Ringing the Bell in Cancer Care: A Scoping Review of Patients', Caregivers', and Healthcare Professionals' Experiences and Implications for Oncology Nursing.

BACKGROUND

Bell-ringing rituals mark the end of active cancer treatment in oncology settings worldwide. Despite their growing prevalence, their emotional and clinical implications across patients, caregivers, and healthcare professionals remain underexplored.

OBJECTIVE

To map and synthesize the available evidence on bell-ringing rituals in cancer care, examining their meanings and implications from the perspectives of patients, informal caregivers, and healthcare professionals.

INTERVENTIONS/

METHODS

A scoping review was conducted following Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines (Open Science Framework protocol: https://doi.org/10.17605/OSF.IO/UCPFV). Five databases (PubMed, Scopus, Embase, CINAHL, and Cochrane Library) were searched from January 1996 to July 2025. Qualitative, quantitative, and mixed-methods studies were eligible. Two independent reviewers performed selection, extraction, and thematic synthesis.

RESULTS

Five studies met the inclusion criteria. Four themes emerged: (1) symbolic closure and transition, (2) emotional ambivalence encompassing joy, guilt, and anxiety, (3) visibility, recognition, and disparities, and (4) absence of institutional guidance. While many patients experienced achievement and community, those with ongoing treatments or advanced disease frequently reported exclusion and distress, including posttraumatic stress disorder triggers.

CONCLUSIONS

Bell-ringing rituals support meaning-making for some patients but may unintentionally marginalize vulnerable individuals when implemented without adequate assessment. No evidence-based protocols currently exist for patient readiness or cultural appropriateness.

IMPLICATIONS FOR ONCOLOGY NURSING PRACTICE: Oncology nurses should conduct preritual readiness assessments and offer individualized symbolic options to protect nonparticipating patients. Findings support inclusive institutional protocols and the integration of ritual literacy into nursing education.