Caring Partnership within Newman's Theory of Health as Expanding Consciousness: Aiming for Patients to Find Meaning in Their Treatment Experiences

Abstract

Despite the continuous advances in cancer treatment, many patients undergoing cancer treatment still suffer because of inability to find meaning in their treatment experiences. Nurses involved also suffer because they prioritize the implementation of treatment protocols rather than providing holistic care. Therefore, special care is needed in clinical settings. This report aimed to demonstrate helpfulness and possibility of “caring partnership” with patients in the treatment phase on the basis of Margaret Newman's theory of health as expanding consciousness. Caring partnership is a nursing intervention in a unitary and relational perspective that helps patients and nurses make a difference. For this intervention, patients need to recognize their own pattern in the relationship to exert their own strengths in finding meaning to their cancer treatment experience and so their lives, while nurses are encouraged to partner with them, trusting patients' own power and becoming a rich environment for them. Hence, dialog is necessary to facilitate patients' pattern recognition in process of the patient-nurse partnership. Three cases are presented for each treatment phase (perioperative, chemotherapy treatment, and prolonged postoperative self-care management). Through caring partnership with an oncology certified nurse, the patients found meaning in their treatment experiences and exerted their own inner strength to establish a new way of life, and the nurses reconfirmed what nursing was. From the theoretical viewpoint, caring partnership was helpful for patients in distress and was possible in clinical settings even with partial involvement during a treatment phase.

Introduction

Advances in cancer treatment have increased the range of options and the possibility of cure for patients in the cancer treatment phase. However, patients have some concerns; they worry about selecting treatment options, exerting desperate efforts to complete long-term treatment, or wanting to overcome stresses from the repeated procedures, implying a treatment-centered life. The nurses involved are also working hard within a limited amount of time to provide safe treatment and self-care support for coping with adverse events.

Although some knowledge about nursing care for patients in the treatment phase have already been accumulated,[1,2] most of them are symptom management care such as anxiety, depression, and quality of life for patients in positivist perspectives. Such research would be of course needed, but our belief is that patients in the treatment phase have a great need of a caring connection with nurses. That is, as medical technology advances, patients are divided into parts and are easily torn the wholeness as human beings. We believe that professional nurses should not accelerate this trend. Assuming more holistic care is needed for patients who are distressed in the cancer treatment phase, we are aiming to help patients find meaning of their treatment experiences and their lives to keep their wholeness.

Purpose, Theoretical Framework, and Method

The purpose of this report was to demonstrate helpfulness and possibility in clinical settings of “caring partnership” within Margaret Newman's theory of health as expanding consciousness (HEC).[3,4,5] HEC emanates from a unitary and relational perspective of nursing. The importance is to see a person as unitary and continuous with the environments. Since the patient with cancer is an undivided whole, and a patient-nurse relationship is also an undivided whole. A parameter for the unitary perspective is “pattern.” Pattern was defined by Newman as “information that depicts the whole, understanding of the meaning of all the relationships at once.”[3] That is, the patient who recognized one's own pattern can get meaning from the information depicted in the pattern of the whole and get insights regarding how to transform one's distressed situation. “Caring partnership” is a nursing intervention created within the same perspective; it could not be explained in a cause-effect relationship. It is in the patient-nurse's interaction for the patient to find meaning into own pattern. This relationship is explained often by imaging the emanating waves that appear when two pebbles are thrown into water.[3] Moreover, a helpful means to support the patient to find meaning in his/her pattern is to have “dialog” in the patient-nurse relationship. Newman suggested that dialog begins with a simple, open-ended statement such as “Tell me about the meaningful persons and events in your life.” [3,4,5] The patient's pattern emerges in the story and the pattern projects meaning of his/her experience. It is crucial that the nurse is genuinely present, in trusting to own intuition,[4] with the patient during times of distress.

Research method was “research as praxis” or “nursing praxis” which involves HEC. Newman emphasized that research conducted by nurses must focus on the reality of practice;[3] research takes the form of practice. In other words, the process of nursing practice becomes the content of nursing research. The data is usually used nurses' records which have been described from memory soon after their clinical practices; but tape-recorded descriptions may be used, if possible. Data analyses are focused on changes of patients' pattern in the process of patients-nurses partnership from the viewpoint of HEC.[4]

There are already some nursing praxes based on HEC in clinical oncology settings, [6,7,8] but these were with patients during the period of end of lives. In this report, we present three cases of the following distressing phases associated with the cancer treatment phase: perioperative that is highly invasive, chemotherapy with many adverse events over a long period of time, and the time when long-term self-care is imposed in the changed body image after surgery. [9,10]

Case Presentations

The cases demonstrated “caring partnership,” which was the nurses' intent to support the patients in deeply understanding HEC and certainly facilitated the patients in finding meaning in their treatment experiences and exerting their own inner strengths to create a new and more personal way of life with cancer.

Case 1

Caring partnership with Ms. A, a perioperative elderly patient with cancer and mild dementia, and her daughter

During the perioperative period, though medical interests focus on patients' physical recoveries, the importance is patients' motivations and decisions to undergo life-threatening surgery. Therefore, nurses must sensitively watch and relate to patients' initiatives. Ms. A with mild dementia did not want to have surgery, despite her family's strong desire. Moreover, Ms. A's daughter looked to be confused how to relate with her elderly mother. Nr. Honda's thoughtful connection with Ms. A helped her to make her decision on her own initiative. In addition, Nr. Honda's extended concern to the mother-daughter relationship motivated Ms. A's primary nurse to support her daughter. The following story shows how caring partnership helped them make a difference in their lives through the meaning of the treatment experience.

Encounter: Night shift on the first day of Ms. A's hospitalization

I (Nr. Honda) first met Ms. A in her 70s, who had mild dementia and was hospitalized for colorectal cancer surgery upon her family's strong desire. I was determined to understand Ms. A as a whole person, not merely as a patient with cancer who was scheduled for surgery. I envisioned her emanating wave and imaged her wave and my wave were interacting each other. Sensing her wave in a calm atmosphere, I called out to her, then she responded to me. Our interaction continued. However, when she noticed the drug I had, her entire body suddenly stiffened. Instinctively, I realized she understood her present situation. I thought it was time for her to think about her cancer and the treatment not for her family's wishes but for her own.

I: Ms. A. Tomorrow is the day of your surgery.

Ms. A: I'm scared of surgery. I'm sorry to say it now.

After a while of silence,

Ms. A: I'm still afraid of the surgery, but I'm thinking of doing it. After having been hospitalized and seeing various patients, I feel I will be able to do my best.

After sharing some thoughts about herself, she took the pill. She looked she took her own steps forward to preparing for the surgery. I listened to her and tried to understand her experience and relationship since she had been diagnosed with cancer. Then, I sensed that she regained her own pace, which she had totally lost because of the idea that resisting hospitalization and surgery was already impossible.

Overnight shift immediately after Ms. A's surgery

I was in charge of Ms. A overnight immediately after the surgery. I was considerate of her, who had finally decided to undergo the operation and was, at the moment, in a period of postoperative burden. To continue my interaction with her, I made the utmost effort to take care of her by providing all her general postoperative care needs such as regular monitoring and assessment and the management of intravenous injection routes and medical device codes. In devoting to what she was experiencing right now, I carefully repeated the explanation of her current situation. She responded by slowly nodding with her eyes closed. I sensed that she was now entrusting herself to me and other nurses.

The next morning, she already woke up. I slowly called out in watching her, and she looked at me. She then replied with a clear appearance indicating a “good morning” greeting. I have determined that Ms. A has successfully survived her critical period.

Farewell-day shift on the day before Ms. A's discharge

Ms. A had a smooth recovery process until she was discharged the next day. However, I was worried about the relationship between her and her daughter, because I felt an uncomfortable feeling when I met her daughter immediately after the operation. She gave instructions to her mother in a strong tone, ignoring her mother's words. I noticed that she was not close to her mother. However, Ms. A clearly cherished her daughter more than anything else. I thought I couldn't send Ms. A merely by her physical recovery.

Ms. A: My daughter gets angry with me because I am very forgetful. When she gets angry, I can't help….”

Though the relationship seemed disagreeable, I sensed her pattern as a mother trying to fully accept her daughter. I also could understand her daughter's overwhelming experience dealing with her gentle mother who was aging and suffering from both dementia and cancer. I realized that both Ms. A and her daughter needed a support. Given that the next day was my day off, I shared my concern with Ms. A's primary nurse, whom I entrusted with her care. The following day, I have received a report from the primary nurse.

The story was as follows. The primary nurse spent time in listening to the daughter's feelings and experiences, including her mother's appearance in her daily life. The daughter looked confused by her aging mother. Thus, the primary nurse gently came close to the daughter and talked that her mother could make decisions on her own here and that her mother would be better when she participated in a slower tempo. The daughter replied that she would try to follow the primary nurse's suggestions and appreciated the nurses' considerate caring for her mother.

Importance of this case according to Newman's theory

Apart from physical recovery support, perioperative care requires nurses to help patients make their surgery experiences and the following lives meaningful. Nr. Honda and the primary nurse demonstrated it, as stated below.

Nr. Honda was in charge of this elderly woman for only three shifts (hospitalization day, overnight after the surgery, and the day before discharge). Each patient visit must have been lasted for only 10 min or less. Of note, by imagining emanating waves, Nr. Honda intended to build a partnership relationship from the beginning. Newman wrote, “…the emanating waves that appear when two pebbles are thrown into water. As the waves radiate toward each other, they meet and interact and an interference pattern evolves.”[3] This intent made Nr. Honda very sensitive toward the patient, even toward her small gesture, a bit of talk, or appearance. In this relationship, Nr. Honda conducted dialog with the patient even in a short time, to listen to and help the patient develop a sense of self. Then, Nr. Honda made the primary nurse aware of the importance of dialog and also suggested a clue to build a new mother-daughter relationship. These considerations and actions indicated “caring partnership” established within the nurse-patient relationship during the perioperative phase.

Case 2

Caring partnership with Ms. B who is angry about receiving postoperative chemotherapy as standard treatment for breast cancer

As treatment progressed to postoperative adjuvant chemotherapy as standard treatment for breast cancer, Ms. B found no meaning in the treatment and described the distress as anger at the medical staff. Nr. Fujiwara repeatedly made the opportunities for dialog with Ms. B. Thanks to caring partnership with Nr. Fujiwara, Ms. B found meaning in her cancer experience and chose her new way as a cancer survivor. The story was as follows.

Encounter: Consultation about Ms. B who was dissatisfied and angry at the explanation of postoperative adjuvant therapy

I (Nr Fujiwara) was consulted by an outpatient nurse about Ms. B, who was in her 40s and living alone. She was diagnosed with Stage II breast cancer, and after her standard treatment (partial breast resection), she was advised to receive chemotherapy and radiation as adjuvant therapy. However, she disapproved to such additional therapy. Hence, I was invited to meet her to know what was happening to her. As soon as Ms. B met me, she spoke in an angry tone about her dissatisfaction with her treatment and medical care.

Ms. B: Does it make sense to treat with chemotherapy even though my cancer has been resected? My friends who have the same breast cancer have not received it. Why do I have to undergo chemotherapy only for myself?

Then, she cried with anger. I instinctively felt that her anger wasn't just anger about the medical staff's responses, but anger toward intricate thoughts including her anxiety and sadness lasted since the cancer diagnoses and other various things. So, I asked her honestly what she was feeling.

I: It seems that there are other things to worry about besides illness. Would you please tell me?

The tears spilled out, and then she started to talk about her father with lung cancer who died after undergoing chemotherapy.

Ms. B: Doctors and nurses explain various things, but I feel that their talk about the treatment for me moves though my feelings that are left behind.

I understood that her anger indicated suffering; thus, she could not keep up with the plan of treatments that were going on one after another without considering her painful memory about her father. I sympathized with her feelings and gave a kind word. Consequently, Ms. B's facial expression softened, and she said that she felt better after talking to me. She reconfirmed the side effect measures of her treatment and then went home. However, I was concerned about her leaving with a bright expression and thought I should observe her for a while.

Dialog in partnership with Ms. B who started receiving chemotherapy

Chemotherapy started and ended without any major adverse events, but after a while, Ms. B urged the medical team to change the order of treatment for her work reasons. I felt that with repeated chemotherapy, she could difficultly control the situation in the same way as before. I thought caring partnership with me would help her; hence, I embarked on it.

I: I want to help you! Ms. B. Please be a partner. Please tell me about your meaningful events and relationship with people in your life.

She gladly accepted the offer and began to talk about her story. I believed in the power within herself and listened to her wholeheartedly to understand her pattern. Her story reflected her pattern, that is, she always cared about her surroundings as a leader and worked hard on her own without making any trouble. She also shared that having witnessed her father's death was difficult for her. I thought that her pattern continued during the treatment and understood that she tried to deal with chemotherapy treatment all by herself. However, facing such challenge by herself alone did not work, and she was caught in a difficult situation. I sensed she was still in a difficult situation where she couldn't live her life in dealing alone. That is why I strongly hoped that Ms. B would find meaning in this difficult situation and build a new way of life with cancer.

I: It looks like you're always working alone.

I honestly conveyed her pattern reflected in the story. Then, she looked worried and began to search within herself.

Ms. B: Yes, that's right. I couldn't open my heart and talk about my worries to others. Yes, I think I've been overwhelmed!

She began to share her realization about herself. I sensed that this moment made her recognized her pattern, “Don't show my true self to others.” I conveyed her my hope that she would deepen her insight into the meaning of that pattern.

I: Isn't it okay to show a soft sound to others?

Then, after a while of silence, she began to speak with a radiant expression.

Ms. B: Is it okay to show my true self… rather than my weak self?

Um…, if I didn't get cancer, I wouldn't have such an opportunity to talk about myself to you. I should be grateful for cancer and chemotherapy.

Thus, I was convinced that Ms. B would begin establishing a new life through recognizing her own pattern and capturing its meaning with her own power.

Second dialog in Ms. B's another predicament during repeated treatments

Ms. B received the treatment with a bright expression. However, after a while, she visited me again with a regrettable expression; she couldn't honestly tell her colleague in her new workplace that she had cancer. She looked so distressed with it.

I thought that Ms. B must face challenges such as anxieties about recurrence, new relationships, adjustment of a new job, and treatment plan, but I believed the power within herself. Hence, I invited her again for another dialog. I hoped for her that this painful experience would turn into a meaningful experience.

I: Ms. B, how did you say about yourself in our last meeting? How do you want to live with cancer now?

My question seemed to suddenly remind her of her pattern, that is, “Don't show my true self to others.”

Ms. B: That's right. Having cancer is neither bad nor embarrassing. I'm all me who has a disease called cancer. This is me!

She spoke powerfully as if she were talking to herself. I was convinced that she found a new way of life, “Accept myself as I am in the present,” and believed her stable walk as Ms. B with cancer. Then, she left.

Importance of this case according to Newman's theory

The importance at the encounter phase was that Nr. Fujiwara, first of all, began to be interested in understanding Ms. B as she was trusting her own intuition. Then, she was committed to “standing in the center of one's truth,” as Newman insisted.[3] By asking her honestly about her thoughts, Nr. Fujiwara was able to recognize Ms. B's need for help. Moreover, when Nr. Fujiwara realized that Ms. B would go on with a life having cancer, she decided to continue to observe Ms. B despite showing relief.

At the dialog phase, the importance was that Nr. Fujiwara entered into the caring partnership with Ms. B with a strong desire to help her; Ms. B was anguished over not being able to live as expected during the treatment process. The premise from Newman's theory is “for the nurse to be fully present with the client in terms of what is most meaningful to the client.”[4] Nr. Fujiwara surely was.

In a long life with cancer, apart from cancer metastasis and recurrence, changes in relationships with the surroundings caused by various life events will also occur. Despite being able to find their own way of life, many patients may face another predicament when the situation changes. Nr. Fujiwara always believed that anyone in any predicament could use one's inner power to find a new way of life. Her belief was another importance in caring partnership.

Case 3

Caring partnership between Mr. C, a patient with colostomy and prolonged self-management and a nurse who recognized her own pattern in the process

Caring partnership is insufficient if it is a nurse's invitation for a patient to talk about his/her life. Both the client and the nurse must be sensitive to themselves to create abundant mutual exchange of thoughts, which aids in promoting pattern recognition. In this case, Nr. Iio experienced having a caring partnership with Mr. C, a patient with delayed wound healing after colostomy. She struggled because the dialog with the patient was prolonged. Nevertheless, when she recognized her own pattern and was committed purposefully to partnership, the patient recognized his own pattern too and began to exercise his own power for colostomy self-management. The story was as follows.

Encounter: Entering into partnership and nurse's confusion as a partner resulting from failure to recognize the patient's pattern

Mr. C was a single man in his 60s. He underwent emergency surgery for ileus caused by colorectal cancer and then repeated surgery for anastomotic insufficiency and wound infection, resulting in artificial anus construction. The nurses tried to provide self-care guidance for his artificial anus but he refused. Thus, the troubled nurses consulted with me.

When I (Nr. Iio) met Mr. C, his first voice was, “I have to be able to do it myself.” He talked about the background of artificial anus construction after three operations in a short time period. However, he was sometimes confused and often repeated, “I will make my younger brother do it.” I was confused by the changes in his talks. Perhaps, he must be struggling to do something about his artificial anus. I felt sympathy for him and really wanted to help him. I was confident that establishing a caring partnership with him would help him overcome this difficult situation. Thus, I invited him as a partner, and he gladly accepted my invitation.

I asked him, “Please tell me about your meaningful events and your relationship with the people in your life.” Then, he immediately began to talk about his own background. I wanted to understand Mr. C as he was and committed to listening to his story. His talk was woven into the social situation and the conversation was lively; thus, I was absorbed in following his story. However, I could not catch his pattern. Nonetheless, I believed that one day, during our dialog, he would be able to realize what he was like, drawing some diagrams between him and his surrounding people. Unfortunately, my efforts were unproductive. He just repeated the same story and I merely continued to listen to him. We already met thrice for our dialog.

I realized it was not the “dialog” that we aimed but I did not know what to do. I visited an adviser to Newman's theory, and she recommended to try to be more intentional to help him. At my next meeting with Mr. C, I asked bravely, “What do you think about yourself?” He finally started talking about himself.

Mr. C: Easy-going? Harmless… Flexible? I'm not a clumsy person; I was able to make my way in the world. I think it is okay to leave the wound to my doctor. My brother will take care of all my artificial anus care.

Through this conversation, I finally captured Mr. C's pattern, “Depending on others cleverly.” I continued to have dialog with him in recognizing this pattern which evolved one after the other. However, he never deepened his insight in process of pattern recognition according to Newman's theory. Talking with him was really fun, but the conversations were just repeated.

Recognition of the nurse's own care pattern and another start of caring partnership with the patient

Looking back on the process of the dialog with him on the base on the adviser's suggestion, I finally realized that Mr. C was only talking merely for me as his dialog partner, not for himself.

I misunderstood that once he recognized his pattern in the dialog, he would naturally obtain the meaning reflected into the pattern and then find a way of achieving a new life. I realized that I had missed all the opportunities of encouraging him to gain insights. Above all, I noticed my own pattern, “Willingly follow others to support them,” in continuing the dialog while unconsciously neglecting the purpose of the dialog, that is, “to support the growth of others.” Thus, I decided to reflect seriously on my own way and try another dialog that more consciously invites his awareness.

Patient's reaching a turning point and starting self-care for his own through caring partnership with the nurse who knew now who she was

I strongly hoped that Mr. C, who lived with a changed body, would be able to find a new way of life through his pattern recognition, and I believed that he had that power within himself. Though the topic in his talk was extensive, I persistently asked him and passionately helped him, wishing that this dialog would help him in his future life. I worked with him wholeheartedly.

I: How do you like to deal with cancer from now on? How do you want to live the rest of your life? Your brother is worrying about your future.

Gradually, he began to look back on himself, his life, and his relationship with his younger brother.

Mr. C: I didn't know that my younger brother was worried about me. I want to care for him, too. I can't promise, but I'll stop drinking and smoking and be careful about my diet.

After this dialog, he began to actively work on his stoma care, and other nurses could not believe what had happened to him. I was confident about the change of his pattern. Several days later, he invited me and appreciated our dialog.

Mr. C: It's not harder than I expected. I'm leaving the hospital today because I can do it myself. Thank you very much for your help.

Clearly, his pattern changed from “Depending on others cleverly” to “Being able to do it for me,” and his wound started to recover steadily. He then returned home where his younger brother was waiting.

Importance of this case according to Newman's theory

In caring partnership, patients do not simply talk about their life events and relationship; they should find meaning in their difficult experiences. Nurses, who have an intention to assist them in recognizing their pattern, must be self-reflective and sensitive in their own way through mutual exchange of thoughts, leading to pattern recognition. Newman wrote, “The way in which nursing theory is applied is by virtue of the transformation that is taking place in the person of the nurse.” She continued, “The transformation constitutes the nurse's field, and through the interpenetration of the nurse-client field, it becomes the client's field.”[3] This case was a good example of Newman's claim. When Nr. Iio did not recognize her own pattern, her dialog with Mr. C became unproductive. However, once she transformed, her pattern interpenetrated into Mr. C's pattern including his body condition. Therefore, whatever transforms us transforms our practice.[8]

Discussion

The three abovementioned cases demonstrated that caring partnership based on Newman's theory helps patients with cancer treatment find meaning in their treatment experience. When patients find meaning in their experiences and so their lives in the process of the patient-nurse partnership in cancer treatment settings, they would gain an insight into the meaning reflected their own pattern and find a new rule to live on.[3] The patients' transformation and growth would lessen medical complications and enhance the effects of medical treatments. It would also make possible for professional cancer nurses to shift from prevailing manual care to holistic care, which includes more meaningful supports for patients' decision-making and their families' participations, connections with their communities and so on, in patients' treatment phase. We believe that nurses' transforming presence makes a difference in patients' lives as cancer survivors.[4]

Conclusions

We emphasize “caring partnership” is possible even with nurses' partial involvement during the treatment phase. Hence, the key is not just to rely on the method but to be a nurse who is guided by the theory and interacts authentically with patients. This is nurses' caring which Newman claims “caring is a moral imperative for nursing.”[3] Thus, nurses should be consciously involved so that the relationship can be developed, always based on mutual exchange no matter how short the time period is. Deepening the understanding of theory through practice and vice versa is also important.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.