“Pattern is information that depicts the whole, understanding of the meaning of all the relationships at once. Pattern recognition provides personal insight into the meaning of the pattern and reveals the potential for action.” 
What do you do, when you want to develop your nursing practice into a more unitary nursing model? We hope this short paper would provide you worth a try in terms of Margaret Newman's theory of health as expanding consciousness (HEC).
HEC emanates from pattern within a unitary nursing paradigm. Newman suggested nurses to assist clients to recognize the power that is within them to move to higher levels of consciousness. For that, clients need to recognize their own pattern. Newman convinced that an important factor in recognizing one's own pattern is the mutuality of the presence of a nurse who has been transformed by the theory with a client being served. It implies that dialog between the nurse and the client is essential because the shared vision will come about through dialog.
Then, we wondered what will happen if dialog-within -group of nurses is conducted. We assumed it would be helpful for nurses to recognize their own care pattern, get meaning into it, and move to potential for action in nursing practice. That is, a nurse tells honestly about his/her nursing practice and others actively listen to him/her, and then they have dialog-within-group. Based on HEC, we predicted that in being conscious about care pattern, each must recognize one's own care pattern, understand the meaning into it, gain insights from it, and find a potential nursing action. Therefore, we thought that the method of dialog-within-group would be helpful for practicing nurses to find how to transform one's own nursing practice toward a more unitary practice which Newman recommended. For this reason, we repeated dialog-within-group based on HEC and nursing practice. As a result, the participants' transforming processes in practice were obvious via pattern recognition.
The purpose of this paper is to present a paradigmatic case in terms of nurses' recognition of care pattern and the following changes in the process of their nursing practice.
The first two of the authors were the facilitators of the HEC and nursing practice study meeting (HEC study meeting) held every month, and the last one, Maki, was a member of this group. She was a nurse practitioner in a hospital and was working with clients with cancer by being referred from practicing nurses or physicians. Maki presented her cases at HEC study meetings, and then we had dialog several times in tracing her nursing practice. As her practice has developed into three phases, each phase would be narrated with her presentation and the facilitator's comments in order.
Phase I: Maki's nursing practice with Mrs. A and recognition of her care pattern through dialog in HEC study meeting
Maki's presentation: My client, A in her fifties, was diagnosed with cancer three years ago. Since then, she received cancer treatments repeatedly; however, it did not work anymore. Though she had her family, she was living along without any relationship with them.
I was working with her almost three years, because her doctor left her to me. She repeatedly complained of disease and often said to me, “Why I have to suffer from this cancer so long time,” “I feel miserable, so please take off this cancer.” Listening to her from my heart, I was present with her and expressed my empathy repeatedly. She appreciated with my presence, and said, “I have not trusted others, so my relationship with others is not deep.” I was startled with her confess, but I did not respond anything to her. What I always did was to concentrate on being present with her with caring.
Comments: The reason why Maki presented this case at the HEC study meeting was that she thought her care to A was fit with nursing practice based on HEC in terms of caring. The participants were actively listening to her, however, the dialog among us moved toward the opposite direction to her thinking. One participant said that nursing practice should make differences in clients, and asked her if any difference appeared in A with Maki's presence. The other pointed out that cancer is a manifestation of a person's life pattern, but Maki did not try to tell anything about how to look at cancer in terms of her life pattern. Maki was advised to describe retrospectively the scenes of her nursing care with A in detail and to search for her care pattern.
Maki's reflection: On the contrary to my expectation, someone commented, “A and myself were just running on a mill which had no place to go.” I have shocked with it, because I thought I was doing good care for her based on HEC. After recovering from the shock, I tried to write my care for her retrospectively as much as in details, and traced back the relationship between A and myself. It was not enjoyable work, but I endured to finish it. Then, what I recognized in my care pattern was a constant evolution of “my fear to hurt her feelings.” I realized that I just expressed my empathy repeatedly without making any in-depth remark or action. That is, I was always present with her with my caring, but that was it and any change did not occur to both A and myself for almost three years.
Comments: Maki's care pattern was the so-called spiritual embrace of A who was suffering from cancer and feeling miserable. This kind of caring was what we have been committed for a long time in nursing. However, Newman claimed, “Caring for the patient has been uppermost in nursing's mission. But caring alone has not been enough.” She continued, “We have to embrace a new vision of health. Our caring must be linked with concept of heath that encompasses and goes beyond disease.” If Maki wants to support A's pattern recognition and finding a meaning of her life beyond her disease experience into her pattern, she needs to move toward her more meaningful presence with her.
Phase II: Maki's support in standing on the center of her truth and Mr. B's pattern recognition Maki's presentation: I was shocked with recognition of my care pattern and my spirit was down. However, in listening to other members' presentations, I realized their openness to one's own care pattern and conscious working with clients based on HEC. So, I encouraged myself and started to search.
My second patient was B in his late forties. He was a single and had little relationship with his mother and sister. The chemotherapy did not work anymore and he was complaining about pain. I had met him two months ago because of pain management. Recently, he was advised to move to a hospital with a palliative care unit, and agreed with it. However, he was keeping delaying an action. One head nurse referred him to me again.
He remembered me and said, “I want to know when I die.” I felt his strong sadness, and I was afraid of talking about his death with him. But in an instant, I remembered my old care pattern; that is, I did not make any in-depth remark or action because of my fear to hurt my clients. B became irritated gradually, but finally decided to move to the other hospital. However, on the right day of his movement, he complained of his physical condition and refused to be transferred to the other hospital. I was referred to meet him again. He said to me, “I have strong pain, so it is difficult to move to the other hospital.”
In his talk, I sensed his real need for my help but I was afraid of facing his need. However, I said to myself, “I have to support his real need. What does it mean?” Immediately I remembered Newman's claim in HEC, “…people has his own power within him.” Then, I decided to entrust myself to go with the flow with him.
I persuaded myself, “it is only me who will be able to face with him at this point.” I asked him, “I suppose you feel death is coming to you. You are afraid of dying. Transferring to the other hospital means death to you. Therefore, you want to stay at this hospital, do you? This is not B who I know. You said to me you have things to finish. I hope you will do it. You have power within yourself.”
He briefly groaned, and then he shouted loudly, “Yes, you are right!” With tears of gratitude, he said to me “Thank you,” and offered me to shake hands. We were moved to tears with handshakes.
Comments: All members applauded Maki's presentation about her experience with B. Remembering the painful support for B and appreciating his decision made by himself by using his own power, she had her tears again, and at the same time, she clearly did understand the meaning of the search for her care pattern.
Maki's caring for B was not simply spiritual caring any more but caring based on HEC. Maki stood on the center of her truth and conveyed in voice what she thought in trusting B's power within him. Maki's new care pattern pushed her practice forward to make a difference within B as a whole.
Phase III: Dialog based on HEC with Mrs. C and expanding consciousness of all environments surrounding C and Maki.
Maki's presentation: C in her sixties had a recurrence of breast cancer, and it has already spread to her bones. The pain management started at the out patients clinic, and her doctor referred her to me for supportive care.
As her husband had passed away, she was living with her son's family. Her daughter whom she relied on lived out of town. When I met C at the outpatient clinic, her pattern looked as if she were refusing any relationship and enduring many difficulties by herself.
When her doctor invited C and her daughter to the clinic to explain her condition, her daughter could not come for her work. C was alone, so her doctor avoided being too explicit. However, she looked barely standing to be there, so I was present with her. She said, “My future looks blind.” C looked full of fear and anxious. I hunched that the dialogue based on HEC must help her. I thought, “It is the time.” I proposed to talk together for a while and she agreed it. At a room, I conveyed my honest thought to her, “Your physical condition is changing now, so you may feel confused with it. I believe it is important for you to find the meaning in your experience in trusting your power within,” “I really wish to support you. Could you tell me about your meaningful relationships and events in your life?” C brightened with my request, and replied, “I appreciate your request.” We made an appointment for a meeting.
The dialog with a client based on HEC was my first experience, but I trusted that pattern recognition occurred via dialog would free C from bindings. At the meeting with C, I asked again, “Could you tell me about your meaningful relationships and events in your life?” Her first voice was, “My experience with cancer is not so important in my life. I had a very happy life. My husband was nice to me and my children have grown up nicely. Additionally, I was blessed with my good friends and fellow workers. So, I worked more than forty years.” Her story was full of the relationships with people and used frequently the words of “happy” and “blessed with good people.”
I listened to her quietly in trying to grasp her pattern. C looked in such a way that she was barely hanging on not by managing herself but by supporting others. At the end, I promised to draw a diagram of her life and to share it with C. She appreciated this opportunity to dialog with me.
At the next meeting, we shared the diagram which I draw. It showed “both-side relationships” with friends and fellow workers, but “one-way relationships,” from her to others, with her family members. At a glance, she has recognized her own pattern, “Up to now, I have thought that good relationships mean to support other people. But I realized now that being supported by others is also important to keep good relationships.” I agreed to her in saying that C needs more both-side relationships. She was so glad with this awareness and wanted to show this diagram to her family. She said, “I thought I shouldn't bother them, and I tried to devote myself to support them. Now I realized I should be willingly supported by my family.”
A few days later, her appearance exactly looked changed. She clearly said, “I talked with my family. I will not receive any cancer treatments any more. I will cherish the time with my family.” She looked so peaceful.
C's condition became severe and finally hospitalized. In becoming powerless, she was laying down on her bed hiding herself in the curtains. Considering C's real need to be surrounded by people, I asked nurses to see C as much as possible and I also tied to meet her. She was so glad to see people and willingly accepted people's supports.
Comments: C's condition declined quickly, but the relationship between she and Maki continued until C's passing. C continued to talk to her in groggy feeling, and Maki was present with her and listened to her with her hearty welcome. Maki's presentation sounded as they were following “a meaning-making-transforming-process together.” After C's passing, her daughter came to Maki and appreciated her in saying, “You kindly kept pace with my mother.” It is sure that keeping pace with clients in moving toward the final transformation is the most meaningful caring with them and their families.
Maki exactly got an understanding about Newman's claim, “To be open is to be vulnerable, an important characteristic of humanness…. Vulnerability, suffering, disease, death do not diminish us. What does diminish us is trying to protect ourselves by binding ourselves off from these experiences.” We believe that C got binding off from her pattern recognition and Maki also had an expanding consciousness in her experience of dialog with C based on HEC.
Final comments: At the beginning of this paper, we asked, “What do you do, when you search for more meaningful nursing practice?” We hope Maki's presentations and our comments will be helpful to this inquiry. Maki had misunderstood about being present with nodding with a client is nursing practice based on HEC. But, she realized it was not. After studying HEC again, she realized her own care pattern in tracing her practice. With the 2nd client, she encouraged herself to stand on the center of her truth and to trust the client's power within him. She could develop her practice with the 3rd client toward more unitary nursing practice through dialog based on HEC.
Newman claimed, “The way in which nursing theory is applied is by virtue of the transformation that is taking place in the person of the nurse. The transformation constitutes the nurse's field and through the interpenetration of the nurse-client field, it becomes the client's field.” Then, she affirmed “Whatever transforms you, transforms your practice.” The evidence of this Newman's affirmation is Maki's transformation in her nursing practice.
At the end, we like to add that dialog-within-group will facilitate nurses' pattern recognition and the following transformation more quickly and surely in cancer nursing.