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Nursing Models and Development

Introduction

According to Newman’s theory, the notion of health is a particular developmental phenomenon that aligns with the evolving course of life (Schlotzhauer & Farnham, 1997; Newman, 1995; Newman, 1997; Litchfield, 1999). Moreover, the author positions health a broader concept than absence of illnesses and dysfunctions (Sethares & Gramling, 2014). To be more precise, Newman’s theory mainly focuses on constructive and gradual expansion of consciousness (Newman, 1983; Newman, Lamb & Michaals, 1992; Sethares & Gramling, 2014; Hayes & Jones, 2007). The authentic theory defines the notion of consciousness as “the informational capacity of the system: the capacity of the system to interact with its environment” (Newman, 1986, p. 32). Hereby, consciousness is a complicated concept that may be triggered and expanded only through particular effective interaction with others and proper acquisition of the positive outcomes.

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Expansion of consciousness is a course of gaining “insights, awareness, or meaning from a life experience” (Schlotzhauer & Farnham, 1997, p. 20). An acquisition of new insights may be related to professional cooperation, personal interactions, or serious crisis and its management. The expansion of consciousness in terms of nursing activity is especially topical in the current course of time. To be more precise, the Newman’s theory posits that the ultimate task of a nurse is to “elucidate a fundamental pattern in the interactions between a person and the environment” (Awa & Yamashita, 2008, p. 459). The importance of nursing influence in the given context is confirmed by Parse (2010); Parker and Smith (2010). It is crucial to highlight that the scope of responsibility and impact of nursing personnel is not narrowed only to patient care in terms of a treatment process. However, it involves a mutual partnership that is based on the previous experience of a patient and his or her responses to the past (Koloroutis, 2004; Cody, 2006; Institute of Medicine, 2010 Sethares & Gramling, 2014). According to Newman’s theory, a nurse has to aim to acquire a multifaceted level of awareness about the experiences, challenges and core determinants of the patient’s life. Awareness is a key to right decision making and health care results (Butts, Rich & Fawcett, 2012). Furthermore, the scholars underline that a nurse should become “a potential catalyst in assisting persons to reflect and grow in awareness and choice during illness” (Sethares & Gramling, 2014, p. 303).

Rosa (2016) highlights that nursing practice should be compared to the course of scholarly inquiry, which is conducted as a clinical training and is characterized by empirical background. It means that a nature of relationship that is gradually formed between a nurse and a patient should be dynamic and proactive (Rosa, 2016). Hence, Newman’s theory delineates the major concerns about patient care and relationship that is formed during an essential holistic and efficient treatment process.

The paper focuses on the practical implementation of the Newman’s theory in clinical performance. Expansion of consciousness can be applied to adolescents in different clinical cases, and each case requires thorough individual approach. The given study aims to explore the Newman’s theory under particular circumstances, namely, its application to a patient who has been recently diagnosed with sickle cell anemia, and currently suffers from depression. The selected clinical case is a vivid example of a complicated scenario, which can benefit from the implementation of Newman’s theory provided it is constructively and professionally applied.

The ultimate purpose of the present study is to discuss the peculiarities, challenges and recommendations for utilization of Newman’s theory when treating a patient with sickle cell anemia diagnosis. The objectives of the study are: 1) to delineate strategies of expansion of consciousness for a given patient; 2) to develop method for expansion of consciousness in family of the patient; 3) to assist the patient in further involvement into community and revival of constructive socialization. The aforementioned diagnosis of the patient will be analyzed thoroughly so as to have a holistic clinical picture and be able to align expansion of consciousness with required patient care and proper attitude. Moreover, the present paper focuses on recommendations concerning effective application of Newman’s theory in complicated clinical cases, which require particular attention, time and effort of the nursing personnel. This theory is an efficient instrument not only for expansion of consciousness, but also for mental recovery of a patient and his/her motivation to interact with the environment in an effective manner.

Discussion

Newman’s Theory

Newman’s theory aims to expand consciousness of a patient, his or her family members in order to conduct a more efficient treatment and, therefore, provide better health outcomes. Newman (1986) highlights the following: evolution of consciousness is a direct determinant of health improvement process. Each new stage of expansion of consciousness involves either elimination of a disease or eradication of future risks related to health condition (Smith, 2011). According to Newman’s theory, nursing paradigm delineates the core concepts, which in the currently discussed theory include “people, environment, health, and nursing” (Sethares & Gramling, 2014). The scholars emphasize that “people are neither diseased nor well; they are whole individuals who express that wholeness in unique dynamic patterns with their environment” (Sethares & Gramling, 2014, p. 303). Hereby, both disease and non-disease conditions are regarded as equal manifestations in a given paradigm. The concept of health is defined as a course of evolution in terms of self-awareness and constructive decision-making process (Sethares & Gramling, 2014). Furthermore, the notion of environment plays a defining role during the process of evolution (Brown, 2011). When a person interacts with the environment, particular patterns are formed. Consequently, these patterns affect the choices of a person. Finally, Newman (1986) interpreted nursing as a process of recognition of the formed patterns, facilitation of the relevant level of awareness in a patient, and expansion of patient’s consciousness. The meaning of a pattern in the given context encompasses behavior of a patient, his/her gestures, handwriting, preferences in word choice, and other evident peculiarities and habits (Schlotzhauer & Farnham, 1997). Similarly, health condition, according to the Newman’s theory, can be interpreted as personal experience (Schlotzhauer & Farnham, 1997). Nurses play an essential role in implementation of the Newman’s theory in practice (Watson, 1999).

The current health condition is strongly affected not only by previous experiences in terms of health care, but also by the future health targets and lifestyle priorities. Therefore, ascertaining the meaning of health, as a patient understands it, is of ultimate importance, according to Newman’s theory. In order to acquire such focal knowledge about a patient, it is essential to identify the prevailing patterns and interpret them properly. In terms of nursing, this process requires gradual learning about priorities and habits, vision of health and the actual degree to which basic health requirements have been met (Newman, 2008). This process requires consistent and effective interaction with a patient and his or her family to gain a holistic picture. One of the major drawbacks in patterns’ identification can be ambiguity, what usually means that a particular pattern is in the phase of reorganization and alteration (Newman, 1986).

Newman positions the currently describes patterns as flows or energy. To be more precise, “disease usually means that there is a blockage or disruption of this flow, and some changes or re-patterning must occur” (Schlotzhauer & Farnham, 1997, p. 21). This is the most challenging phase, but it can contribute to positive dynamics of change if treated properly and timely. Each case can easily align this approach, identify the reason of blockages, and recognize opportunities for positive adjustments.

It is also important to highlight that recognition of the core patterns by a nurse is not sufficient to expand consciousness. To be more precise, the next task of a nurse is to assist in patient’s recognition of his or her own patterns and their proper comprehension. This step is vital for further effective interaction. The scholars underline that “the developmental task for an adolescent includes the need to search and try out new ways of relating and responding to his/her environment” (Schlotzhauer & Farnham, 1997, p. 21). Hereby, this process is continuous and multidimensional.

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Patient’s Background

The current paper deals with a specific case acquired from actual clinical practice. Recently, a patient diagnosed with sickle cell anemia was admitted to the unit. The patient was diagnosed several months ago. The course of diagnostics and consequent treatment resulted in deep depression. Moreover, depression is accompanied by refusal to socialize. Both family members and friends experience similar emotions. Several weeks ago, the patient refused to go to school. It was a direct result of the crisis provoked by SCD. The severity of the disease required the patient to stay at the clinic, and undergo 35 days of intensive treatment. As a result, he experienced an acute deficit of interaction with the environment and communication with peers what resulted in subsequent refusal to return to school, when the crisis was eliminated and the patient’s condition became more stable. Isolation contributes to incremental development of depression, and, as a direct consequence, the patient is reluctant to proper and timely treatment. Disease crisis is a critical point for the patient and it requires an immediate constructive intervention.

It is also important to highlight peculiarities of the patient’s background and its potential impact on expansion of consciousness. First, relationships in the family of the patient are complicated. Patient’s mother is a reserved woman who dedicates very limited time to communication with the daughter. As a result, the patient does not have a strong bond with the mother and receives no significant support from her. Patient’s stepfather also does not care for the patient. There are no cousins or other relatives. Hence, it is apparent that staying at home is an apparent isolation for her. Nonetheless, there are several friends who regularly visit the patient and who are trustworthy. The patient perceives teachers and classmates negatively by since they are associated with the dimension of her life where currently he does not fit. Depression has increased after their visits. Finally, the patient has two major hobbies, namely, reading and horse riding. Horse riding is not allowed at this time, and the patient simultaneously stopped reading. The patient keeps silent primarily when she has visitors, and prefers music when she is alone.

Diagnosis: Sickle Cell Disease

In order to contribute to the expansion of patient’s consciousness, it is recommended to start with a through discussion of the diagnosis. Sickle cell disease (hereinafter, SCD) is a serious illness that causes morbidity and mortality, especially in young adults (Crosby, Joffe, Peugh, Ware, & Britto, 2016). One of the major hazards is that the given disease tends to progress in adolescence. As a direct result, its chronic nature and complications often contribute to social isolation and impaired academic performance (Crosby et al., 2016). According to Neville and Panepinto (2011), the condition of SCD is provoked by “an autosomal recessive inherited hemoglobinopathy which results in the vaso-occlusive phenomena and hemolysis” (p. 2). Abnormality is formed on the genetic level when amino acid valine is substituted with glutamic acid. Such mutation occurs at the sixth position “on the beta globin chain” (Neville & Panepinto, 2011, p. 2). The disease is widespread in the African area, whereas other continents regard it as a rare, but serious condition. There are diverse complications related to the SCD, such as stroke, pain, and acute SCD syndrome that consequently can lead to death (Neville & Panepinto, 2011). Moreover, chronic cerebral ischemia is also related to SCD development (Verduzco & Nathan, 2009). The ramifications of such complications are serious and require constructive preventive measures since they tend to have a destructive impact on a patient’s health. Valavi, Ansari and Zandian (2010) underline that often it is a challenge to diagnose timely a particular form of SCD in pediatric patients. It is a crucial aspect, since treatment of the disease requires timeliness, systematic approach and specific cure.

Since modern methods of treatment are not sufficient to fight all forms of SCD, contemporary achievements in medicine permit healthcare experts to enhance quality of life and prolong life expectancy in patients diagnosed with SCD (Odievre, Verger, Silva-Pinto, & Elion, 2011). Healthcare professionals in pediatric practice face the most serious challenge (Cober & Phelps, 2010). Acute condition is the major hazard in pediatrics (Kavanagh, Sprinz, Vinci, Bauchner, & Wang, 2011). Therefore, a history of previous treatment and patient’s response to it as well as records on acute conditions have to be analyzed thoroughly, since the effect of further treatment relies primarily on relevant curative methods and proper choice of medicine. Attitude and expansion of consciousness of the patient is another constituent element of the holistic approach to treatment of SCD cases.

Expansion of Consciousness

The initial step in expansion of the patient’s consciousness is an establishment of mutual relationship. The given case imposes a serious challenge in terms of relationship formation, since the patient alienates herself from all interactions, even with family members. Newman’s theory relies on acquisition of particular insights from previous experiences of the patient. Such achievement for a nurse is possible once the meaning of the notion of health as perceived by the patient is decoded.

According to Schlotzhauer and Farnham (1997), the notion of health has to be comprehended as “a personal experience that is unique to the individual and is manifest by pattern.” (p. 20). The meaning of health encompasses personal feelings of a person aligned with the results of tests and examinations. It is recommended to apply the strategy of insightful discussion of the current diagnosis, but first, the doctor has to gradually discuss acquired analyses and his conclusions. When applied to the currently discussed patient, such approach resulted in incremental effectiveness. To be more precise, initial efforts were followed by silence. Even positive results evoke apathy and reluctance to communicate. It can be explained by the complicated health condition and ramifications of the acute stage of SCD. Moreover, Schlotzhauer and Farnham (1997) highlight that the meaning of health is usually predetermined by “past health experiences, future health goals, and expectations, as well as by significant relationships in one’s environment” (p. 20). Itemized study of the medical records should be conducted to get a holistic picture of the disease progress and potential hazards. Furthermore, it will contribute to further discussion with the patient. The patient demonstrated particular reluctance to reveal details when she was asked about some stages of disease and its development.

It is important to notice that the highest level of reluctance to interact emerged when questions about recovery have been asked. To be more precise, the patient endured a significant phase of positive dynamics after five weeks of intensive therapy. Consequently, she returned to regular attendance of school and spent ten days before the next diagnosis. The acute condition of SCD was a breaking point of depression and was a reason for refusal to interact with others. Such revelation leads to a deeper understanding of patient’s comprehension of meaning of the notion health. As Newman’s theory of health posits, possibilities to socialize and/or perform professional activities, what is an attendance of school in the given context, are crucial constituent elements of the health framework. If the patient understands that health condition does not permit him or her perform his/her social and professional duties properly, the prevailing majority of the diagnosed patients refuse to interact with peers, especially when they witness their success and activity. The patients are usually unwilling to discuss such decisions with healthcare experts, but it is of vital significance for a nurse to identify the core factors that drive the patient’s decisions in such situations. Such an insight should be justified, since further stages of the Newman’s theory of health implementation require sufficient awareness of the major patterns of the patient and potential opportunities for their qualitative change.

As Schlotzhauer and Farnham (1997) underline, the process of pattern identification in patients with acute conditions and complicated diagnoses is multi-dimensional. Hence, it requires diversity of nursing activities. Each activity will be targeted on the acquisition of maximal quantity of information on background and experience, which involve family members. Hereby, communication with family members is another underlying step in preparatory course for expansion of the patient’s consciousness. The given step may be actualized in different ways. For example, 1) inviting parents to the clinic; 2) visiting when the patient is at home; 3) conversing with patient and parents; 4) inviting patient’s parents to seminars dedicated to expansion of consciousness and consequent conversation with them; 5) contributing to the communication between parents of the currently treated patients with the same diagnosis or similar complications. It is crucial not only to learn necessary information about experiences and vision of health in the patient’s family, but also to contribute to a constructive enhancement of their vision. In such a way, expansion of the patient’s consciousness will be supported properly and regularly by family members.

It is also important to take into consideration age peculiarities of a patient. To be more precise, the patient is a 13-year-old girl, who is the most challenging period of transition between adolescence and adulthood. Schlotzhauer and Farnham (1997) opine that manifestations of health during the period of puberty establishment are impacted and adjusted by hormones. Similarly, scholars state that physical changes during the given period are inseparable from the psychological ones: “cognition begins to change from concrete thinking to a more abstract level” (Schlotzhauer & Farnham, 1997). Hence, nurses are expected to respond to such fundamental shifts in the patient’s body, perception and life through relevant approaches to communication. To be more precise, minimum of pressure and maximum of sincere involvement into the patient’s experiences, feelings and patterns is required.

The onset of puberty is also characterized by serious changes in relationship with other people. As a rule, adolescents who endure the phase of transition to adulthood alter their attitude towards parents and relatives. Teachers and other people associated with authority, requirements and obligations can also be perceived negatively. Therefore, it is required to build a mutually beneficial relationship and become a friend, since only friend’s opinion and recommendation are regarded as important viewpoint. Once such type of relationship has been established, it is essential to remember that nurse’s support and comprehension is temporary, whereas parental care and understanding are crucial permanently. Hence, nurse’s task at a given stage of expansion of patient’s consciousness is to improve relationship between the patient and his or her parents. In the present context, it is significant to align problematic relationships of the patient with parents and the challenges brought by SCD crisis. Conversations initiated by a nurse should be supported by actual care and support offered by the parents. In order to promote such activity, nursing personnel is expected to improve the awareness of parents about SCD, its major threats, potential complications as well as patient’s needs and requirements (Tommet, 2003). Parents should be aware of a fundamental shift that transpires during SCD crisis and treatment courses. Moreover, it is of ultimate significance to recommend specific interventions, which can help if initiated by parents. For instance, reminiscences from the childhood that trigger positive emotions should be recommended if the depression is not excessive. The reason is that in case of excessively depressed condition, memories can remind the patient about the happy life he or she used to have, but leave emptiness and dissatisfaction because of the disease. Therefore, such conversations should be conducted in an optimistic and constructive manner so as to promote expansion of consciousness and support of the patient. Furthermore, parents and their child are recommended to find common interests if interaction is complicated (Tommet, 2003). For example, the parents are recommended to get involved in their child’s reading interests, music, movies’ or other preferences. Such engagement will both demonstrate dedication of close people, their willingness to share their interests and discuss neutral topics promoting communication, what permits them to form trust and affection to each other, which the currently discussed patient and her parents evidently lack.

Once the nurse discovers the previous experience, major challenges and overall comprehension of the notion of health, it is recommended to develop a strategy of re-patterning. To be more precise, it is necessary to adjust the currently existing patterns of the patient in her routine activity and treatment course as well as form new, more relevant habits. SCD requires constant cooperation of the patient with the healthcare personnel in the process of treatment. Therefore, several strategies targeted on re-patterning should be developed and implemented.

The ultimate task of the re-patterning is to expand patient’s consciousness to a degree that the patient can adjust her habits, behavior and choices according to the demands of the disease. This is a main achievement of nurse’s assistance, according to the Newman’s theory of health. To be more precise, the patient should be educated to comprehend the importance of such fundamental shift in the consciousness, and afterwards it is necessary to control, support and improve the patient’s efforts to contribute to a healthy lifestyle, proper treatment and expansion of the notion of health under the given diagnosis.

One of the strategies requires acquisition of proper perception of the given diagnosis and its actual impact on daily life, capabilities of the patient and perspectives for the future. It is the most challenging part of expansion of consciousness, since it requires change in the understanding of the notion of health by a person with a diagnosis. First, it is recommended to share the knowledge about SCD, its peculiarities and possibilities to improve the current condition. Positive examples are a proper choice of words, since they trigger motivation to act in the patients. As Schlotzhauer and Farnham (1997) underline, constructive and properly applied knowledge give a patient a potential to be healthier in comparison with other patients with the same diagnosis and similar condition.

In order to demonstrate the potential of knowledge and change in terms of improvement of SCD condition, it is recommended to develop a healthcare plan. It should be developed individually and be a result of interaction between the patient and the nurse. This plan should rely on the patient’s health history and health appraisal to ensure that the chosen activity is relevant to the patient’s condition and aligns with the ultimate health care outcomes. The framework for healthcare plan development is Newman’s theory, and the patient’s patterns become a background. To be more precise, the pattern should encompass considerations concerning “interactions with family and friends, academic demands, community involvement, past regrets, and future goals” (Schlotzhauer & Farnham, 1997, p. 22). Each point should be elaborated thoroughly with a patient. If the patient is not ready to face the problems she has with the family and at school, it is an optimal choice to make reasonable recommendations. For instance, the family may be recommended to partake in one of the offered activities for the patients such as a seminar or an evening of reading. Since the patient used to consider reading as a major hobby, the involvement of the family into the process can help them reunite and shift focus from the SCD hardship to the activity that is more positive. The health plan can include visits of parents and friends, their mutual activities and time for individual conversations with the nurse. Parents will need individual consultations as well as further guidance, since the patient needs a constructive relationship and significant support from them, and they apparently lack capacity, comprehension and necessary knowledge.

The next strategy involves changes in attitude to the treatment course, contribution to its efficiency and relevant lifestyle changes. For instance, U.S Department of Health and Human Services (2014) underlines the significance of timely immunization practices and regular involvement of preventive measures, which aim to eliminate the risk of development of other acute conditions. Therefore, the patient should be motivated to contribute to the course of treatment. A proper and potentially constructive motivation is considered a qualitatively enhanced notion of health that has been acquired through preliminary insights into the patient’s understanding of health. This notion involves the following core aspects. First, the patients was free from sickle cell disease recently, she was free of pain that accompanies the given stage of SCD, she was able to attend school without being sick and missing studies for a long time. Furthermore, the patient was capable to partake in all the activities the peers attend to, and was able to see the future without acute SCD hazard. At this point, assistance and positive influence of the teachers and classmates may be required. It is recommended to start with minimum attention and support, since an excessive involvement of people can have a destructive effect on the patient in such an unstable and vulnerable stage of SCD crisis development. Hence, phone calls are recommended with consequent visits of the patient’s close friends. Teachers and especially students should also be informed about the hardship of the patient’s condition and provide necessity of support and understanding.

The attitude to the course of treatment is important, but effective interventions are crucial and predetermine not only the wellbeing of the patient, but also potential hazard to her life. Therefore, the patient and her parents have to be aware of the risks, challenges and hazards they can face when the patient returns home after efficient crisis treatment. Hereby, the patient should be provided with all the necessary information and be motivated to employ it to benefit health improvement. For example, therapy aimed at increasing hemoglobin is a sufficient step after crisis, but its further maintenance is a responsibility of the patient and her parents when she returns home (Maakaron, 2016).

Furthermore, lifestyle changes are required, and acquisition of new habits and proper adherence to the rules will be a proof of efficiency of the patient’s consciousness expansion. The patient is required to follow the rules willingly and upon personal determination, including 1) high level of the fluid intake, namely, approximately 10 glasses of water per day (CDC, n. d.a); 2) timely and intensive treatment of pain with prescribed medicine; 3) regular visits of the doctor and attendance of the clinic in case of acute conditions or unconventional developments; 4) transfusions conduct when required (Sloan, 2012). It is also important to adhere to the prescriptions and recommendations of the healthcare personnel, since no self-treatment is permitted. The patient is encouraged to discuss preferences and express complaints in the process of treatment, but efficiency of the disease management depends to a certain extent on patient’s proper adherence to the prescriptions (Hankins, et al., 2007).

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Carson-DeWitt (n.d.) highlights that the patient with expanded consciousness under such diagnosis should also maintain a specific balanced diet and balance physical activity. CDC (n. d.b) emphasizes that physical activity is required for patients with SCD, but once a person is tired, rest, sufficient nutrition and water are compulsory. Simon (2013) focuses on the vital importance of warmth and sufficient rest the patient needs constantly. Furthermore, neither emotional, nor physical stress is allowed (Food and Drug Administration, 2014). Finally, a mentor or a person that has significant awareness and constructive vision of SCD treatment may be of ultimate importance, since patients can be discreet with the doctors. A nurse or another person with SCD with positive dynamics can be able to help.

Conclusion

Thus, sickle cell disease is a serious and hazardous condition that endangers patient’s life, health and social status. The case of the patient diagnosed with SCD illustrated the depth of the destruction this disease imposes on an individual as well as challenges the nursing personnel face, especially in the period of the acute condition and after it. The Newman’s theory of health was employed as a framework for expansion of the patient’s consciousness in order to facilitate effective treatment. Depression, refusal to attend school and communicate with family members, school teachers and classmates, doctors and nurses were the major disturbing factors that were taken into consideration when the preparatory measures and healthcare plan development was developed under the guidance of the nurse. Implementation of the Newman’s theory of health in the given case resulted in constructive interventions purported to improve the relationship between the patient and the family; to provide support and understanding for the patient from both teachers and classmates; and to expand the consciousness to the level where health and elimination of risks is a patient’s direct responsibility.

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