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by Heather Wolfe – Number of replies: 0 Margaret Newman is a unitarian theorist known for her “Theory of Health as Expanding Consciousness”. Her work was influenced by the works of many other theorists including Martha Rogers, Itzhak Bentov, Arthur Young and David Bohm (Petiprin, 2016). Her theory “invites nurses to focus on being fully present to the meaning and patterns in patients’ lives” (Smith, 2020, p. 271). “In this model, nursing is “caring in the human health experience.” It is seen as a partnership between the nurse and patient, with both growing in the “sense of higher levels of consciousness” (Petiprin, 2016). It will be shown that both the Triple Aim and Quadruple Aim can be examined through the lens of Newman’s theory. They all share similar concepts at their core and draw upon nurses (but also all healthcare professionals) to have an awareness that health and health outcomes are interconnected with addressing vulnerable populations, patient experiences, patient environments, a patient’s awareness of self and determinants of health. All three express the need to view patients as a whole and “reaching new heights of connectiveness with other people and the world (Smith, 2020, p. 271). The Triple Aim article depicts how the IHI feels “improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick et al., 2018). Doctor Rishi Manchanda took these ideas a step farther and expanded upon them by developing the “Quadruple Aim” which includes outcomes, costs, patient experience but also adds in the provider’s experience or job satisfaction (Manchanda, 2016). Manchanda focused a great deal on what he called “moving upstream” and addressing social determinants of health, placing value of care over volume, and improving civil society by examining and helping address the populations that are facing isolation (Manchanda, 2016). He pointed out that isolation can be caused by many factors which include but are not limited to; racial, economic, cultural, social, and political disparities (Manchanda, 2016). Both the Triple Aimand Quadruple Aim echo the core concern of Newman’s theory, that is, “concern for those whom the absence of disease or disability is not possible” (Petiprin, 2016). In order words, they all discuss the crucial need to recognize vulnerable populations and our role as healthcare professionals to view these patients entirely, taking into consideration all the issues that surround their health status. Only by doing so, can we achieve the goals set in the Triple and Quadruple Aim. Manchanda made a powerful statement in his presentation in which he said we need to “step outside of our walls” (Manchanda, 2016). Newman too stated this in another way by saying we have “the need to step inside to view the whole from within” (Smith, 2020, p. 284). In other words, we must look beyond a patient’s illness or level of health and dive into how they got there and what makes them who they are. All three of these look deeply into patterns of patient as well, as a key tool to develop initiatives that will invoke change in the future of healthcare. Newman gave clear definitions to the four nursing metaparadigms while some of the components are defined more broadly. Nursing (1) is seen as a partnership between the nurse and the patient. Nursing care “within a unitary perspective unveils meaning and opens the possibility for a new way of living for people with chronic conditions” (Smith, 2020, p. 276). “Concepts important to nursing practice grounded in the theory of HEC include expanding consciousness, time, presence, resonance with the whole, pattern, meaning, insights as choice points, and the mutuality of the nurse-patient relationship” (Smith, 2020, p. 276). Newman defines health (2) as “an expansion of the consciousness” and it “encompasses conditions heretofore described as illness, or, in medical terms, pathology” (Petiprin, 2016). “The theory asserts that every person in every 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 in life, and of reaching new dimensions of connectedness with other people and the world” (Petiprin, 2016). Newman defines person (3), in this case, humans, as unitary systems and are understood by observation of pattern recognition. “Humans are open to the whole energy system of the universe and constantly interacting with the energy” (Petiprin, 2016). This rolls into how Newman define the environment. Environment (4) was the least defined paradigm, much more vague than other components. She defined environment as a “universe of open systems” (Smith, 2020) and “addresses the interrelatedness of time, space, and movement. Time and space are the temporal pattern of the patient and have a complementary relationship. People are constantly changing through time and space, which is movement, which shows a unique pattern of reality” (Petiprin, 2016). By looking at the ways Newman viewed patients and their environments, it is evident her theory can be applied to the Triple and Quadruple Aim because are three believe a patient’s environment directly impacts their access to health necessities. They all call on nurses and healthcare professionals to treat patients as a whole being, understanding where they live, what they do or do not have access to, and, how their societal determinants and personal needs impact their health outcomes on an individualized level. Manchanda expressed that there exists a huge opportunity to change from “healthcare providers to civil providers” and specifically looked at what he called upstream medicine which looked to improve health systems, population driven medicine and social determinants of health (Manchanda,2016). This greatly expands upon what the IHI laid out in the Triple Aim and echoes the core sentiments of Newman’s theory. It can be said after studying the Triple Aim, Quadruple Aim and Newman’s theory that there is a call to nurses to look far beyond just a patient’s illness. All three are asking nurses to take a patient’s totality into consideration. All three concretely believe a person is comprised of many components and their environment directly impacts their life and overall health. As advanced practice nurses it is crucial to not only understand the community in which we are serving, but furthermore, be an active participant in creating change for those populations through the care we provide. Newman believed “the disruption brought about by the presence of disease, illness and traumatic or stressful events represents a time when patients most need an HEC nursing partnership” (Smith, 2020, p. 281). Manchanda echoed that strongly. He felt we all have a duty to increase upstream awareness and understanding vulnerable populations, he felt, was key to that. Manchanda made many powerful statements in his presentation but one addressed vulnerable populations very clearly. He discussed a particular patient who was homeless, had diabetes, was admitted for a near diabetic coma and he discussed the various levels of failures in his care (Manchanda, 2016). He explained that social and civil disparities exist for vulnerable populations, and it is important as providers to ask about, fully assess and address such areas as education, housing, food security and transportation with every patient. According to his presentation, it was stated that “social factors account for 60 % of premature death and impact the quadruple aim. Only 1 out of 5 MDs have the confidence to address them” (Manchanda, 2016). This is alarming especially as a soon to be FNP. It is our duty as providers to understand what our patient is going through, where they live, what they do and do not have access to and realize that all have grave impact on their health outcomes. If we do not address the issues in their environment, we can never help them reach a high level of health. In fact, these disparities can be causing their health issues. Manchanda discussed many different initiatives such as the “Special Homeless Initiative” which since being implemented helped reduce hospital costs by 93% and reduced health care costs annually by 18 million dollars (Manchanda, 2016). Addressing housing as an intervention helped the patient, he discussed who could not administer his insulin because he had no place to store it, since he was homeless, which was just one issue impacting his overall health. Also discussed was the notion that we must “look outside our walls”, which is a sentiment echoed in Newman’s theory. It was stated in the presentation that libraries for example are becoming “hubs for health” and “out of 6 million visitors, 500,000 of them attended specialized programs for multiple health determinants such as housing and literacy” (Manchanda, 2016). It puts into perspective that healthcare settings are not the only “hubs” for health. Places like hospitals for example do not have the ability to be the end all be all when it comes to addressing community health issues. Therefore, it is the duty of APRNs to know this, be willing to examine our current shortcomings and pledge to make a difference in the communities we serve. Newman felt “as nurses come to understand the meaning of patterns in the lives of individuals, families, and communities, they gain insights that inform population level dialogue for health policy transformation” (Smith, 2020, p. 289). This is exactly what the Triple and Quadruple Aim is asking us to do. By applying Newman’s theory, we could achieve the goals outlined in the Aims. In summation, Newman’s theory “calls on nurses to focus on that which is meaningful in their practice and in the lives of their patients. It attends to the evolving pattern of interactions with the environment for individuals, families, and communities. It is a theory that is relevant across practice settings and cultures” (Smith, 2020, p. 289). It can be said that Newman’s theory, the Triple Aim and Quadruple Aim all share similar beliefs and heavily focus on the need to identify and help vulnerable populations to better our healthcare system. The Triple Aim was the start, laying out the need to better outcomes, lower costs and improve patient experiences. The Quadruple Aim took things further and added in provider experience (job satisfaction) as well but clearly and eloquently defined the need to help those patients in vulnerable populations. By doing so, we can see a direct positive correlation between improved patient outcomes, decreased cost and increased job satisfaction for providers as well. It is evident to see that all three of these topics outline a need for practitioners to place value on the quality of our care versus the volume of care, the need to identify societal isolation factors, a willingness to address those disparities and meaningful patient-nurse relationship founded on trust and understanding all the components that make a patient who they are.
