546408
research-article2014
NSQXXX10.1177/0894318414546408Nursing Science QuarterlySethares and Gramling
Article
Newman’s Health as Expanded
Consciousness in Baccalaureate Education
Nursing Science Quarterly
2014, Vol. 27(4) 302­–307
© The Author(s) 2014
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DOI: 10.1177/0894318414546408
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Kristen A. Sethares, RN; PhD1 and
Kathryn L. Gramling, RN; PhD2
Abstract
The purpose of this article is to describe the use of Newman’s theory of health as expanding consciousness by baccalaureate
nursing students in clinical learning experiences. After a brief overview of Newman’s perspective, the authors report the
context, the process, the challenges, and possibilities of participating in theory-based nursing care as reflected by students and
faculty. Two exemplars of student-client partnerships highlight the process. The authors underscore the significance of early
exposure to application and reflection on discipline-specific knowledge in the socialization of the future nurse.
Keywords
Newman, nursing education, nursing theory, theory-guided practice
Nursing is at another critical crossroad with the call for interdisciplinary practice from among others, the Institute of
Medicine (2009). At the same time, scholars warn that there
is a need for a stronger nursing disciplinary grounding before
merging with other disciplines (Cody, 2006; Parse, 2010);
“true interdisciplinary practice cannot occur if members of
each discipline do not fully understand the conceptual models, theories, practice focus and research methodologies of
their own discipline" (Butts, Rich & Fawcett, 2012, p. 151).
Indeed, in 2006, Cody wrote that “The full realization of
nursing theory-guided practice is perhaps the greatest challenge that nursing as a scholarly discipline has ever faced”
(p. 119). The challenge has yet to be fulfilled. While nurses
are guided by some theory, or pattern of thinking, it is seldom
explicit and is often eclipsed by medical frameworks, diseases, diagnoses, and treatments that do not represent the
focus of the nursing discipline (Parker & Smith, 2010). The
purpose of this paper is to demonstrate that undergraduate
students can learn and appreciate the perspective of the nursing discipline from their first patient encounter.
Educators need to prepare undergraduate nursing students
with grounding in discipline-specific practice as well as fostering interdisciplinary collaborations. Students of professional nursing may not have the opportunity to participate in
nursing theory-based practice unless their program uses a
specific nursing framework. Similar to many schools, the
curriculum framework at the authors’ college is an eclectic
one. Therefore, the primary author needed to create learning
opportunities for enhancing nursing theory-guided practice.
The authors contend that students will be more appreciative
of disciplinary theory if it is intentionally used in a clinical
encounter early in the formal learning process. Such clinical
application may serve to anchor disciplinary grounding and
promote valuing of the contributions of nurses in concert
with other healthcare providers. Masters (2012) calls for students to “build a culture in which nursing theory becomes the
framework for practice (pp. xxvi)” and she urges exposure of
multiple theories so that the student can experiment with the
best fit. In this project, the authors chose to organize a theory- guided learning experience directed by Newman’s theory of health as expanding consciousness (HEC). Newman’s
theory offers the student an alternative view of patient care
that is contrary to illness- and disease-focused models that
emphasize cure. Rather, it is more in line with goals of health
promotion, relationship building, personal participation, and
growth. Newman enlarged the notion of health to the “human
experience of health” as it is disclosed through a caring nurse
patient relationship (Newman, 2011).
Newman’s Focus for the Discipline
Thirty-five years ago Newman introduced a particular worldview for nursing that sought to consider health as more than
the absence of disease, and illness as a possible health experience, an experience that may lead to “expanding consciousness” (Moch, 1990).
In order to use any nursing theory, students must first
understand how that theorist views the concepts, goals, and
process of professional nursing. Newman and colleagues
defined nursing as “caring in the human health experience”
(Newman, Sime, Corcoran-Perry, 1991, p.4). She situated
1
Professor of Nursing, University of Massachusetts Dartmouth
Associate Professor of Nursing, University of Massachusetts Dartmouth
2
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303
Sethares and Gramling
the nurse as a potential catalyst in assisting persons to reflect
and grow in awareness and choice during illness. According
to Newman, “The process of the evolution of consciousness
is the process of health” (Newman, 2000, p.43). Furthermore,
Newman (2000) addressed the major concepts of the nursing
metaparadigm: people, environment, health, and nursing, as
follows:
1. People are neither diseased nor well; they are whole
individuals who express that wholeness in unique
dynamic patterns with their environment. Nondisease and disease are both considered manifestations of the person’s underlying patterns.
2. Health is viewed as an evolving process of selfawareness and choice.
3. Patterns develop through interaction with the environment. New patterns may surface in personenvironment interactions. Meanings are generated by
exploring patterns.
4. Nursing, according to Newman (2000) is to participate in recognizing patterns, to facilitate awareness
and promote higher levels of consciousness.
Newman’s perspective invites the student to see the client
as a unique human being who has a personal history of living
life that may become disorganized by illness or disease;
however, disease does not define who they are (Pharris,
2011). Illness may be the “choice point” or transitional
opportunity for increased awareness and positive change
(Newman, 2000). The nursing student may be able to foster
personal transformation by helping the client recognize patterns that have either promoted or thwarted positive health
by reflecting on life stories with the client.
Within Newman’s practice model, nursing students will
seek to create a “dialogue” with their clients to discuss meaningful events and people in their lives. Such intentional conversation is designed to assist both clients and students to
recognize patterns that may lead to awareness and new
choices. The nurse-client relationship is viewed as a “partnership” created to help people make order out of chaotic
events that often hurl them into healthcare settings. To do so,
students are asked to be “fully present” (Newman, 2000,
p.148) with openness to what clients are experiencing without the overlay of their own agendas and interventions.
Newman, like many grand theorists, continued to refine her
understanding of what was uniquely nursing. In five books,
multiple scholarly articles and theory presentations, Newman
has generated a wealth of interest and studies in the health as
expanding consciousness (HEC) theory. An integrative review
of the literature revealed 24 studies using Newman’s theory
and method beginning in 1999, with 14 published in the last
five years (Smith, 2011). Smith identified four major categories of studies using Newman’s theory: (a) life patterns within
shared diseases and predicaments of clients; (b) the evolving
patterns in nurse-patient relationships, (c) the process for
implementing HEC in practice settings, and (d) community
pattern recognition as a catalyst for change (2011). There are
no studies yet reported about the use of Newman in undergraduate curriculum. Published literature related to the use of
Newman’s theory with undergraduate nursing students is limited to one project in the psychiatric setting (Picard & Mariolis,
2002).
Picard and Mariolis (2002) describe the development of a
baccalaureate student clinical learning experience guided by
an integration of the caring ideals of Roach and the notion of
praxis in Newman’s theory. Faculty modeled caring behaviors for the students with the goal of having the students mirror these behaviors in their relationships with clients.
Students were instructed in the key ideas from Newman’s
theory including: being fully present, wholeness and reflection as a process essential to the recognition of life patterns.
Clinical learning experiences included journaling that provided an opportunity for students to reflect on patterns. This
study, similar to ours, used concepts from Newman’s theory
to guide the nursing care provided to clients by undergraduate students. The reported projects differ in the length of
time, setting of the interactions and use of Newman’s HEC
with Picard and Mariolis (2002) reporting an integrated
model to guide client care.
The Clinical Project
The students who participated in the present project were in
the second semester of the sophomore level in a baccalaureate nursing program. All students had completed a health
assessment course where they learned interviewing techniques and basic assessment skills. Students practiced interviewing skills with both a healthy peer, and an older adult in
a day care setting, guided by a functional health pattern
framework.
The project took place during the students’ first experience in a hospital setting. The first six weeks of the semester
were spent learning basic caregiving skills in the college
laboratory. The following eight weeks were spent on a 22-bed
rehabilitation unit in a community hospital that had a population of primarily older adults with cardiovascular, neurological, and orthopedic diagnoses. There were nine students in
this clinical group with the first author as their instructor.
Students were assigned one client each clinical day to allow
both the student and client time to develop a relationship.
Newman’s model was chosen to guide the assignment
because of a focus on relationship-based care which is a core
nursing value. This framework describes unique perspectives on relationships that differentiate the discipline of nursing from other disciplines.
Appreciating Pattern: The Assignment
Students were instructed to read the data collection process
as outlined in Newman’s (2000) protocol of health as
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304
Nursing Science Quarterly 27(4)
81 Year Old Female
Dancing
Father
Dancing
Gym Class
Sports
Mother
Brother
College
Sports
Dancing
Sports
Illness
Children
Grandchildren
Young Adult
Adolescense
Adulthood
Older Adulthood
Father distanced
himself from the
family. Dancing
became an
important part of
her life.
Ballet, tap & jazz
lessons with her
mom.
Sports, dancing &
gym class were an
important part of
her life.
Met her husband at
a dance. Fell in love
& married after
high school.
Dancing was
important to
herself and her
grandchildren.
Family stays close.
Loves to travel.
Dancing was
important until she
became ill. She
longs to be able to
dance again.
Family is still close
knit.
Had a stroke and
difficult to move
due to left side
weakness.
Figure 1. Exemplar 1 of pattern analysis.
expanding consciousness in preparation for the first clinical
post conference of the semester. At that time, the faculty
member facilitated discussion about the concepts embedded
in the Newman’s theory and the nurses’ role with clients
guided by this particular nursing theory. The metaparadigm
concepts described above were part of that discussion and
also the notion of patterning and the goal of expanding consciousness. Recognition of the need to be fully present and
listen to the client’s story was also reviewed. On the third and
fourth weeks of the semester, students were given the opportunity to practice Newman’s protocol by interviewing each
other and by developing a pattern analysis with a peer. The
interviews typically took about 30 minutes and handwritten
notes were taken by students rather than audiotaping the
interviews and formal transcriptions as noted in the protocol
since it is not feasible to tape and transcribe an interview during the course of a clinical day.
During the fifth, sixth, and seventh clinical weeks, students assessed clients using Newman’s protocol. The assessment was completed in the morning then students
concentrated on recognition of the life pattern and creating a
pattern analysis during the course of the day. Students took
handwritten notes from the interviews and used these to construct an initial pattern analysis by putting the data in chronological order as described in the protocol. An initial diagram
was constructed by the student to be shared with the client.
Later in the day, the students shared the diagrams with the
clients. During this sharing, the clients had an opportunity to
confirm, clarify, or revise the story (Newman, 2000, 148). As
Newman suggested, by sharing the analysis with the clients,
both the students and clients had the opportunity to reflect
upon and recognize life patterns with a goal of expanding
consciousness of health. Post-conferences centered on
reporting what the student learned about the client as a person and how this informed their way of being as a nurse with
the client. Patterns were shared along with both student’s and
client’s interpretation of the pattern. Ultimately, students
shared the unique care plans and personalized interventions
that they created in partnership with their clients. The final
stage of Newman’s protocol, application of the theory of
health as expanded consciousness was not formally completed with the students although the post-conference review
highlighted several of the concepts in action.
Patterning: Exemplars of the Learning
Experiences
Exemplar 1. The first exemplar described the experiences of
one student and client’s experience with using the Newman
protocol and the data derived from that protocol. An example
of the pattern analysis that was generated during this relationship is depicted in Figure 1. Karyn is a 19-year-old nursing student who lives at home and commutes to college. She
is the oldest in her family of four and the first to attend college. She had no previous clinical experience and her family
members are primarily healthy. This was her first exposure
to clients in the role of the nurse other than a three-week
experience the previous semester with a relatively healthy
older woman at a local senior center. Her client, Mrs. James,
was an 81-year old female who fell at home and fractured her
pelvis. She had a medical history of hypertension, cerebrovascular accident, osteoporosis, breast cancer and a
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305
Sethares and Gramling
80 Year Old Female
Mother
Stepfather
Father
Wedding
Mother
Stepfather
Husband
Stepbrother
Young Adult
Adulthood
Father passed away
before she was
born. Her mother
raised her by
herself and they
had a good
relationship. She
met her husband at
age 12 and have
been together ever
since.
Happy, fulfilled,
in love
Husband at
WWII
Bought cottage
in NH
In-laws very
supportive
Friends met
in NH
Scared, worried,
very anxious while
he was gone.
When he came
home, it was very
strange & she felt
distant. It took a
little while to get
adjusted to how
each had changed.
Loved their cottage
in NH. Place where
they relaxed & felt
at peace.
Grieving period
because of mother
and stepfathers
deaths.
Stepbrother
Retirement
Co-workers
Older Adulthood
Worked as a nurse
for 30 yrs. Loved
her job and those
she worked with.
Figure 2. Exemplar 2 of pattern analysis.
left-sided mastectomy. She lived with her husband of 62
years in a seaside cottage. Mrs. James loved to travel and had
another home in a nearby state. She comes from a large and
loving family who visit her often. There is concern that the
client may not be able to return home due to her unsteady
gait and history of falling.
Both Karyn and Mrs. James readily established a relationship because both were from the same small seaside town.
Once the ice had been broken, Karyn interviewed the client
beginning with, “Tell me about the most meaningful persons
and events in your life?” according to the Newman protocol
(2000). The client shared her story with minimal prompts
from Karyn. When asked about the interview later, Karyn
said she was surprised by how much the client shared and
how open she was about her life. Incidental revelations
expanded their connection. The student took notes and later
constructed the narrative and diagram of the pattern analysis
in chronological order. Karyn subsequently returned to the
client’s room to share the narrative and diagram of the pattern
analysis and follow-up the analysis with the client. Together
the client and student reviewed the analysis and clarified the
pattern. In this case, the student identified the need for movement and the role of dancing in the client’s life as an important component. Because of Mrs. James’ current state of
health, movement was difficult. Mrs. James confirmed that
movement and dance were an important part of her life and
shared with the student how sad she was that she could not
move easily due to the stroke. Therefore, together with the
client, the student found a way to bring music into the room
and assisted the client to perform her physical therapy to
enjoyable dancing music. Without this prior understanding,
the nursing intervention in this case would have been different and not as personal. The student also came to know herself as a caring nurse and understood more deeply the
relational role of the nurse and its’ potential impact on
outcomes.
Exemplar 2. The second exemplar depicts another student
and client’s experience guided by the Newman protocol.
Brittany is a 20 year old nursing student also new to the role
with no prior clinical experience. She was shy and reluctant
to spend a lot of time in her client’s room. With faculty
encouragement she agreed to use the Newman protocol as a
guide to establishing a relationship with her client. The pattern that developed from this relationship is depicted in
Figure 2. The outcome of this relationship in one word was
happiness from both the student’s and client’s perspective.
Mrs. Sommers was an 80-year old female with a history of
coronary artery disease, myocardial infarction, hypertension,
multiple angioplasties, cholecystectomy and recent history
of lung cancer. She was in the hospital this admission with
heart failure. She also shared with the student that she was
trained as a nurse and really enjoyed that role in her earlier
life. The interesting piece to this relationship was that both
student and client assisted one another to develop the relationship. The former nurse was happy to guide the shy beginning nurse in establishing a relationship and readily shared
many life stories.
Brittany asked the client about her life experiences guided
by Newman’s protocol and Mrs. Sommers proceeded to tell the
student about her life, again, with minimal prompts. The student was immediately able to recognize a pattern of happiness
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Nursing Science Quarterly 27(4)
throughout the client’s life despite multiple illnesses. The student reported that Mrs. Sommers’ life was fulfilling with multiple positive connections. The student made an interesting
observation about the role of the heart in this client’s life and
that a number of her current health problems were related to the
heart. The role of happiness and heart difficulties and the positive outlook Mrs. Sommers maintained was impressive to the
student. When Brittany later shared her observations with Mrs.
Sommers, they were both able to reflect upon the role of a positive attitude as a coping mechanism that the client felt contributed to her health. For the student, this was a revelation of sorts
that she learned in relationship with the client. She later reported
in post-conference about the role of happiness in positive health
and was interested in this connection as a potential nursing
intervention. At the end of the clinical day, Mrs. Sommers
reported that her day with the student was therapeutic for her
and helped her to regain some of her positive energy for healing. She shared that the opportunity to shape the development
of a future nurse was enjoyable and made her happy. Prior to
this encounter, she worried about the future of the healthcare
system. These exemplars are meant to demonstrate particular
episodes of nursing care guided by Newman’s protocol. The
beginning students were able to use the protocol to establish a
relationship with their clients and in the process expanded not
only their own views of health and illness but also that of their
clients.
Outcomes of the Learning Experience: NurseClient Partnership Knowing the Person
Newman’s theory initiates the beginning nursing student in
developing patterns of relating to a client in the clinical environment. Similar to Newman’s revelation while caring for
her mother (Pharris, 2012), students in this project learned
that life can be affected by illness but is not necessarily
defined by it. A number of the students were impressed by
how little a role illness played in the lives of their clients.
Students reported that clients rarely talked about pathology
or disease. Instead, they shared what was most important in
their lives. This allowed the students to know the person in
unique ways, promoted comfort between the student and client, and provided data that served to individualize interventions. In post-conferences, instead of conversations about
what procedures the student observed that day, discussions
about their client’s lives was shared. Students also shared
their surprise at how open their clients were to the idea of
reflecting on their health and how easily a partnership
developed.
Structuring and Evolving Process
Because it was the first clinical learning experience students had many preconceptions about the role of the nurse in
a practice setting. Early on in the semester some of the
students voiced concern about not using a framework for
assessment that was guided by the functional health patterns.
Their perceptions about what an assessment of a client
should be did not include many of the principles found in
Newman’s model. Students saw assessment of the client as a
nursing task rather than as the beginning of a relationship
that would allow a pattern to emerge. Additionally, they were
concerned about being able to engage the clients in conversations and felt more comfortable having a series of questions
to guide the interviews, which is often seen with rule-based
early learners. These factors initially contributed to students’
reluctance to use Newman’s protocol to guide client assessments. Additionally, most of the students in the program tend
to arrive directly from high school and have had little professional working experience.
Initially, students reported some data gleaned from their
clients that would not have been obtained from the functional
health pattern method of assessment. Successful use of the
model led to student excitement and what began as an
instructor-driven assignment became instead something the
students enjoyed and readily used for the rest of the
semester.
Living as Primary
Students were able to view clients from a more holistic perspective and framed nursing interventions using Newman’s
method rather than from a medical model approach. This was
at first awkward but later became a part of who they were as
emerging professionals. When asked how the nursing care
provided differed from medical care, students were able to
clearly articulate how the care they provided did not just
focus on physical illness. In fact, one student remarked that
“the client didn’t even mention diabetes once during our conversation and that is why she is in the hospital”. Instead the
client shared important life experiences and hopes for life
after discharge.
Relationships
Newman’s protocol allowed the nursing students to see and
relate to the clients as persons. The relational disciplinary
perspective of nursing was preserved by allowing students to
intentionally engage with clients for the purposes of revealing patterns. Through this relationship, both the nursing student and client came to understand health in a new way. The
relationship became a partnership with both participants
equal members of the process.
The goal of the nurse-client relationship, as defined by
Newman (2000), is to expand consciousness. In this case, both
students and clients in partnership came to new levels of consciousness through recognizing and understanding life patterns.
Both students and clients reflected on lifelong patterns with the
goal of understanding self and hopefully initiating change.
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Sethares and Gramling
Conclusion
Cody’s call for a “full realization of nursing theory-guided
practice” cannot occur without offering opportunities for practice based on theory in the socialization of the nurse” (2006,
p. 120). The authors believe that the process can begin early in
baccalaureate education. There is no question that Karyn,
Brittany, and others in the clinical group understand how using
Newman’s nursing theory helped them achieve therapeutic
relationships with their clients; generated data uniquely personal to the experience, and guided them to an individualized
plan of care. Equally important, nine students of nursing now
have the possibility of bringing this knowledge forward into
their understanding of professional nursing.
The findings of this project should encourage educators
to: seek opportunities for undergraduate students to use nursing theory in the care of their clients; support students while
they are approaching nurse-client encounters in new ways;
help students to integrate routine methods of data collection
within a larger nursing frame; and bring to light the process
and outcomes of a nursing theory-based practice.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the authorship and /or
publication of this article.
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