JOURNAL

Brush et al.OF
/ FORGIVENESS
HOLISTIC NURSING / March 2001

Forgiveness
A Concept Analysis

Barbara L. Brush, R.N.C., Ph.D., F.A.A.N.

Boston College
Eileen M. McGee, R.N., M.S.N.
Director of Health Care Services, Pine Street Inn
Bonnie Cavanagh, R.N.C., M.S.N.
Winchester Women’s Health Care P.C.
Mary Woodward, R.N.C., M.S.N.
St. Joseph Parish Ministry

This article provides an operational definition of forgiveness as a first step in the sys-
tematic analysis of the concept. Using the method described by Walker and Avant
(1995), the authors identify the attributes and characteristics of forgiveness and its
theoretical and practical implications for nursing. Sample cases from clinical practice
help illustrate the concept further. Further nursing research needs to test the theoreti-
cal relationships between forgiveness and nursing practice outcomes.

For centuries, the healing aspect of forgiveness has been advocated

within the context of religious practice and one’s relationship with
God (Blumenthal, 1998; Drabkin, 1993; Jenson, 1993; Mul-
ler-Fahrenholz, 1998). More recently, the connection between forgive-
ness and individuals’ spiritual and mental well-being has been the
subject of much interest and research, especially among family thera-
pists, clinical and social psychologists, ethicists, theologians, and phi-
losophers (DiBlasio & Proctor, 1993; Walrond-Skinner, 1998).
There has been limited research in the area of forgiveness by nurses
and little discussion of its implications for nursing practice. Nursing
articles and texts that mention forgiveness often do so within a larger
religious, often fundamentalist Christian context (O’Brien, 1999; Ott,

JOURNAL OF HOLISTIC NURSING, Vol. 19 No. 1, March 2001 27-41

© 2001 American Holistic Nurses’ Association
27
28 JOURNAL OF HOLISTIC NURSING / March 2001

1997; Singer, 1997; Tucakovic, 1994; Workman, 1988). To date, how-

ever, there is no systematic method of defining or identifying the exis-
tence of this phenomenon in nursing.
This concept analysis proposes to develop an operational defini-
tion of forgiveness and identify its applications to nursing theory and
practice. Using the method described by Walker and Avant (1995), the
attributes, characteristics, and uses of the concept will be thoroughly
examined. The results of the analysis will provide enhanced under-
standing of the concept of forgiveness in the nursing care of patients.

DEFINITIONS AND USES OF THE CONCEPT

As a first step in the concept analysis of forgiveness, common

descriptive definitions were gleaned from dictionaries and other ref-
erence texts. According to Webster’s New World Dictionary and Thesau-
rus (1996), to forgive is “to give up resentment against, or the desire to
punish; pardon (an offense or offender)” (p. 243). Synonyms for for-
giveness include absolution, pardon, acquittal, remission, dispensa-
tion, reprieve, justification, amnesty, and respite. One is forgiving
when they are charitable, openhearted, or generous. Common
expressions of forgiveness such as forgive me and pardon me are often
conveyed when someone is interrupting, asking for clarification, or
seeking exoneration for certain acts.
In business and finance circles, forgiveness is the act of granting
relief from a financial obligation or debt (Granof, Bell, & Neuman,
1993). The erasure or cancellation of loan payments is analogous to
the act of cleansing one’s moral transgressions, common in the teach-
ings of most of the world’s religions (Enright, Freedman, & Rique,
1998). Even so, religious definitions of forgiveness are as varied as
religious practices themselves.
Certain individuals, such as South African President Nelson
Mandela, have come to symbolize the concept of forgiveness.
Imprisoned for 27 years, Mandela later forgave his captors and
worked toward reconciliation in his racially torn country. Regarding
Mandela’s forgiveness of the South African government as the
embodiment of the concept of forgiveness, Archbishop Desmond
Tutu noted, “[Mandela’s] forgiveness still leaves the world gasping at
the sheer wonder of it” (Muller-Fahrenholz, 1997, p. xiii).
Brush et al. / FORGIVENESS 29

The idea of forgiveness as a collective phenomenon was also

described by Muller-Fahrenholz (1997) as a process releasing people
from past evils that may have inhibited trusting relationships. He
referred to the Truth and Reconciliation Commission in South Africa
and the Arab-Israeli peace process as examples of groups exploring
collective forgiveness. He argued that forgiveness is a crucial aspect
in allowing nations to successfully maintain their interests and
resolve their conflicts.
Many current definitions of forgiveness focus on its theoretical
meaning or conceptualization from a behavioral-science perspective.
Forgiveness is described as a process or journey whose aim is to
release or decrease bitterness, anger, resentment, or hatred toward
another or others (DiBlasio & Proctor, 1993; Freedman & Enright,
1996). Others define the process of forgiveness as a means of freeing
oneself from past judgments and perceptions or misperceptions of
others (Grosskopf, 1999) or a learned response to certain situations
(Ufema, 1994). Often, the process of forgiveness is linked to individ-
ual efforts to heal past wounds from interpersonal injury or harm
through the willingness or ability to release negative feelings or hurt
(Baures, 1996; Hope, 1987). Simply put, forgiveness is the process of
“giving up one’s right to hurt back” (Pingleton, 1997, p. 404).

REVIEW OF THE LITERATURE

Flanigan (1992) identified forgiveness as a five-phase process liber-

ating individuals from hatred and desire for retribution against injur-
ing parties. As she put it, “[forgiveness] is for those people who are
willing to confront their pain, accept themselves as permanently
changed, and make difficult choices” (p. 39). The first phase of the
process involves naming the injury and interpreting its meaning
within one’s broader life context. From there, the individual must
claim the injury (phase two) and assign blame to the injurer (phase
three) to begin “balancing the scales” (p. 91) in phase four. At this
point, one can relegate the injury to the past, confront the injurer, or
mirror the behavior or injury. Eventually, the individual moves to
phase five, “choosing to forgive” (p. 92) and the ability to let go of the
injury and move forward.
30 JOURNAL OF HOLISTIC NURSING / March 2001

Hargrave (1994) also identified forgiveness as a multistage process

attained “a little at a time over a long period of time” (p. 108). He char-
acterized forgiveness as a four-station therapeutic process beginning
with exoneration and ending with forgiveness. The “overt act of for-
giving” (p. 185) in the fourth station enables the victim to provide
opportunity for the victimizer to demonstrate love and trust. Trust
can only be restored in a relationship when the victim and victimizer
do not forget the past but make efforts to live life differently as a result
of remembering it.
Smedes (1984) agreed that the process of forgiving and the act of
forgetting are separate issues; that is, one may forgive the pain associ-
ated with a harmful action but seldom forgets the action itself. In the
process of forgiving, one must work progressively through four dis-
tinct steps: hurt, hatred, healing, and coming together (Smedes, 1984).
Although forgiveness has been more commonly addressed in the
psychotherapy literature, Denton and Martin (1998) found that
among a random sample of 101 clinical social workers, many lacked
general knowledge about the concept of forgiveness and its broader
practical utility. Most agreed, however, that forgiveness therapy was
useful when counseling patients with relationship problems or chem-
ical dependence issues. Indeed, forgiveness has been deemed benefi-
cial for individuals dealing with anger and depression (Davenport,
1991; Fitzgibbons, 1986), family-of-origin issues (Hargrave, 1994),
victimization (McCullough & Worthington, 1994), problems with
alcoholic family members (Khantzian & Mack, 1994; Kus, 1992), and
broken marriages or relationships (Sells & Hargrave, 1997;
Worthington & DiBlasio, 1990).
Religious interpretations of forgiveness differ from secular models
in their focus on the offender rather than the victim. Offenders are
encouraged to seek forgiveness from God or from those they have
injured as a matter of moral and social conscience. Steps toward for-
giveness and repentance are often grounded in religious traditions
that prescribe certain actions and behaviors necessary for
exoneration.
In Judaism, for example, the path to forgiveness is grounded in five
steps to repentance: recognizing one’s sins as sins, remorse, desisting
from sin, restitution when possible, and confession (Blumenthal, 1998).
Although all five are necessary in the process of forgiveness, they may
begin at any point. Moreover, in the rabbinical view of forgiveness,
the onus of repentance is placed squarely on the offender such that
Brush et al. / FORGIVENESS 31

“only the offending party can set the wrong aright and only the
offended party can forego the debt of sin” (Blumenthal, 1998, p. 78).
Drabkin (1993) proposed that God’s ability to forgive is a reflection
of unconditional love that is guaranteed regardless of sin. Thus,
whereas forgiveness in Drabkin’s (1993) model is absolute and joyful,
the harmful event is not necessarily forgotten. As he put it, “there is no
erasing of past sins; there is only rejoicing that the sins are in fact past
and not present” (p. 235). Similar to Drabkin (1993), Jones’s (1993)
Christian account of forgiveness explores the interconnection
between acts of forgiving and the process of being forgiven. He
argued that seeking God’s forgiveness does not undo the past but
helps instead to heal “the brokenness of the past so as to enable new
and renewed community in the future” (p. 356). Thus, he maintained,
“forgiveness is a way of life rather than a simple word to assuage
guilt” (p. 357).
Twelve-step recovery programs for individuals with addictive be-
haviors incorporate both secular and spiritual approaches to facilitate
forgiveness among members. Literature published by Alcoholics
Anonymous (AA), for example, emphasizes identifying and making
reparations to persons harmed as a critical component of recovery
(Alcoholics Anonymous, 1976). As Hart (1999) noted:

The process of making amends to people one has harmed rids the self of
guilt, shame and remorse (forgiveness of self) [italics added], bitterness,
resentment and the desire for revenge (forgiveness of and by others) [ital-
ics added], and fear of God’s wrath (forgiveness by God) [italics added].
(p. 28)

This multidimensional perspective of forgiveness mirrors Gorsuch

and Hao’s (1993) assertion that “a truly comprehensive theory of for-
giveness needs to integrate relevant cognitive, affective, behavioral,
volitional, motivational, spiritual, religious, and interpersonal as-
pects” (p. 346).

OPERATIONAL DEFINITION

From the review of the literature, media interpretations, and per-

sonal experience of the authors, a summary of the antecedents, defin-
ing attributes, empirical referents, and consequences was synthesized
to provide an operational definition of the concept forgiveness.
32 JOURNAL OF HOLISTIC NURSING / March 2001

Forgiveness is thus defined as a time-dependent process of recogniz-

ing harm to or by others and the willingness to change hurtful actions
or behaviors, repair or restore relationships, and let go of past
wounds. Sample cases from clinical practice helped illustrate the con-
cept further.

ANTECEDENTS

According to Walker and Avant (1995), antecedents are events or

incidents that must occur prior to a concept’s occurrence. For forgive-
ness to be rendered or sought, for example, there must be recognition
of a preceding harmful injury or event warranting redemption
(Hargrave, 1994). Individuals who have been harmed must have the
internal motivation to forgive their injurers (McCullough, Rachal, &
Sandage, 1998), whereas injurers must be willing to seek forgiveness
and change hurtful actions or behaviors (Blumenthal, 1998). As a pro-
cess involving healing and releasing negative energy, forgiveness also
requires time for change and letting go of bitterness and hate (Baures,
1996; Jones, 1993). The antecedents to forgiveness include (a) honest
recognition of harm to self or others, (b) open-mindedness, and (c)
willingness to change.

DEFINING ATTRIBUTES OF FORGIVENESS

Defining attributes are critical characteristics that, similar to signs

and symptoms, help differentiate one concept from another related
concept (Walker & Avant, 1995).
Most frequently used in the literature, defining attributes provide
the clearest sense of how the concept is defined. Three key defining
attributes have been identified for the concept forgiveness: (a) the
ability to acknowledge an injury to self or others causing resentment,
anger, or hatred; (b) redirection, or letting go, of negative emotions,
past incidents, or perceived injuries; and (c) freedom from the desire
to retaliate or punish those responsible for the injury in question.
Elder (1998) argued that forgiveness must be separated from
pseudoforgiveness, or false forgiveness. Pseudoforgiveness is a ploy
to gain power over others by reminding them of their failures and
exhibiting moral superiority (Enright et al., 1998). Forgiveness does
not imply a state of amnesia, where the past injury is glossed over or
Brush et al. / FORGIVENESS 33

ignored. Neither does it mean accepting, forgetting, ceasing to be

angry about injustice, condoning, or excusing wrongdoing (Elder,
1998). Rather, forgiveness implies a deliberate and thoughtful
remembering of past injuries.

EMPIRICAL REFERENTS

Empirical referents are categories or classes of actual phenomena

that by their existence demonstrate the occurrence of the concept
(Walker & Avant, 1995). Essentially, they are measurable objects,
properties, or events that verify the existence of the concept. In the
present analysis of the concept of forgiveness, there are no instru-
ments available that measure this phenomenon as it relates to nursing
practice. The related concepts of self-esteem, hope, anxiety, and
depression, however, have been measured in behavioral-science
studies in an attempt to determine the effect of forgiveness on psycho-
logical health (Freedman & Enright, 1996; Hebl & Enright, 1993).
Enright and colleagues conducted much of the empirical work
related to forgiveness. For example, acknowledging Hope’s (1987)
claim that forgiveness is “a key part of psychological healing” (p. 170),
psychologists Freedman and Enright (1996) measured the outcome of
forgiveness therapy on the psychological well-being of 12 female
incest survivors. As study participants forgave their offenders, they
exhibited higher self-esteem and hope and lowered depression and
anxiety than a control group of similar victims without forgiveness
therapy. Using Hebl and Enright’s (1993) Psychological Profile of For-
giveness Scale as the basis for measuring the degree to which partici-
pants forgave their offenders, the researchers concluded that forgive-
ness intervention improved participants’ overall psychological
health.
A positive association between forgiveness and improved psycho-
logical health in older women (Hebl & Enright, 1993), college stu-
dents (Al-Mabuk, Enright, & Cardis, 1995), and men whose partners
underwent abortion (Coyle & Enright, 1997) has also been noted. In
all three instances, the study participants, who harbored ill will over
past harms, were randomly assigned to forgiveness therapy or a pla-
cebo discussion program. The concept of forgiveness was not dis-
cussed in any of the control sessions. At the end of an 8-week period,
experimental subjects in the older women group exhibited higher
scores in self-esteem, anxiety, and depression compared to the control
34 JOURNAL OF HOLISTIC NURSING / March 2001

subjects; experimental college subjects experienced greater improve-

ments than control subjects on willingness to forgive, attitudes
toward parents, hope, and anxiety; and postabortion men in the
experimental group displayed greater improvement in forgiveness,
anxiety, anger, and grief.
Whereas these first-generation empirical studies on forgiveness
emphasize what forgivers derive psychologically through forgive-
ness, Enright et al. (1998) urged future researchers to expand the vari-
ables of study and include both forgiving and forgiven parties in the
analysis. They also recommend examination of the benefits of for-
giveness on the forgiver’s entire circle of family and friends. “When a
forgiver gives up displaced anger,” they noted, “we can envision his
or her immediate community of family and friends benefiting from
the transformation. . . . We should cast our empirical net more widely
in examining who benefits from forgiveness” (Enright et al., 1998,
p. 59).

CONSEQUENCES

The consequences related to the concept are those events and/or

internal changes that result from its occurrence (Walker & Avant,
1995). Often, consequences stimulate new ideas or avenues for
research pertaining to certain concepts. Possible consequences of for-
giveness include healing, resolution of past trauma, personal trans-
formation, restoration of relationships, balancing of power, relin-
quishment of anger, and redirection of negative energy.

MODEL CASE

Walker and Avant (1995) advised using cases to exemplify the con-
ceptual meaning of various phenomena. The model case provides a
clear example of the concept that includes all of the antecedents and
critical attributes of the concept. Created in the form of a scenario, the
model case must be an absolute, paradigmatic, and real-life portrayal
of the concept (Walker & Avant, 1995).

Brian M. is a 40-year-old critical care nurse who is attending couples

therapy in an attempt to preserve a troubled marriage. Brian was raised
in a violent, alcoholic home where he witnessed his father’s brutality
and bore the brunt of his father’s rage. His father stopped drinking with
Brush et al. / FORGIVENESS 35

the help of the Alcoholics Anonymous program when Brian was in his
late teens. Since then, he has attempted to make amends to Brian and
other family members. All of his efforts have been spurned, however,
with Brian emphatically stating that his father’s efforts are “too little,
too late.” He punishes his father by refusing to have contact with him.
Brian has abstained from drugs and alcohol throughout his life, deter-
mined not to repeat the past and to be like his “lousy father.” Despite his
efforts, he is frequently rageful, emotionally unavailable, and unable to
sustain intimate relationships. Until beginning couples therapy, Brian
blamed all his life’s troubles on his father. Although Brian has found
therapy to be very difficult, he has stuck with it and has begun to realize
that he must change his behavior to preserve his marriage. He now is
able to acknowledge that his father is not the cause of all of his current
problems. Brian has developed a willingness to change, not only to
save his marriage but also because he has begun to realize the toxic ef-
fects of his unwillingness to relinquish the past. He now is more aware
of the past’s effect on his present life and is willing to work through past
traumas and redirect his energies toward a positive future. Recently,
Brian allowed his father to visit him and his family. He no longer expe-
riences a desire to punish his father and is open to the idea of relinquish-
ing past resentments.

This model case demonstrates all of the critical attributes of for-

giveness. Brian acknowledged the injury that created resentment,
anger, and hatred; was willing to let go of negative emotions associ-
ated with the past injury; and released the desire to retaliate or punish
his father.

BORDERLINE CASE

Borderline cases contain some but not all of the critical attributes of
the concept (Walker & Avant, 1995). These cases are inconsistent with
the concept such that they provide an example of attributes that the
concept does not possess.

Dom is a 30-year-old guest in a homeless shelter. He is currently in a

substance abuse rehabilitation program where he is in treatment for
heroin addiction. He suffers from severe depression and has attempted
suicide three times in the past. Despite therapy, psychiatric medication,
and family and group support, Dom is tormented by his past. He ad-
mits to his counselor that he “has done terrible things” to support his
drug habit and that “even if God could forgive me, I could never forgive
myself.” Dom has been attending meetings of Narcotics Anonymous
(NA) where he hears the stories of other recovering addicts and alco-
holics. He is shocked to hear others relate stories of what their lives
36 JOURNAL OF HOLISTIC NURSING / March 2001

were like when they were active in addiction. He cannot imagine him-
self standing at the podium and relating the events of his past, yet he
sees that the people who do so seem happy and secure in their recovery.
Dom does not know if the day will come when he will share his past
with others in the NA program, but he has agreed with his sponsor to
adhere to the program admonition to “just keep coming.”

Clearly, Dom is struggling to forgive himself for past deeds. He

acknowledges that he has caused harm to himself and others but is
unable to let go of negative feelings associated with his past behavior
and continues to punish himself. Dom is going through the motions of
forgiveness but is passively complying with a prescribed program
rather than actively demonstrating the attributes of forgiveness.

RELATED CASE

The related case does not contain the critical attributes of the concept
but may reflect similar ideas (Walker & Avant, 1995). Thus, it is con-
nected in some way to the main concept but differs from it when ex-
amined closely.

Cheryl is a 35-year-old unemployed office worker. She lives with her el-
derly parents and spends most of her days watching television and eat-
ing. She is 5 feet, 4 inches and weighs 250 pounds. Cheryl’s blood pres-
sure has recently been elevated such that she was prescribed an
antihypertensive medication. She does not take the medication regu-
larly because she reports an inability to remember to take it. When
Cheryl was between the ages of 10 and 11, her parish priest sexually
molested her. Cheryl eventually told her parents about the abuse.
When they reported this to the pastor of the church, he rebuked them
for spreading false rumors about a man of God. However, shortly after
this conversation, the priest was transferred to another parish. No fur-
ther mention was made of the incident, and Cheryl’s parents hoped it
would be forgotten. When Cheryl recalls the events of the molestation
she is filled with feelings of remorse, guilt, and disgust. Recently, old
classmates approached her to reveal that they too had been molested by
the priest and were in the process of filing criminal charges against him
and also bringing civil suit against the diocese for ignoring the problem
for so long. Cheryl is thrilled with the idea of the priest being brought to
justice and hopes that he is sentenced to jail for a very long time. She is
happy too that the diocese is being held accountable for its dereliction
of duty and hopes to see the case succeed in court. In talking with her
classmates, Cheryl is beginning to learn that many have suffered from
long-term effects of the abuse. Several of her classmates struggle with
addictions, failed relationships, and employment issues. Hearing these
Brush et al. / FORGIVENESS 37

stories, Cheryl has begun to wonder if the abuse she endured in the past
has had an effect on her life. For the first time in many years, Cheryl ex-
periences a glimmer of hope that her life could extend beyond the con-
fines of the television set and refrigerator.

In this case, although Cheryl is able to acknowledge the harmful

event of the past and see its consequences on her health, she is unable
to let go and free herself from punishing thoughts or deeds. Thus,
rather than exhibiting forgiveness, she is seeking retaliation and
vengeance.

CONTRARY CASE

According to Walker and Avant (1995), the contrary case represents

the clearest example of what a concept is not. In other words, the con-
trary case is the antithesis of the model case, allowing a better under-
standing of the concept through contrast.

Mary has recently discovered that her husband of 10 years has engaged
in yet another extramarital affair. Joe’s cheating has been a chronic
problem throughout the course of their marriage. Each time his infidel-
ity is revealed, Joe is contrite, begs for forgiveness, and promises he will
never stray again. Mary is terrified of the prospect of divorce and can-
not envision life independent of Joe. She has dismissed her friends’ sug-
gestions that she and Joe seek marriage counseling, stating, “There is
nothing to discuss, he has admitted he was wrong and I forgive him.”

The situation between Mary and Joe illustrates an example that is

clearly not forgiveness. In this case, neither party honestly acknowl-
edges the repeated harm precipitating hurt, anger, and resentment,
nor are they working toward redirecting behaviors or reconciliation.
Mary’s claim of forgiveness is a verbal compromise against her
greater fear of divorce and loneliness instead of a healing process.

IMPLICATIONS FOR NURSING PRACTICE

Forgiveness is a phenomenon integral to human existence that has

yet to be sufficiently studied to provide a base for nursing knowledge.
Analysis of the concept forgiveness helps nurses develop clinical
interventions based on the premise that the ability to forgive and to
accept forgiveness contributes to positive physical, psychosocial, and
38 JOURNAL OF HOLISTIC NURSING / March 2001

spiritual health outcomes. Nurses working with particular popula-

tions may find forgiveness an integral part of assessment and inter-
vention. For example, Brush and McGee (2000) suggested that for-
giveness may be a key component in maintenance of sobriety among
a group of homeless men in recovery from substance addictions.
Clearly, this is an untapped area of clinical research for nursing that
can extend to all settings and individuals.

CONCLUSION

A first step toward developing a theory of forgiveness is a system-

atic analysis of the concept. This concept analysis has identified the
antecedents, the defining attributes, and outcomes of forgiveness.
Forgiveness is theoretically defined as a process whereby an individ-
ual and/or group acknowledges a past injury or injustice and its asso-
ciated negative emotions and thoughts, becomes willing to relinquish
and redirect negative energies, and derives freedom from the desire to
retaliate and punish those responsible for the injury.
According to Walker and Avant (1995), after constructing an opera-
tional definition of a concept, location of a research instrument that
accurately reflects the concept’s defining attributes should follow.
Thus, a next step in the development of a theory of forgiveness for
nursing is the construction and testing of theoretical relationships
between forgiveness and outcome variables. Qualitative methodolo-
gies may be helpful as well in describing the phenomenon of forgive-
ness as it relates to nursing practice. Systematic studies of forgiveness
can ultimately enhance nursing’s holistic knowledge base and con-
tribute to the improvement of health.

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Dr. Barbara L. Brush is an assistant professor and director of the family nurse
practitioner program at Boston College School of Nursing (BCSON). Since 1998, she
has directed the Expanded Care for Healthy Outcomes (ECHO) Project, a fac-
ulty/student practice that integrates spiritual assessment into the primary health care
Brush et al. / FORGIVENESS 41

of homeless men recovering from substance addiction. This article and numerous
journal publications and book chapters highlight this work.
Eileen M. McGee, R.N., M.S.N., is a doctoral candidate at Boston College School
of Nursing and the director of Health Care Services at the Pine Street Inn, Boston. She
was also the project director of the Expanded Care for Healthy Outcomes Project.
Bonnie Cavanagh, R.N., M.S.N., is a family nurse practitioner at the Woburn
Medical Associates in Wilmington, MA. A 1998 BCSON graduate, Ms. Cavanagh
practiced as part of the ECHO project team for a year before taking her current clinical
position.
Mary Woodward, R.N., M.S.N., is a family nurse practitioner and coordinator of
program development in parish nurse ministry at St. Joseph Parish in Needham, MA.
A BCSON graduate in 1999, Ms. Woodward provides spiritual and primary care to
individuals and families across the life span.