A Patient with Cancer and Her Family in Caring Partnership Based on Margaret Newman's Theory of Health as Expanding Consciousness.

The purpose, on the basis of Margaret Newman's theory of health as expanding consciousness in a unitary perspective, was to practice the caring partnership with a client who could not share their desires and find their future direction at a gear change period and document the process of their relational changes within this process. The design was research as praxis. The participant was a patient with cancer and her family in the midst of a difficult health situation. Through caring partnership, a nurse researcher asked to tell "the meaningful events and relationships in their lives" over four in-depth dialogue meetings. Data were collected from the tape-recorded dialogue transcriptions. In the process of caring partnership, the patient and each family member recognized their own pattern and family pattern of "being closed off," their approach to the situation, and found a new direction through this process. The finding suggested that caring partnership as a nursing intervention would be helpful for nurses as well as for patients and their families in difficult health situations.

Introduction

Patients with cancer often look as if they closed off so as not to give any worry to their family members, while family members worry about their loved one. Such situations are challenges for nurses and patients alike.[12] We propose that a special nursing intervention is needed to help patients and their families connect and talk more openly. The author utilized Margaret Newman's theory-based “caring partnership” with a client in a predicament within a client–nurse relationship.[34]

The purpose of this case study was two-fold: one was to practice the caring partnership with a patient with cancer and her family who were in a situation where future direction was extremely difficult to realize after having been informed a gear change toward palliative care by a medical doctor and the other was to delineate the process of their relational changes within the caring partnership.

Case Report

Methods of the caring partnership

The design was research as praxis which synthesized research and practice. Newman's praxis protocol[4] was utilized as a nursing intervention in unitary perspective: (1) to invite a participant to “talk about meaningful relationships and events in your life,” (2) to share a diagram illustrating her life drawn by a researcher and to invite her family in sharing her story with each agreement, (3) to have follow-up meetings. Data were mined from the transcriptions of dialogue and the researcher's journals. A dialogue meeting was about 60 min and repeated 4 times. The dialogue was audiotaped with the participants' agreement, and all data were transcribed by the researcher soon after each meeting and read carefully[5].

The data were analyzed as follows: after the first meeting, the researcher selected the statements deemed most important to the participant from the transcription and wrote her memos in the 2.5 inch space of the right side of transcription. Then, the key segments in the memos were arranged in a chronological order to highlight the most significant persons and events, and the narrative relating to the significant person was transmuted into a diagram of the sequential pattern configurations. For the follow-up meetings, the family relational changes in the participants' verbal, emotional, and behavioral expressions were traced in the transcriptions, and the key segments were organized chronologically and added in following the diagram of the first meeting. All data were interpreted from the standpoint of Newman's theory.

Ethical Considerations

Ethics Committee approvals were obtained from the related university and hospital. The purpose, method, and participants' rights were explained to the prospective participants, and when they gave their informed consent, the agreements were exchanged in a written form.

Mrs. A and her family participants

A in her fifties was living with her husband, daughter, and mother-in-law. A's parents lived in the same neighborhood. When A's unusual body condition became a concern, A visited a hospital alone. The diagnosis was an advanced cancer (Stage IV). She was hospitalized without informing her family and colleagues at work. Unfortunately, treatments did not work at all. She was in a difficult predicament and avoided relating with other people including nurses. A imparted only vague information to her family when questioned about her health or what she was doing. A's husband did not know how to communicate with his wife. Their daughter chose to ignore the situation by pretending as if she had no worries. Her parents were searching for what they could do for her. Her mother-in-law, although aware of the difficult situation, did not want to express her sympathy to her daughter-in-law.

The process of caring partnership with Mrs. A and her family

As a nurse researcher, I sensed A's pattern of “being closed off” and wanted to help her by any means. I visited her hiding behind a curtain. Unexpectedly, she welcomed me so that I sensed that she was looking for someone with whom to talk. I said honestly, “I want to enter into partnership with you because I want to help you.” She was so glad for my offer.

The first meeting: Evolution of Mrs. A's life pattern of self-isolation and closed off

I asked A, “Tell me about your meaningful relationships and events in your life.” After some pause, she started to tell her story, and I actively listened. A's life pattern came forth in her narrative when she said: “I thought I had to take care of my younger brother as my responsibility,” “I gave up entering into a college to avoid giving my parents a monetary burden,” “I tried my best not to bother other people,” “I planned my way and chose what I wanted by myself without receiving any advice,” “I do not want to give worries to my family about my cancer; but I do not know how I should be not to bother them.” After this meeting, I told A how much I appreciated the opportunity to talk with her about her life.

The second meeting in which a transformation occurred: Mrs. A's realization of need to “RELY ON OTHERS,” and her husband's and father's deeper understanding about the family's pattern

A's husband and her father joined in the second meeting. We shared A's life pattern illustrating the sequential configurations of relationships and events [Figure 1]. I asked, “Do you have any idea about your life pattern?” Following my question, A's pattern recognition occurred! A said, “Oh! I surely realized my life pattern. My belief was not to bother others. So, I have hidden my true self. I was not open and honest. I was struggling how to keep my rules and to manage my life. I know now I should be more open with my family and others.” Her husband said, “I did not know your thoughts at all, though I knew you never wanted to bother others. We need to be more open.” Her father said, “I may have forced you to do hard tasks. That was our fault. We need to be more open.”

Figure 1

Diagram of Mrs. A's life pattern of one-way flow. (Flow of Relationship: unidirectional, mutual, conflict, unclear)

The third meeting: Realization of the family's pattern and evolution of the new way of living

In addition to A's husband and her father, their daughter, who had already been informed of her mother's cancer, joined in. I did feedback the contents of 1st and 2nd meetings for them. The daughter said, “It was so good to talk together. My mother and father changed. It is awesome!” A said, “Thank you, my daughter! I am glad to know you are growing up. I will try to be more open. I have changed. I want to go back to our home with all.” Her husband said, “We could understand each other. We should be more honest.” Her father said, “My daughter changed and I did too. This opportunity was so valuable for all of my family.”

The final meeting: The family's realization of growth through cancer experience

A said, “My mother-in-law came here alone and gave me a massage in her tear. Her words, 'You are my daughter' was so touching to me.” I gave a feedback of the process of all meetings to the family [Figure 2]. A said, “We could finally build a good relationship. We are now a new family. I may not be able to live so long, but I feel better than ever.” All members agreed that the family, including the mother-in-law, changed and grew through this cancer experience. Caring expressions were expressed from each, and I felt my own expansion as a professional nurse. We terminated our caring partnership at this point.

Figure 2

A diagram of evolving process of Mrs. A's life pattern. (Flow of Relationship: unidirectional, mutual, conflict, unclear)

Discussion

Caring for patients and their families at the period of gear change and/or end of life is truly a challenge to nurses.[26] Newman's caring partnership as the nursing intervention presented here could provide a potential for connections between clients and nurses and at the same time patients and their families. The key is clients' pattern recognition. For this, two critical things are discussed here.

One is nurses' ability to recognize clients' pattern. When nurses sense clients' need to be helped, nurses are required to express actively, “I want to help you,” and to be present with clients as a rich environment, trusting their power within. The other is to utilize clients' life pattern diagrams which reflect the meaning of their lives. “Pattern recognition comes from within the observer,”[3] therefore, nurses' help is needed for clients' pattern recognition. Nurses could use the diagram as a tool in partnership process. The diagram is easy to draw when nurses focus on clients' relational patterns as a whole.

The finding in this case study was that a family that was “closed off” could benefit from the caring partnership by getting insight into the meaning of the pattern. Any family member's pattern overlaid with others and consciousness expanded through the whole family.[7] It was suggested that Newman's theory-based nursing intervention would be helpful for nurses as well as for clients in a predicament.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.