes

We suggest that in the cognitive analysis phase, a number of moderating and interacting variables may be identified which may either preserve the possibility or increase the probability of achieving the hope, but which do not similarly actively influence the expectation. These characteristics, both separately and in combination, function to motivate behaviours and beliefs which maintain or increase the probability of realizing the preferred outcome, thus halting or reducing the differentiation expressed by θ and rendering the distinction between hopes and expectations as less.

Temporal proximity

Temporal proximity describes the process whereby personal experiences are interpreted with reference to time, which provides order, coherence and meaning to events that have been, are being, or will be experienced. ⁷⁵ , ⁷⁶ The temporal proximity between current beliefs about prospective outcomes and when actual outcomes occur has been found to influence a person’s optimism. ⁷⁷ When the actual feedback about the likelihood of achieving positive outcomes was proximal rather than distal, individuals were more likely to abandon overly optimistic beliefs. ⁷⁷ Hope may be influenced in a similar manner, in that when feedback (i.e. the event that can confirm or disconfirm hopes) is in the distant future, people may be better able to maintain hopes or believe that hopes are achievable compared to when feedback is imminent.

Controllability

The premise that hopes motivate strategies that will preserve or increase the likelihood of achieving preferred outcomes is dependent, to an extent, on how controllable those outcomes are. Controllability may be defined as a person’s ability to make a response that modifies the future. ⁷⁸ While some hoped‐for outcomes are controllable by the individual (e.g. a person hopes to better manage his diabetes), other hoped‐for outcomes are less so (e.g. a person hopes to survive aggressive cancer). In low controllability situations, the probability of hopes may be more dependent on external resources, such as the skills of physicians and availability of treatment options rather than on the person’s behaviour. Therefore, controllability may influence how other moderating factors such as a person’s external resources, goals, agency, and pathways are formulated and perceived.

External resources

Although Snyder and colleagues situated their hope theory in an egocentric framework, other researchers have emphasized the importance of external resources, especially interpersonal relationships. ¹¹ , ¹² , ⁵⁹ , ⁷² Family members and friends may provide encouragement, social support and reinforce a person’s hopefulness. ⁵⁹ Service providers are vital sources of information about illness management strategies, treatments and prognosis. ³⁵ In addition, skills of health professionals, availability and quality of external resources may affect the perceived probability of hope realization. ²¹ For instance, studies have found that as long as parents of terminally‐ill children believed that there were still treatment options available, they sustained hope that their child may be cured. ⁷

Goals

Identifying goals is considered to be an important strategy for maintaining and realizing hopes. ⁷⁹ Short‐term, realistic goals can exert a strong impact on behaviour and can help an individual gauge progress. ⁸⁰ Specific goals in particular may aid the formation of the requisite pathways and agency. ²⁵ Ultimately however, the appropriateness of selected goals is paramount. Gum and Snyder’s study of hope in palliative care found that articulating situation‐appropriate goals (e.g. hoping to spend quality time with family as opposed to hoping to live longer) could ameliorate negative emotional experiences. ⁶⁰ Setting goals can empower an individual, and maintain or increase the perceived likelihood of hopes being sustained.

Affect

In our model, the influence of emotions is complex and cyclical. Emotions can mobilize attention to goal‐relevant features, ⁸⁰ and signal the relative success in accomplishing them. ²⁵ Moderate negative affect arising from goal‐impediments can foster further analysis and improve troubleshooting. However, extreme negative affect, such as depression and a sense of powerlessness, can immobilize action and lead to hopelessness and despair. Affect influences the probability of continued maintenance or achievement of hopes, and subsequently, the amount of divergence between hopes and expectations.

Pathways and agency

Within our model for explaining the process of hope‐expectation differentiation, we suggest that agency (a product of self‐efficacy expectancies) and pathways (a product of behaviour‐outcome expectancies) ⁵⁶ interact specifically with each other to produce behaviours which tend in favour of a preferred outcome and reduce disparity between hoped‐for and expected outcomes. By formulating goals targeted at achieving preferred outcomes, individuals consider what pathways are needed to achieve those goals, and their agency towards accomplishing them. ²⁵ Research suggests that individuals who are able to identify more viable pathways to achieving their goals, as well as having a strong sense of agency or efficacy, are more likely to be able to achieve their preferred outcomes. ²⁵

Goal Pursuit

Strategy performance and reflection

Based on the cognitive analysis phase, individuals may identify and engage in the strategies that are subjectively believed to increase the likelihood of maintaining or realizing hopes. As individuals carry out their strategies, we suggest that they will concurrently reflect on the relative utility. ⁸¹ Perceived ineffectiveness will encourage further cognitive analysis about other strategies, while perceived effectiveness will increase the sense of agency, in particular and reinforce the usefulness of a particular pathway. ⁸¹ This feedback will dynamically influence the divergence of hope, and the experience gained will become a part of one’s knowledge.

Actual outcome

The occurrence of the actual outcome terminates this phase of the process. The relative success of hope achievement compared to the actual outcome will feed back to the various levels of cognitive processing, including the person’s life narrative, and will influence future appraisals of expectations and hopes. Successful goal pursuits will increase the probability of achieving one’s hopes, and decrease the perceived divergence between hopes and expectations. Unsuccessful goal pursuit may result in mourning, but personal resiliency can be fostered if new hopes are developed, especially if these new hopes target more achievable outcomes. ⁶⁰

Discussion

This preliminary conceptual model presents a longitudinal and cyclical representation of how hopes and expectations develop and become differentiated, and suggests possible moderating factors that influence their re‐convergence. A major aspect of this model is that hopes and expectations are conceptualized as being identical in the appraisal phase but diverge when a precipitating phenomenon induces more realistic assessments of potential outcomes, during which assessments of preference and probability become influential. This relationship may help to explain the tendency to equate hopes with expectations in the literature, and may lead to a better understanding of both concepts. ⁸² However, it is important to clarify that in our view, the sequential process of hope‐expectation development and initial divergence takes place simultaneously. Therefore in practise, identifying the precise ‘point of divergence’ between the principal hope and expectation is unlikely to be feasible, given the nearly instantaneous and concurrent assessments of possible outcomes, desirability and probability. Our model has also highlighted the dynamic relationship between hopes and expectations even after they have diverged. Understanding that modifying factors like temporal proximity, controllability, external resources, pathways and agency can affect the perception of hope, and may thus moderate the degree of divergence between hope and expectation, can have implications for research and clinical care.

Although to our knowledge, little theoretical or empirical work has been conducted on how to distinguish hopes and expectations, this conceptual model attempts to build upon the available research. In their study of hopes and expectations regarding non‐volitional outcomes, Montgomery and colleagues found that these constructs were related but independent, and factors such as experience and optimism influenced their relationship, though in unknown ways. ³⁶ Based on the appraisal phase of our conceptual model, we postulate that probability mediates the perceived relatedness or divergence between hopes and expectations, and that experience and prior knowledge influence what hopes and expectations are seen as possible as well as the probability and desirability of those outcomes. Likewise, for the cognitive analysis and goal pursuit phases, we attempted to synthesize the literature on hopes in particular, and to build upon Snyder’s model of pathways and agency ²⁵ by integrating other perspectives on the importance of external resources ¹² and emotional context. ²³

A strength of conducting an integrative literature review is that it grounds the emergent conceptual model in the current theory, and offers cohesion to the diverse but often disparate literature. ³⁸ Elements such as the optimistic bias, probability, motivation, pathways and agency have been extensively investigated and validated, but their integration into a single model is novel, and hence, requires empirical examination. However, the integrative literature review method also has a number of limitations. This conceptual model is, to an extent, constrained by the literature that was included in the synthesis. As our interest lay in theoretical constructs, this model may not as strongly reflect other important research domains, such as the religious perspective and phenomenological experience of hope. These domains may provide further insight into the maintenance of hope (e.g. the influence of belief and prayer). Methodologists also acknowledge that because such reviews often integrate a large number of articles, only brief illustrative summaries can be feasibly reported rather than entire analyses. ³⁸ Therefore, the analytic process of narrative‐based reviews may not be as transparent as systematic reviews. ³⁸

Nonetheless, we consider that the model presented here will stimulate more work and debate in the area of hopes and expectations. At a fundamental level, greater attention to clarifying constructs is needed in research. For example, the question of whether patient expectations are predictive of satisfaction with care remains largely inconclusive despite nearly four decades of research. ⁸³ This ambiguity may be partially attributable to the conflation of hopes and preferences as a form of expectation. ³² Future research might also include comparing the hopes and expectations of health outcomes in both healthy and disease‐specific populations, determining whether there are differences and why (in the appraisal phase) as well as investigating whether the perceived probability of hope realization changes in relation to the strength, number and ease of hope‐promoting strategies (in the cognitive analysis and goal pursuit phases). Lastly, with the burgeoning interest in developing health expectations assessment tools, ⁸⁴ strong theoretical underpinnings of constructs are needed not only to ensure that these expectations tools actually measure what they purport to measure (e.g. not hopes or preferences), but also to facilitate research into their utility and validity.

Perhaps more importantly, however, in the context of clinical care, recognizing hope as a separate entity from expectation may be beneficial. Encouraging care providers to deal with each concept separately and independently, and not to conflate the two, may lead to simpler and less ambiguous discussion of treatment processes and outcomes, leading to improved decision‐making on all sides.