American Journal of Nursing Science

2015; 4(1): 6-11

Published online November 10, 2014 (http://www.sciencepublishinggroup.com/j/ajns)
doi: 10.11648/j.ajns.s.20150401.12
ISSN: 2328-5745 (Print); ISSN: 2328-5753 (Online)

Applying Margaret Newman’s theory of health as

expanding consciousness to psychosocial nursing care of
HIV infected patients in Kenya
1 1 2
Kamau Simon Macharia , Rotich Rose Jelagat , Mwembe David Juma
1
University of Kabianga, Department of Nursing Sciences, P. O. Box 5, Kapkatet, 20214 Kenya
2
Kenya Medical Training College, Kapkatet Campus, Department of Nursing Sciences, P .O. Box 35, Kapkatet, 20214, Kenya

Email address:
[email protected] (Kamau S. M.), [email protected] (Rotich R. J.), [email protected] (Mwembe D. J.)

To cite this article:

Kamau Simon Macharia, Rotich Rose Jelagat, Mwembe David Juma. Applying Margaret Newman’s Theory of Health as Expanding
Consciousness to Psychosocial Nursing Care of HIV Infected Patients in Kenya. American Journal of Nursing Science. Special Issue: Mental
Health Care: Aspects, Challenges and Perspectives. Vol. 4, No. 1, 2015, pp. 6-11. doi: 10.11648/j.ajns.s.20150401.12

Abstract: Margaret Newman’s Theory of Health as Expanding Consciousness is considered a grand nursing theory, she described
a process of becoming more of oneself, of finding greater meaning in life, and of reaching new dimensions of connectedness with
other people and the world. Nurses in Kenya have mostly used the psychosocial-medical model to nurse HIV infected patients which
fails to answer many of the nursing concerns and reduces their autonomy in carrying out nursing care. Newman’s theory proposed
that: Health is not lack of illness, or a process to become healthy from being ill, but it instead the expansion of consciousness as a
result of choices made within the context of patterns of behavior. Methodology: This mini review was an evolving emergent design.
Slightly adapted ‘Advanced Theory in Nursing’ coursework materials were used. The greatest resource were referrals to links and
hints as offered by those who got interested in the study. A best case scenario is appended. Conclusion: Newman’s Theory of Health
as Expanding Consciousness is therefore a generic tool applicable to guide psychosocial nursing care of clients infected with HIV. It
would be a great resource with a potential to evidence based nursing care. It would provide a basis for several case studies. Nurses
find more fulfilment in their work by utilizing a nursing theory.

Keywords: HIV, AIDS, Margaret Newman, Health as Expanding Consciousness, Psychosocial, Walter Reeds Project,
Kenyan Nurses, Nursing Theory

1. Background 2. Why Theory

Anecdotal evidence shows that nurses involved in the care Everyday practice enriches theory and vice versa as both
of HIV infected patients in Kenya have mostly used the practice and theory are guided by values and beliefs. Theory
psychosocial-medical model whose primary focus is on the helps to reframe our thinking about nursing and guides use of
diagnosis and treatment of symptoms and disease. This fails ideas and techniques. Theory can close the gap between
to answer many of the nursing concerns and reduces their theory and research and envision potentialities. “The study
autonomy in carrying out nursing care. For example many and use of nursing theory in nursing practice must have roots
HIV-infected persons have high levels of depressive in the everyday practice of nurses” [2]. It guides nursing
symptomatology, as well as suicidal ideation and practice and generates knowledge, it helps to describe or
hopelessness being increasingly reported, usually upon explain nursing, it enables nurses to know WHY they are
knowing their seropositive status or precipitated by doing WHAT they are doing [3] and enhance evidence based
progression of the illness [1]. How would the nurse best nursing. Another example might be why health-supporting
handle these concerns? A Theory (or a combination of activities inside the hospital can be carried on outside the
theories) might come as a handy relief. hospital [4].What evidence, best practices (including theories)
are there that would support this?
“Practicing nurses who despise theory are condemned to
 American Journal of Nursing Science 2015; 4(1): 6-11 7

performing a series of tasks - either at the command of a 4. Assumptions

physician or in response to routines and policies”, an
Newman held the view that Health as an Expansion of
observation made by Leah Curtin, a former editor of Nursing
Consciousness (HEC) is based on five assumptions [9]:
Management [5]. Newman on the other hand showed the
necessity of linking practice with theory by saying, “We have 1. Health encompasses conditions previously viewed as
to embrace a new vision of health. Our caring must be linked pathology,
with a concept of health that encompasses and goes beyond 2. “pathology” can be a manifestation of the total pattern,
disease”. The theory of health as an expanding consciousness 3. Pathology may exist as a manifestation of a pattern that
provides this link. exists prior to the manifestation of physical or structural
changes (manifesting as pathology),
As we introduce this theory it’s good to recognize that
Patient-as-person involves an appreciation for the patient’s 4. Removal of the pathology does not change the
pathology, and
self-perception and expression of an illness and the
recognition that the patient’s illness is a unique experience, 5. “Illness” maybe be the only way an individual’s pattern
one that is influenced by the patient’s attitudes, knowledge, can manifest, and as such that is health for that individual We
and current personal or social context [6]. Two patients can wanted to add a sixth assumption that, ‘The tension in illness
have varied responses to the same illness or chronic can allow patterns of expanding consciousness to emerge’.
condition due to their personality, different life experiences
and circumstances. These are some of the reasons why 5. Concepts
nurses need to use a nursing theory in patient care.
Some of the concepts of this theory are;
According to Polit referred to in [7], ‘Theory is the
ultimate aim of science: It transcends the specifics of a ‘The theory of health as expanding consciousness (HEC)
particular time, place, and group and aims to identify was stimulated by concern for those for whom health as
regularities in the relationships…’ A statement by College of the absence of disease or disability is not possible’. Nurses
Nursing of University of Colorado Denver, Guidelines for often relate to such people: people facing the uncertainty,
Evaluating Published Research Reports (NURS 6031) debilitation, loss and eventual death associated with
Themes or Rules-Of-Thumb, item number 11 states that: chronic illness’.
‘Other things being equal, research related to theories is more
important than non-theoretical research’. The theory has progressed to include the health of all
persons regardless of the presence or absence of disease --
asserts that every person in every situation, no matter how
3. Theory of Health as disordered and hopeless it may seem, is part of the universal
Expanding Consciousness process of expanding consciousness – a process of becoming
more of oneself, of finding greater meaning in life, and of
Margaret Newman’s Theory of Health as Expanding reaching new dimensions of connectedness with other people
Consciousness (HEC) posits that “every person in every and the world [10].
situation, no matter how disordered and hopeless it may seem, is
part of the universal process of expanding consciousness – a
process of becoming more of oneself, of finding greater meaning 6. Propositions
in life, and of reaching new dimensions of connectedness with
other people and the world” [8]. The theory proposed that: Health is not lack of illness, or a
process to become healthy from being ill, but it instead is the
Newman wanted to move from the reductionist model of expansion of consciousness as a result of choices made
‘health is the absence of disease’, and develop a model that within the context of patterns of behavior. Although this
would articulate the essence of nursing practice. Health theory can be abstract and challenging to grasp, one of the
within illness dichotomy may not be a readily accepted main strengths of this model is that it addresses the patient
concept. This theory considers illness as an opportunity for and their choices, experiences and state of health (and un-
awareness and growth. 1t also shifts the focus of health care health) as a whole [11].
from fighting the enemy of illness to learning about oneself
through the illness experience.
The concept of consciousness as defined by Newman is
7. Application to Practice
the informational capacity of the system (in this case, the
Kenya has been battling with HIV/AIDS since it was recorded
human being); that is, the ability of the system to interact
in 1984, HIV infection has spread very rapidly in the country
with the environment. Consciousness includes not only the
and the magnitude and impact of HIV/AIDS is a major public
cognitive and affective awareness that is normally associated
health and development challenge. To date it is estimated that
with consciousness, but also the inter-connectedness of the
more than 2.2 million Kenyans are infected with HIV and that
entire living system that includes physiochemical
over 1.5 million Kenyans have died of AIDS and AIDS related
maintenance and growth processes as well as the immune
illnesses. In Kenya the HIV infection rates are at 5.4% with
system [8].
some counties like Homa Bay
8 Kamau Simon Macharia et al.: Applying Margaret Newman’s Theory of Health as Expanding Consciousness to Psychosocial Nursing
Care of HIV Infected Patients in Kenya

recording as high as 14% of their population as having the realized new strengths unknown to them before the diagnosis
virus [12]. Estimates show that the undiagnosed figures with terminal illnesses, one Asumpta Wagura has achieved
could be higher. exponential feats [15]. Her motto goes like ‘Do not take life
A diagnosis of HIVAIDS can be devastating to persons and for granted. Celebrate it’. She has been a beacon of hope for
their families as they face a multitude of physical, emotional, people living with HIV/AIDS (PLWHA). She is the
spiritual and social stresses from the effects of treatment, Executive Director of Kenya network of women with AIDS
changes in lifestyle, disruption of home and family roles, and (KENWA). Many people look forward to her diary in
fears of stigma. People infected with HIV are challenged by Wednesday’s edition of Daily Nation, Kenya’s leading
changes in their endurance and strength, reproductive newspaper.
capacity, sexuality and self-image, as well as their own Time is a treasure for the HIV infected persons, they can
mortality. make a choice on how best to use it to gain maximum returns
For the newly diagnosed HIV positive client just as in terms of their future and that of their children by making
Newman referenced in [13] they learn that “each day is realistic goals based on the life expectancy. Increased insight
precious and that the time of one’s life is contained in the into the meaning of their experience and the meaning of
present.” Stigma has to be fought and that simply having a health can be realized when the client and the carer(s)
disease does not make a person unhealthy. One could connect in their new roles in health during counselling and
experience health and wholeness in the midst of having a social support.
chronic and progressive disease, before and even after CD4+ The theory applies to the nursing today because of the
T cells levels prognostic indicators signify need to initiate increasing emphasis on continued care outside of the hospital.
ARTs and opportunistic infections (OI’s) medications. Whereas health-supporting activities inside the hospital can be
We tended to relate this with Martha Rogers (Newman carried on outside the hospital, a lot of social support and
stated that Roger's theory of Unitary Human Beings was the empowerment is needed. Home-based care has been shown to
main basis of the development of her theory) who had said reduce the workload of the health care providers and lowers
earlier that health and illness may not be two separate the economic burden of rural/local health care centres to care
realities, but rather as a unitary process. Rogers’ Science of for HIV/AIDS patients [4]. But home-based care as taught in
Unitary Human Beings puts the key thesis of the model as: nursing curriculum is a new concept in Kenya although it has
The individual is a unified whole in constant interaction with always been practiced in the African traditional cultures. The
the environment; nursing helps individuals achieve patient needs to be psychologically prepared for the recovery
maximum well-being within their potential… in that people at home and to accept this as part of his/her medical/nursing
can experience health even when they are physically or history now. Helping them understand that this is not
mentally ill. temporary but will be the norm will help them get the
Nursing must find ways to care creatively for patients. available resources they need to function. While home nursing
Holistically to encompass the whole person, not just a body does not seem readily appealing to the nurses in Kenya, it
part or system. We need to emphasize this at every would in a big way ‘…bring out the significant caring manner
opportunity and during their appointments to the witnessed by the power of nursing presence in the patient’s
Comprehensive Care Centers (CCC). Indeed health is not the usual surroundings’ as was proposed by Newman.
opposite of illness, but rather health and illness are both The patient needs to acknowledge the issue before anything
manifestations of a greater whole. One can be very healthy in can be done about it. Acknowledging and accepting it will
the midst of a terminal illness as long as they maintain a lead to this new wonderful consciousness (expanding
healthy mind-set, positive self-image, eat well, involve in consciousness) where help can enter the patient's life. In this
social support, avoid reinfection and adhere to treatment new consciousness, the nurse needs to involve the patient in
among others. We have a saying here in Kenya that, ‘One is the nursing care plan. Define what their goals are, whether
either infected or affected by HIV’. At least every Kenyan they are new or still the same goals, and how to get there.
knows someone who has it. In some regions of this country Newman talked about making deliberative observations
people know entire households that have been wiped by the
about patients and reflecting what she observed back to the
virus. Not long ago it was not possible for people to own up
patient. This specific attention stimulates patients to respond
in public disclosures about their seropositive status. We now
by talking about what was meaningful in their unique
have people living with HIV (PLWHA) for over 25 years and
are apparently healthy. Discordant couples are still a big circumstances and their subtle needs. From our
dilemma for us even as we endeavor to move towards experience(s) and as seen in the case study below, HIV
elimination of mother to child transmission of HIV (eMTCT) infected persons really appreciate this: they wish to connect
in sub-Saharan Africa by December, 2015[14]. with self, interpersonal and the community in a holistic sense
to achieve a greater sense of health. The point is; if you can
An important realization by Newman was that (orientation
to- emphasis mine) time, movement, and space were in some get a patient to identify their goals and then give them tools
way interrelated as parameters of health. Every remaining to achieve those goals, that patient can continue to help
faculty must be appreciated especially during the times of him/herself and "transcend" their current state, adds
diminishing health or terminal stages. Some people have Newman. The meaning of the new seropositive status and
illness will
 American Journal of Nursing Science 2015; 4(1): 6-11 9

need to be understood within the context of the patient’s The nurse at the Comprehensive Care Centre utilized the
entire life, not just his/her physical state (whether ill or just components of Margaret Newman’s Theory of Health as
HIV positive). This way a path towards health becomes Expanding Consciousness to assist Mrs. Y. in pattern
apparent to the patient. The eventuality (about full blown recognition so she may understand new possibilities for
AIDS) can be postponed but it will catch up with time. The action; that in illness, there is room for health. Expanding
patient will be prepared in advance on what to expect as consciousness around her illness helped her see that within
CD4+ T cells counts start going down significantly and AIDS the confines of her disease, she could enjoy aspects of health.
sets in ‘… and if becoming “ill” is the only way a person’s Illness was not something that “happened to her”, but was a
pattern can be manifested, then be it! That is health for the part of her life’s pattern.
person’ adds Newman. This process of focusing on meaning Nurses have had wider role since they are with the patient
in patients’ lives to understand where the current health every other time which enabled them to win the couples’ trust
predicament fits in the whole of people’s lives has endured as and confidence leading to a therapeutic nurse-patient-
central to the Theory of Health as Expanding Consciousness. relationship over the years. Weekly visits by a home-care
We felt that the following Newman’s quote, though a paradox nurse includes- assessments of her weight, blood pressure,
in light of public health, holds some truth; B12 injections and reviewing medication adherence. The
home-care nurse also identified potential for increased
“[t]he responsibility of the nurse is not to make people interaction with others and an increase in consciousness by
well, or to prevent their getting sick, but to assist people to triggering understanding of new possibilities for action. To
recognize the power that is within them to move to higher recognize past patterns of relating and how present
levels of consciousness” [12]. circumstances have changed those patterns.
There is an increasing interest in personal transformation Something interesting the couple once said was ‘…the best
during illness. Case studies from clinical practice illustrate medication for patient with human immunodeficiency
the potential contribution of 'shared consciousness' or..... For virus/acquired immune deficiency syndrome is acceptance of
Newman, disease is a meaningful reflection of the whole and the status’. They added nutrition and adherence to
health is 'expanding consciousness' in assisting people to use antiretroviral medication regimens as very important. They
the power within them. The two (illness and health) are thus recognized psychosocial support as a means of coping among
seen as a continuum. those with HIV/AIDS, Mrs Y. belongs to a peer group, she
says ‘…it has proved to be thoroughly effective’. Previously
she had also felt that she did not want to ‘feel like a burden’
8. Case Study Mrs Y. to anyone. However she adds that most of her long-time
friends have since passed away, she says these were mainly
Utilizing Margaret Newman's theory through a case of a
those with very little social exchange.
family experience of HIV/AIDS in Kenya “This is a case of
Mrs.Y, a 32-year-old female, a resident in the Kericho Mrs Y. represents over 2.2 million people Kenya living
County in south rift region of Kenya. She is a housewife and with HIV/AIDS (PLWHA). Kenya’s population was 40
the husband is a small scale farmer. She is married a mother million people by 2009 census. An early step for the
to eight (8) children; four boys and four girls, all alive. She discordant couple in HIV preventive counselling on
tested HIV positive in 2002 but the husband is HIV negative behavioral risk assessment was done to the couple as high
to date. She started using antiretroviral (ARV) drugs eight risk individuals.
years ago when her CD4’s were 250. The family has been Her health has taken a nose dive in the last few months.
enrolled with Walter Reed Project (an NGO Supporting She has become debilitated and sick with side effects from
HIV/AIDS patients- through, counselling, testing, medication ART therapy. She is unable to work, play with her children or
and food Supplements for free. The project is a partner with keep up the chores around their home. Were it not for the
PEPFAR- Presidential Emergency Plan for AIDS Relief). help they get from the Walter Reeds all their financial
resources were but exhausted, they were running low on all
The rest of the children are negative apart from the last
including groceries.
born who is seven months old and now sickly. All the 8
children were born in hospital, 4 after they knew their status. She said she was able to face her death with pride and
Mrs Y. has been in and out of hospital since 2006 with dignity. She felt that she had continued to live and enjoy her
complains of chest congestion, oedema, difficulty in children as much as possible. She had provided real hope and
breathing and fatigue. Most notably her health has been encouragement to others experiencing a HIV/AIDS diagnosis.
down with every subsequent pregnancy. On the other hand, She made the following comment close to her death, “I may
Mr.Y has been undergoing a series of regular laboratory tests be dying of AIDS, but I feel healthier than I have ever felt”.
but remained HIV Negative. The couple verbalized
appreciating their support for one another despite their status 9. The Future
view life positively for the sake of their children who are
unaware of the health status of either of their parents. We saw from Margaret Newman’s various writings on
Furthermore the health care team have been helping them Theory of Health as Expanding Consciousness [10, 13, 17]
especially when they are admitted. posits that humans cannot be divided into parts, but are
10 Kamau Simon Macharia et al.: Applying Margaret Newman’s Theory of Health as Expanding Consciousness to Psychosocial Nursing
Care of HIV Infected Patients in Kenya

inextricably whole beings. Health is central to the theory importantly how accessible (even in terms of understanding)
“and is seen as a process of developing awareness of self and HEC is to you? How can it benefit your practice?
the environment”. That “Consciousness is a manifestation of
an evolving pattern of person-environment interaction” and Acknowledgment
that consciousness is an ongoing process.
We felt that the theory of Health as Expanding We are so grateful to the client’s family for allowing us to
Consciousness (HEC) helps direct nursing in supporting use their case study. The authors had hoped that Mrs. Y.
patients of today and if integrated with current social media would be alive by the time of making this presentation and
technologies like Web 2.0, will be one that will prove useful we would have appended the case study instead of making it
well into the future. For example a social platform “Patients part of the main article.
Like Me” [16] was designed to help patients encourage “S.M.K” thanks the students, presenters and discussants
others beginning the journey, find support with others who (2014, Spring Semester). Lecture notes and presentations.
were dealing with similar conditions. Taking HEC literally, NURS 6012: Advanced Theory in Nursing. University of
these technologies really can support patients in “finding Colorado Denver, USA.
greater meaning in life and of reaching new dimensions of
connectedness with other people and the world”. Nursing can
help patients navigate to such resources that will support References
them through their health experiences. Theories like Dr.
Newman’s will offer direction on how to find consistency in [1] Govender R. and Schlebusch L. Hopelessness, depression and
supporting patients in an ever changing landscape of suicidal ideation in HIV-positive persons. South African
Journal of Psychiatry 2012; 18; No 1
knowledge and care.
[2] Alligood, M. R. Nursing theorists and their work. Elsevier,
Mosby 2014: 442-463.
10. Conclusion
[3] Gordon, Parker, and Jester “Theories of nursing practice:
Margaret Newman's Theory; expanding consciousness is a Lecture notes and presentations”. Delmar Learning, a division
process wherein an individual becomes more of his/her real of Thomson Learning 2001. Retrieved on 12th March 2014.
self, as he/she finds greater meaning in his/her life and the [4] Halie B. Affordability of Home-Based Care for HIV/AIDS.
lives of those people around him/her. Self-awareness may South Africa Medical Journal 2000; 90 (7): 690-691.
eventually lead to acceptance of one's self and one's
circumstances and limitations. Newman’s theory of pattern [5] Leah Curtin. “Performance edge”. Nursing Management1989;
recognition provides the basis for the process of nurse-client Vol. 20(6). Retrieved from:
http://faculty.mercer.edu/stewart_dj/Web%20Pages/Nurse%20
interaction. She suggested that the task in intervention is a Theory%20Module.ppt
pattern recognition accomplished by the health professional
becoming aware of the pattern of the other person by [6] Mead, N., & Bower, P. “Patient-centeredness: A conceptual
becoming in touch with their own pattern. Humans cannot be framework and review of the empirical literature”. Social
Science and Medicine 2000; Vol. 51: 1087-1110.
divided into parts, but are inextricably whole beings. Health
is central to the theory “and is seen as a process of [7] Polit, D.F., & Beck, C.T. Nursing research: Generating and
developing awareness of self and the environment” assessing evidence for nursing practice (9th ed.), Philadelphia:
(Newman, 2010). “Consciousness is a manifestation of an Lippincott, Williams, and Wilkins 2012.
evolving pattern of person-environment interaction” [8] Newman, M. “Newman's Health as Expanding Consciousness”
(Newman, 2013).This consciousness is an ongoing process. 2013. Retrieved:
Therefore, we submit that Margaret Newman’s Theory of http://currentnursing.com/nursing_theory/Newman_Health_A
Health as Expanding Consciousness (HEC) is a generic tool s_Expanding_Conscious
that would be applicable to psychosocial nursing care of [9] Newman, M. Transforming presence. Philadelphia, PA: F. A.
clients with HIV in Kenya and elsewhere. It is therefore a Davis. 2008.
great resource. Several case studies based on this model
would be possible. Nurses would find more fulfilment in [10] Newman, M. Health as expanding consciousness. National
League of Nursing. New York 1994. Retrieved:
their work by utilizing a nursing theory. Hopefully, readers http://www.healthasexpandingconsciousness.org/home
will be directed to seek further information, some of which
are contained in the links below in order to fully appreciate [11] Lecture notes and presentations by Sage Mehew et al.,
the utility value of this approach to nursing care. A home (student presenters and discussants) to Geer Betty PhD. (2014,
page referred in [17] would be a great place to refer. Nurse Spring Semester).NURS 6012: Advanced Theory in Nursing.
University of Colorado Denver, USA.
Managers in charge of nursing units (including CCC’s) are
encouraged to consider adopting on a minimum one relevant [12] Kenya AIDs Indicator Survey- KAIS, 2014.
nursing theory/model [18, 19] as a step towards evidence
based practice. On a minimum it is not hard to think of an [13] Parker, M. & Smith, M. Nursing theories and nursing practice
(3rd ed.). F. A. Davis Company. Philadelphia 2010, p290-313.
experience where the theory could have been applied. More
 American Journal of Nursing Science 2015; 4(1): 6-11 11

[14] Born Free. Initiative to end mother-to-child transmission of [17] Home Page
HIV in Africa by December 31st, 2015. (2014). Retrieved: http://www.healthasexpandingconsciousness.org/home
http://bornfreeafrica.org/,
http://bornfreeafrica.org/BORNFREE_BLC.pdf [18] Yang, A., Xiong, D., Vang, E., & Pharris, M. Hmong
American women living with diabetes. Journal of Nursing
[15] Living with purpose | wamakeri Scholarship. 2009; 41, 139–148.
https://wamakeri.wordpress.com/tag/living-with- purpose/
Assumpta Wagura's Diary, Wednesday Daily Nation. [19] Papathanasiou I., Kourkouta L., Sklavou M. Holistic Nursing
Care: Theories and Perspectives. American Journal of Nursing
[16] Patients Like Me: http://www.patientslikeme.com/ Science 2013; 2(1): 1-5.

View publication stats