Secondary Logo

Journal Logo

Original articles

The Omnipresence of Cancer

Two Perspectives

Zumstein-Shaha, Maya PhD, RN; Lynn Cox, Carol PhD, RN, FHEA; Fawcett, Jacqueline PhD, ScD (Hon), RN, FAAN, ANEF

Author Information
doi: 10.1097/ANS.0000000000000314
  • Free

Abstract

A PROFESSIONAL DISCIPLINE, such as nursology, is recognized by its knowledge development through empirical research and other methods of inquiry and its application of that knowledge to innovative practical activities.1 One method involves the exploration of diverse perspectives of research findings for theory development.2 The purposes of this article are to discuss 2 perspectives of a phenomenon called “the omnipresence of cancer” and thereby to offer the basis for the evolution into a nursology theory of praxis for persons diagnosed with cancer. This endeavor also addresses the possibility of determining the scope of the theory of the omnipresence of cancer as mid-range theories in nursology need to be derived from a grand theory.2

The first perspective, Heidegger's3 philosophical ontology of dasein, reveals a view of human beings as “being there” or “present” and have a connectedness with others (“the they”). Dasein is frequently discerned as meaning existence, which is a fundamental concept in existential philosophy; it is a form of existence that incorporates being aware of one's personhood and mortality within a paradox of living in relationship with other human beings while being entirely alone within oneself. Heidegger's philosophical ontology predominantly focuses on individuals and their daily life. The second perspective, Newman's4,5 theory of health as expanding consciousness (HEC), focuses on how a life-limiting and/or chronic disease, such as cancer, may lead to personal growth, that is, expanding consciousness, due to confrontation with life's transitory nature.4,5 In addition, Newman's theory addresses the nurses' role in the support and care of persons at critical junctures in life, such as those that may occur during chronic or life-limiting diseases. By using Newman's theory, the nursology perspective of the theory can be highlighted and extended. Thus, Newman perspective allows for determining the contribution of the omnipresence of cancer to nursology.

Statement of Significance

What is known or assumed to be true about this topic:

The experience of living with cancer has not been formalized into nursology theories to date. In order for nurses to provide adequate and high-quality care to this patient group, theorization is necessary.

What this article adds:

In this article, the development of a nursology theory is described. The nursology theory—the omnipresence of cancer—is interpreted using 2 different perspectives. The philosophical lens was drawn from Heidegger's ontology of dasein, and the nursing perspective was drawn from Newman's grand theory “Health as expanding consciousness.” The interpretation of the theory yields insights into nursology theory development, which culminates in the theory, the omnipresence of cancer.

BACKGROUND

Worldwide, at least 18.1 million persons are diagnosed with cancer annually, and approximately 9.6 million persons have been estimated to die from cancer each year. Over 43.8 million persons are estimated to be living with cancer 5 years after diagnosis.6 These numbers are expected to rise by 70% over the forthcoming 2 decades.7 Most types of cancer have evolved from a primarily fatal disease to a chronic condition due to advances in diagnostics and treatments. The chronic nature of cancer imposes many consequences that require major life-style changes, which may give rise to rarely acknowledged or treated existential concerns.8 A cancer diagnosis remains a rupture in a person's life, affects family and work life, and highlights the transitory nature of human life. Although it is known that persons and their families have to find ways of dealing with the associated challenges as they live with the disease, substantial gaps in knowledge regarding living with cancer and finding ways to integrate the disease into one's personal and family life remain.9

Although research to date has focused on descriptions and explanations of the experiences of being diagnosed with and then living with cancer,10,11 the findings typically have not been formalized as theories. An exception is the theory of symptom management,12 which focuses on cancer as the target disease and how health professionals can provide high-quality tailored care to patients during various stages of cancer. However, neither the diagnostic phase nor the psychosocial aspects of the cancer journey are specifically addressed in that theory. In addition, cancer treatment and end-of-life periods are at the center of most scientific work. The start of the disease trajectory rarely constitutes a research focus. This is a substantial gap in our understanding of the experience of the disease trajectory, as the start of the disease trajectory, and, thus, the period of being told about having cancer and the start of the treatments constitute essential moments in a person's life. Not only are physicians present in this phase but also many other health care professionals, nurses among them. As this population remains understudied, the respective nurses' role has required clarification. The theory presented in this article, the omnipresence of cancer, is the formalization of an iterative process of integrating findings from 14 studies focused on persons who had been diagnosed with and were living with diverse types of cancer (eg, colorectal cancer, breast cancer).

The collective study findings, as interpreted from Heidegger's ontology of dasein, yielded 4 multidimensional concepts—toward authentic dasein, mapping out the future, living with cancer, and influencing factors. Reinterpretation of these concepts from the perspective of Newman's theory of HEC yielded a description of pattern as a whole.3–5

METHODOLOGIES: EMERGENCE AND EVOLUTION OF THE THEORY

The descriptions of the 14 studies—which were conducted by the first author and her colleagues and students—that were used for interpretation and reinterpretation of the findings leading to articulation of the theory of the omnipresence of cancer are listed in Table 1. All these studies constitute the entirety of a program of research about living with cancer within the first year following diagnosis. As can be seen in Table 1, the purposes and results of some of the studies overlap because of the need to clarify findings of previous studies. The studies encompassed qualitative description, concept analysis, literature review, and correlational research designs. All studies had obtained institutional review board approval or approval from respective ethics committees. Evolution of the program of research and, hence, theory development progressed as an iterative process with the findings of each study informing the conduct of subsequent studies (see Table 1). Study 144 constituted the start of the iterative process with theory concept identification from the perspective of Heidegger's ontology of dasein, and the findings of studies 2 through 513,19,22,30 also were interpreted from Heidegger's ontology. Data obtained from studies 6 through 1431,32,37,39,41–43 yielded more detailed identification and understanding of the theory concepts, their dimensions and subdimensions, and the relational propositions (Figure).

Figure
Figure:
Diagram of the theory of the omnipresence of cancer. This figure is available in color online (www.advancesinnursingscience.com).
Table 1. - Overview of the 14 Studies Used for the Development and Evolution of the Theory of the Omnipresence of Cancer
Study No. Purpose Evolution of the Theory Citations Design Sample Findings
1 To explore the experience of being newly diagnosed with colorectal cancer.13–17 Preliminary theory development with identification of 3 of the theory concepts and dimensions. Phenomenological approach guided by Heidegger's ontology of dasein.2
Data collected by 3 in-person interviews over a year; analyzed using Colaizzi's 8 steps.18
N = 7 persons (3 women) with colorectal cancer.
Mean age: 64 y.
Identification of 3 potentially interrelated concepts and their dimensions:
  • Toward authentic dasein: dimensions of uncertainty, transitoriness, and reconsideration of locus of control (LOC).

  • Mapping out the future: dimensions of coping with uncertainty, coping with transitoriness, and regaining control of the situation.

  • Omnipresence of cancer (which later becomes living with cancer): no subdimensions at this point.

2 To extend understanding of the meaning of uncertainty19 and to clarify the meaning of uncertainty as a dimension of toward authentic dasein. Comprehensive literature review N = 40 published reports with samples of persons with colorectal cancer (n = 6), breast cancer (n = 8), and prostate cancer (n = 26) The 3 dimensions of uncertainty:
  • Lack of comprehensive information about cancer and its evolution.

  • Concerns about future life.

  • Making plans despite having cancer.

3 To extend understanding of the meaning of transitoriness,13,20 and to clarify the meaning of transitoriness as a dimension of toward authentic dasein. Evolutionary concept analysis.21 N = 66 published reports of samples of healthy students and persons with various types of cancer (brain, bladder, breast, hematological, gynecological, lung, gastrointestinal, pancreatic, or prostate cancer). Identification and description of the 3 dimensions of transitoriness:
  • Awareness of the finality of life

  • Anxiety and fear

  • Change

4 To identify influencing factors as the fourth concept of the theory, to identify the preliminary dimensions of living with cancer, which are quality of life and spirituality, and to test the relations of the 3 dimensions of toward authentic dasein (uncertainty, transitoriness, reconsideration of LOC as belief in chance) with living with cancer, and influencing factors.22 Correlational design Study variables and instruments:
  • Transitoriness: State-Trait-Personality-Inventory (STAI)23,24

  • Uncertainty: Uncertainty in Illness Scale25

  • LOC: Locus of Control Scale26

  • Living with cancer: Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp)27,28 and Euroqol Quality of Life Questionnaire.29

  • Influencing factors: Demographic data form

Sample of N = 126 persons (64 women) with a new diagnosis of cancer (lung, n = 38; gastrointestinal, n = 65; or other [stomach, liver, gall, anal], n = 23)
Mean age: 61.4 y
Determination of statistically significant correlations among the dimensions of toward authentic dasein, namely, among uncertainty, transitoriness, and LOC— belief in chance; establishment of additional significant correlations between dimensions of toward authentic dasein, influencing factors, and living with cancer.
5 To further extend the understanding of the meaning of transitoriness as a dimension of toward authentic dasein.30 Secondary analysis of qualitative data. N = 16 young women with newly diagnosed stage 1 to stage 3 breast cancer.
Mean age: 34.13 y.
Identification of 3 additional subdimensions of transitoriness:
  • Being remembered

  • Landscape of emotions and perspectives

  • Omnipresence of life's finitude.


These subdimensions were factored into the established subdimensions from study 3.
6 To validate the content of the transitoriness instrument, to conduct a pretest of this instrument with the target population,31 and to test the relations between transitoriness (a dimension of toward authentic dasein) and the concept of influencing factors. Mixed methods design. Study variables and
instruments:
  • Transitoriness: Transitoriness instrument.15,31

  • Influencing factors: Demographic data form

N = 11 expert panel members (8 women) to determine content validity; N = 20 persons (13 women) with newly diagnosed cancer (gastrointestinal, n = 5; gynecological/lymphoma, n = 4; breast, n = 4; other cancers, n = 7) for the instrument pretest.
Mean age: 58.2 y.
Development of the transitoriness instrument, which includes 46 items, arranged into 3 subscales as identified in studies 3 and 5:
  1. Awareness of life's finitude (12 items)

  2. Anxiety and fear (12 items)

  3. Change (22 items)

7 To test the relations between 2 measures of anxiety32 and the relations of influencing factors with anxiety. Correlational design.
Study variable and
instruments:
  • Anxiety: Anxiety and Fear subscale of the Transitoriness instrument15,31 and State-Trait-Anxiety-Inventory-State Anxiety (STAI-S).23,24

  • Influencing factors: Demographic data form

N = 30 persons (24 women) with newly diagnosed cancer (breast, n = 21; gastrointestinal, n= 3; lung, n = 1; lymphoma, n = 2; melanoma, n = 1; other cancers, n = 2).
Mean age: 53.5 y.
Establishment of relations between subdimensions of transitoriness, namely, anxiety and influencing factors, thereby continuing the dimension development of transitoriness.
8 To test the relations between the subdimension change of the subdimension transitoriness and personal growth,32 and the relation of dimensions of influencing factors with change and personal growth. Correlational design.
Study variables and
instruments:
  • Change: Change subscale of Transitoriness instrument15,31

  • Personal growth: Post-Traumatic Growth Inventory (PTGI)33

  • Influencing factors: Demographic data form

N = 30 persons (24 women) with newly diagnosed cancer (breast, n = 21; gastrointestinal, n = 3; lung, n = 1; lymphoma, n = 2; melanoma, n = 1; other cancers, n = 2).
Mean age: 53.5 y.
Establishment of relations between subdimensions of transitoriness, namely, change and influencing factors, thereby continuing the dimension development of transitoriness.
9 To test the relations between thoughts of death, as a subdimension of transitoriness and proximity of death and death anxiety32 and to test the relations of influencing factors with the 3 dimensions of toward authentic dasein. Secondary retrospective design Study variables and instruments:
  • Awareness of life's finitude: Awareness subscale of the Transitoriness instrument15,31

  • Proximity of death: Subjective Assessment of the Disease Situation and Proximity of Death (SEKT)34,35

  • Death anxiety: Death and Dying Distress Scale (DADDS)36

  • Influencing factors: Demographic data form

N = 30 persons (24 women) with newly diagnosed cancer (breast, n = 21; gastrointestinal, n = 3; lung, n = 1; lymphoma, n = 2; melanoma, n =1; other cancers, n = 2).
Mean age: 53.5 y.
Establishment of relations between subdimensions of transitoriness, namely, awareness of the finality of life and influencing factors, thereby continuing the dimension development of transitoriness.
10 To test the relations between transitoriness and coping strategies, as a dimension of the concept of mapping out the future.37 Correlational design.
Study variables and instruments:
  • Awareness of life's finitude: Subjective assessment of diseases situation and proximity of death (SEKT)34,35

  • Coping: Jalowiec Coping Scale (JCS).38

  • Influencing factors: Demographic data form

N = 40 persons (19 women) with newly diagnosed gastrointestinal cancer.
Age range: 56-74 y.
Establishment of relations between the dimension transitoriness of toward authentic dasein and mapping out the future and influencing factors, thereby contributing to the testing of the relational propositions of the theory. Establishment of statistically significant correlations between influencing factors (level of education) with coping, thereby contributing to the development of the dimension coping with uncertainty and transitoriness of mapping out the future.
11 To describe and to test the relations between spiritual well-being, as a dimension of living with cancer39 and the dimensions of influencing factors. Correlational design.
Study variables and instruments:
  • Influencing factors: Demographic data form and

  • Edmonton Symptom Assessment System (ESAS)40

  • Spiritual well-being: Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp)18,27

N = 30 persons (22 women) with newly diagnosed cancer (breast, n = 18; gastrointestinal, n = 7; other (lung, hematological, etc), n = 5).
Age range: 37-55 y.
Positive correlation between influencing factors (age) and the spiritual well-being dimension of living with cancer, thereby developing living with cancer.
12 To test the relations between spiritual well-being, as a dimension of living with cancer, coping, as a dimension of mapping out the future, and influencing factors.41 Correlational design.
Study variables and instruments:
  • Spiritual well-being: FACIT-Sp27,28

  • Coping: JCS38

  • Influencing factors: Demographic data form

N = 48 persons (22 women) with cancer (breast, n = 8; gastrointestinal, n = 14, lung, n = 6; other (brain, gynecological, hematological), n = 20). Mean age: 57.37 y. Establishment of significant correlations between the dimension coping with uncertainty and transitoriness of mapping out the future with influencing factors and living with cancer, thereby contributing to the testing relational propositions of the theory.
Establishment of statistically significant correlations between supportive, self-reliant, emotive, and fatalistic coping style (representing the dimensions of coping with uncertainty, transitoriness, and LOC belief in chance of mapping out the future) with the spiritual well-being dimension of living with cancer, and statistically significant correlations between influencing factors (marital status) with the spiritual well-being dimension of living with cancer.
13 To test the relations between spiritual well-being, as a dimension of living with cancer, anxiety, as a subdimension of transitoriness, the relations of spiritual well-being,42 as a dimension of living with cancer, and anxiety, as a subdimension of transitoriness, with influencing factors. Correlational design Study variables and
instruments:
  • Spiritual well-being: Facit-Sp27,28

  • Anxiety: STAI form Y23,24

  • Influencing factors: Demographic data form

N = 49 persons (22 women) with newly diagnosed cancer receiving initial treatment (gastrointestinal,
n = 20; breast, n = 12; lung,
n = 4; others [head and
neck, lymphoma; n = 13).
Mean age: 53.89 y.
Establishment of significant correlations between the subdimension of anxiety of the dimension transitoriness of toward authentic dasein with the dimension of spiritual well-being of living with cancer, mapping out the future with influencing factors and living with cancer, thereby contributing to the testing relational propositions of the theory.
Establishment of statistically significant correlations between influencing factors (religious affiliation, education) and spiritual well-being, influencing factors (education) with anxiety as a subdimension of transitoriness, and between spiritual well-being as a dimension of living with cancer and anxiety as a subdimension of transitoriness.
14 To compare the coping strategies of inpatients with outpatients with cancer, as a subdimension of mapping out the future,43 and to test the relation between influencing factors and the coping dimension of mapping out the future. Secondary retrospective
design Study variable and
instrument:
  • Coping: JCS.38

  • Influencing factors: Demographic data form

N = 88 persons (41 women) with newly diagnosed cancer (gastrointestinal, n = 51; breast, n = 8; lung, n = 6; gynecological, n = 4; others (hematological, head and neck, testicular, brain, sarcoma, melanoma), n = 19).
Age range: 56-74 y.
Identification of relations between influencing factors (setting) and the dimension of coping with uncertainty, transitoriness, and LOC belief in chance of the concept of mapping out the future, thereby contributing to this latter concept.

The target population for all the studies included persons with various types of cancers, including colorectal, breast, prostate, and hematological cancer, who were in the early stages of the disease trajectory, specifically from 3 months to 1 year after diagnosis, and were undergoing initial anticancer treatment. For the purposes of the research, the target population was recruited at medical centers, either as inpatients or outpatients.

Newman's theory of HEC4,5 was selected to guide reinterpretation of the 4 concepts of the omnipresence of cancer with the goal of development of innovative nursology.

THE OMNIPRESENCE OF CANCER AS A THEORY FOR PRAXIS: HEIDEGGER'S PERSPECTIVE

Heidegger's3 ontology of dasein includes concepts, referred to as existentials, which describe human life. The ontology of dasein was the initial lens through which the study findings were interpreted. Concepts that constitute the theory of the omnipresence of cancer were related to the existentials. The most relevant existentials associated with the omnipresence of cancer along with their definitions are listed in Table 2.

Table 2. - Heidegger's3 Ontology of Dasein: Relevant Existentials, Their Definitions, and the Corresponding Concepts of the Theory of the Omnipresence of Cancer
Existentials Definitions Theory Concepts
Dasein Everyone who finds himself or herself in the world. Another term for person. Influencing factors
Living with cancer
State-of-Mind Everyone is always in some mood, which influences awareness and recognition of one's life, other people, and environment. Toward authentic dasein
Understanding In any given situation, everyone has many different possibilities from which to choose. The person is free to make a choice and execute it or to leave things be. Mapping out the future
The They Everyone lives within a world with other people and society. Daily life means a person does not want to be and is not distinguishable from other people and is part of society. One does what one must or is expected to do. Influencing factors
Being-Toward-Death Everyone lives life implicitly aware that there will be an end at some point. Life is finite, which will become explicit, for example, when a person is diagnosed with a potentially fatal disease or when experiencing a potentially fatal accident of a loved one. Toward authentic dasein
Influencing factors
Authentic/Inauthentic Authentic and inauthentic are modes of dasein. As a result of a diagnosis of a potentially fatal disease, life as usual is disrupted. At this point, a person has the possibility of glimpsing his or her authentic self or to ignore this and choose to carry on as before in an inauthentic way. Living with cancer
Temporality A person is subjected to clock time, the fact that human life is finite, and the respective context, in which he or she lives. Toward authentic dasein, mapping out the future Influencing factors

Toward authentic dasein

Toward authentic dasein includes the dimensions of uncertainty, transitoriness, and reconsideration of locus of control (LOC) as belief in chance. It refers to patients recognizing the importance of the disease for themselves. Questions about the reason for the disease and its influence on daily life arise as persons engage in introspection and search for meaning. The concept, toward authentic dasein, which describes the person's experience of being diagnosed with cancer, emerged from the findings of study 1.44 The 3 dimensions of this concept, uncertainty, transitoriness, and reconsideration of LOC as belief in chance, also emerged from the study 1 findings.

Findings from study 219 provided additional insight about uncertainty, which is defined as lack of comprehensive information about cancer and its evolution, concerns about daily life and about making plans despite having cancer. Findings from studies 3,13 4,22 5,30 6,31 7, 8, 9,32 and 1037 provided an in-depth understanding of transitoriness, defined as the experience of facing life's finitude or the transitory nature of life due to cancer. Its 3 subdimensions, which emerged from the findings of studies 313 and 5,30 are awareness of the finality of life, fear and anxiety, and change. These findings subsequently informed studies 6 through 10.31,32,37 Reconsideration of LOC as belief in chance, defined as the belief that chance has control over one's health,26 was identified in study 422 findings.

Toward authentic dasein reflects state of mind and being-toward-death. State of mind influences the person's perception of the actual situation. A person may be aware or unaware of his or her perception of the situation. Uncertainty, transitoriness, and reconsideration of LOC as belief in chance reflect the person's state of mind and its influence on awareness and recognition of the importance of cancer as a chronic, potentially life-limiting disease. Being-toward-death indicates that the person may be confronted with the finitude of life (temporality/temporal nature of life) due to the diagnosis of cancer.

Mapping out the future

Mapping out the future encompasses the dimensions of coping with uncertainty, coping with transitoriness, and regaining control of the situation. Despite the cancer, life is continuing, and persons have a need to get back to everyday living. They adjust their lifestyle as they consider the future and may begin to experience personal growth.

The concept, mapping out the future, which describes persons' coping strategies for dealing with a diagnosis of cancer, also emerged from the study 144 findings, as did its 3 dimensions—coping with uncertainty, coping with transitoriness, and regaining control of the situation. The findings of studies 10,37 12,41 and 1443 yielded additional insight about mapping out the future and its dimensions.

The dimension of coping with uncertainty is defined as the use of avoidance and supportive strategies to palliate the experience of uncertainty. These strategies facilitate the location of information resources, including consultation with health professionals. The dimension of coping with transitoriness is defined as use of optimistic, self-reliant, confrontative, and supportive strategies for dealing with having cancer. These strategies promote writing letters to the family to leave a legacy or to be closer to the family. The dimension of regaining control of the situation is defined as use of confrontative and self-reliant strategies to cope with having cancer. These strategies, for example, contribute to improving pain control, organizing holidays, and obtaining support from family members.

Mapping out the future is indicative of understanding, which means that persons realize that they always have several choices in relation to coping strategies and whether to utilize these. It denotes a person's efforts to redefine life and carry on. In mapping out the future, its dimensions of coping with uncertainty, coping with transitoriness (temporality), and regaining control of the situation reflect the possibility of choice inherent in understanding.

Living with cancer

Living with cancer refers to person's experience of the disease as all-encompassing and overwhelming. New values are identified, and integrated, and old values are revised. With time, the disease is relegated to the back of their minds as they find a new normal and experience personal growth and change. The concept, living with cancer, which refers to persons' capacity to find a way to live with the disease, was also evident in the study 1 findings.

Persons try to find ways to live with the disease, which may involve changes in lifestyle, values, meaning, or outlook on life as well as changes in relationships. Because of the disease, persons with cancer consider themselves to be a group apart from other people, which reflects Heidegger's view of being entirely alone within oneself. Having cancer is considered isolating; this experience cannot be shared with persons without cancer. Living with cancer is more challenging the closer a treatment session becomes, or a follow-up screening occurs, which initially became evident in study 144 findings.

Study 422 findings indicated that living with cancer is similar to the concept of quality of life and, as such, encompasses 5 dimensions: functional well-being, physical well-being, emotional well-being, social well-being, and especially spiritual well-being.27,28 Studies 1139 and 1342 highlighted the importance of spiritual well-being.

Living with cancer is indicative of dasein and the authentic/inauthentic modes of dasein. This means that a person adapts to changes in life that may be due to cancer as a chronic, potentially life-threatening disease. The confrontation with a threat to life offers the possibility for persons to gain more insight about themselves. Furthermore, the idea of society as proposed in “the they” (see Table 2) is evident in living with cancer. Persons who experience the potentially life-altering situation of being newly diagnosed with cancer also experience a sense of having lost what is usual in life and their place in society. Therefore, these persons desire to regain normalcy in life and thus reclaim their place in society.

Influencing factors

Influencing factors, as a concept, along with its dimensions and subdimensions, emerged from the findings of studies 4,22 10,37 11,39 12,41 13,42 and 14.43 Influencing factors involve the dimension of disease-related factors, which have 3 subdimensions. These are symptoms, medications, and metastasis. Disease-related factors as a dimension are evident in characteristics found in the population studied within the boundaries of the research. Sociodemographic factors, as a dimension, have 5 subdimensions that are gender, education, marital status, professional status, and religious affiliation. Finally, the dimension of context-related factors discerned from the research has 2 subdimensions, which are the settings for cancer diagnosis and settings for cancer treatment.

Influencing factors reflects dasein, temporality, being-toward-death, and the they. “The they” is interpreted as living in a relationship with others (see Table 2). Sociodemographic factors are indicative of dasein and temporality. Disease-related factors point to the research population as having been confronted with a life-threatening disease and may be indicative of being-toward-death and the they, which refers to the idea of society (others) (see Table 2). Context-related factors point to the treatment setting. In a cancer trajectory, treatment settings are indicative of different time periods and may be indicative of temporality (see Table 2).

Propositions of the theory of the omnipresence of cancer

Definitions of the concepts and their dimensions and subdimensions, given previously, constitute the nonrelational propositions of the theory. These were mainly drawn from the qualitative descriptions in the research process. The relational propositions, which were extracted primarily from the correlational study findings, are as follows:

  • Influencing Factors is related to Toward Authentic Dasein, Mapping out the Future, and Living with Cancer (studies 4,22 10,37 11,39 12,41 13,42 and 1443).
  • Toward Authentic Dasein is reciprocally related to Mapping Out the Future and Living with Cancer (studies 1,44 4,22 10,37 and 1342).
  • Mapping Out the Future is reciprocally related to Living with Cancer (studies 1,44 4,22 and 1241).

THE OMNIPRESENCE OF CANCER AS A THEORY FOR PRAXIS: NEWMAN'S PERSPECTIVE

Through the initial lens of Heidegger's3 ontology of dasein, findings of the 14 studies (Table 1) evolved from simple description to a formal theory for nursing: the omnipresence of cancer. At this juncture, evolution of the theory into nursology required association with a multidimensional nursology theory that reflected the views inherent in the omnipresence of cancer. A goal inherent in nursology is to inform nursing practice. The collective study findings being viewed through the lens of Newman's4,5 theory of HEC has facilitated the process of informing nursology discipline-specific practice. Interpretation of the collective study findings was initiated by asking the question: What is the pattern of the whole as persons learned of their medical diagnosis of cancer, the choices they made about treatment, and how they continued living to the possibility of expanded consciousness?

Health as expanding consciousness was deemed particularly appropriate due to inclusion of a focus on personal growth in the presence of illness, disease, or other challenges to well-being. Personal growth may include changes in lifestyle or relationships with other persons.10,30,45 Specifically, Newman maintains that both wellness and illness situations provide opportunities for expansion of the person's consciousness.4,5 Expanding consciousness is “a process of becoming more of oneself, of finding greater meaning in life, and of reaching new heights of connectedness with other people and the world in which one lives.”14(p650) In particular, Newman4 proposed that consciousness expands in a series of stages: potential consciousness, time, space, movement, infinite space or boundaryless, timelessness, and absolute consciousness. In an integrative review of HEC, Smith found that several studies focused on “life patterning within shared life predicaments,” such as diseases, with an emphasis on “the underlying pattern of the whole.”14(p257)

Pattern, according to Newman,5(p99) “is a process of recognizing and creating meaning in life.” Cancer can be viewed as a situation that leads to the expansion of consciousness, manifested by recognizing the pattern and the meaning of living with cancer.

The HEC research method, termed praxis, typically involves engaging the practitioner/researcher with the client/participant in meetings and interviews to discuss the most important persons and events in the client/participant's life.4,5 The practitioner/researcher then interprets the client's/participant's responses as a life pattern of the whole, which includes the current health condition. The perspective of Newman's HEC was applied to the 4 concepts of the theory of the omnipresence of cancer, their dimensions and subdimensions as a pattern of the whole, instead of reinterpreting the results from each of the 14 studies (Table 1). In other words, as researchers, we engaged with the entirety of content of the theory of the omnipresence of cancer rather than with clients/participants, as none of us no longer had access to the participants in the 14 studies.

The pattern of the whole

Our engagement with the content of the theory of the omnipresence of cancer, including its concepts, their dimensions and subdimensions, yielded a pattern of the whole of the person living with cancer. This pattern reflects the evolution from Newman's stage of potential consciousness to the stage of absolute consciousness as persons confront a medical diagnosis of cancer and progress to living through cancer treatment and beyond treatment. During their evolution, persons experience Newman's stages of time and space. Persons then experience Newman's stage of movement as they decided that they will live day to day despite an uncertain and transitory future. This includes the treatments the persons will accept, the coping strategies they use, and what they believe they can control and what has to be left to chance. Settings also play a significant role in persons' living with cancer and indicate Newman's HEC nursology in relation to connectedness with others. This pattern of the whole involves understanding the meaning of the many aspects of well-being despite the medical diagnosis of cancer. As this occurs, persons ideally experience Newman's stage of infinite space or boundaryless and stage of absolute consciousness.

DISCUSSION

The theory of the omnipresence of cancer emphasizes cancer as a life-changing event with far-reaching consequences for persons with this diagnosis.8,10,11 To date, this experience has been described in the literature, but no formal theory has emerged. The omnipresence of cancer, as nursology, provides the theoretical basis for this experience to inform nursing practice. Initially, in studies 1 through 5,13,19,22,30,44 Heidegger's3 ontology of dasein, with its existentials facilitated the construction of the theory comprising 4 concepts and their relations.15,46 Subsequent studies (6 through 1431,32,37,39,41–43) provided detail and insight into the 4 concepts and their relations, thereby allowing for the construction of a theory.

Reinterpretation of the findings from the 14 studies within the context of HEC resulted in a description of the pattern of the whole as the pattern evolved from potential consciousness to the possibility of absolute consciousness.

By drawing on the 2 perspectives, Heidegger's ontology of dasein,3 and Newman's HEC,4,5 it has been possible to redefine the findings from the program of research to inform nursology's knowledge development. Theories “may emerge from synthesizing and integrating research findings and clinical exemplars about a specific situation or population with the intent of developing a framework or blueprint to understand the particular situation of a group of persons.”47(p16) For the theory of the omnipresence of cancer, early studies employed existing validated quantitative measurements to determine extent and associations among the main concepts and their dimensions.22 The selection of the respective instruments entailed a careful evaluation of the underlying concepts of each instrument. It could be argued that selection of these instruments was biased as the instruments were not constructed to focus entirely on the concepts and dimensions with the theory of the omnipresence of cancer. For example, the dimension of transitoriness could not be measured in its entirety with existing instruments. Therefore, further exploration of the theory concepts as well as their dimensions is important to determine empirical adequacy and inform nursology knowledge development.

By employing the HEC perspective of the omnipresence of cancer, the pattern of the whole emerged. Thus, the omnipresence of cancer can be associated with the HEC. It can be argued that engaging with the theory by employing the HEC perspective can be indicative of the theory's scope. Therefore, the omnipresence of cancer may be a mid-range theory and as such can shape practice.

Studies designed within the context of Newman's praxis methodology are needed to determine whether our interpretation of the data from the 14 studies as evolution of a pattern of the whole from potential consciousness to possible expanded consciousness is empirically adequate. Such studies require engagement of the practitioner/researcher with the client/participant, the data from which the practitioner/researcher develops a diagram of the pattern of the whole, and client/participant's recognition of the pattern.

Education drawing on Newman's HEC will promote nursing students' and nurses' capacity of identifying the pattern unique to each person, engaging in promoting recognition, and obtaining higher levels of consciousness. Thus, nurses will provide better support for patients in their disease situations. Nursing education integrating HEC will promote nurses grounded in nursology.48,49 Thus, nursing management and policy will be strengthened.

Implications for practice

Heidegger's3 ontology of dasein provides guidance for the development of theory but does not lead directly to nursology practice processes. In contrast, Newman's theory,4,5 HEC, allows for explicit nursology practice implications and processes. Newman4 indicated that challenges to well-being may lead to the client/participant's changes in his or her unique pattern. As a result, the client/participant may consider changes in his or her life, which require direction and assistance from the nurse. Nurses are expected to provide supportive measures for persons' evolvement of pattern due to experiencing a cancer trajectory. Assisting persons with a diagnosis of cancer requires a dual understanding of the content of the theory of the omnipresence of cancer, as well as the pattern of the whole, to provide essential guidance through the disease/wellness experience.

CONCLUSION

Engaging in the development and evolution of theory is essential to advance knowledge in the discipline of nursology. The evolution of the theory of the omnipresence of cancer from a series of studies has been explicated in this article. Interpreting the study findings from the perspectives of Heidegger and Newman has yielded insights into its relevance for nursology.

REFERENCES

1. Fawcett J, Desanto-Madeya S. Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories. 3rd ed. Philadelphia, PA: F A Davis; 2013.
2. Smith MC, Parker ME. Nursing Theories and Nursing Practice. 4th ed. Philadelphia, PA: F A Davis; 2015.
3. Heidegger M. Being and Time. Oxford: Blackwell; 1996.
4. Newman MA. Health as Expanding Consciousness. 2nd ed. Sudbury, MA; London: Jones and Bartlett; 2000.
5. Newman MA. Transforming Presence: The Difference That Nursing Makes. Philadelphia, PA: F A Davis; 2008.
6. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.
7. WHO. Cancer. Fact sheet. World Health Organization. http://www.who.int/mediacentre/factsheets/fs297/en/index.html#. Published 2018. Accessed February 11, 2018.
8. Boerger-Knowles K, Ridley T. Chronic cancer: counseling the individual. Soc Work Health Care. 2014;53(1):11–30.
9. Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: Institute of Medicine; 2008.
10. Hubbard G, Kidd L, Kearney N. Disrupted lives and threats to identity: the experiences of people with colorectal cancer within the first year following diagnosis. Health (London). 2010;14(2):131–146.
11. Wenzel J, Shaha M. Experiencing cancer treatment decision-making in managed care. J Adv Nurs. 2008;63(5):455–464.
12. Humphreys J, Lee KA, Carrieri-Kohlman V, et al. Theory of symptom management. In: Smith MJ, Liehr PR, eds. Middle Range Theory for Nursing. 2nd ed. New York, NY: Springer Publishing; 2008:145–158.
13. Shaha M, Cox CL, Belcher AE, Cohen MZ. Transitoriness: patients' perception of life after a diagnosis of cancer. Cancer Nurs Pract. 2011;10(4):24–27.
14. Smith MC. Integrative review of research related to Margaret Newman's theory of health as expanding consciousness. Nurs Sci Q. 2011;24(3):256–272.
15. Zumstein-Shaha M, Cox CL. A Theory of Cancer Care in Healthcare Settings. 1st ed. London: Routledge; 2017.
16. Shaha M. [Life with intestinal cancer. A pheno-menologic-empirical study]. Pflege. 2003;16(6):323–330.
17. Shaha M, Cox CL, Hall A, Porrett T, Brown J. The omnipresence of cancer: its implications for colorectal cancer. Cancer Nurs Pract. 2006;5(4):35–39.
18. Haase JE. Components of courage in chronically ill adolescents: a phenomenological study. ANS Adv Nurs Sci. 1987;9(2):64–80.
19. Shaha M, Cox CL, Talman K, Kelly D. Uncertainty in breast, prostate, and colorectal cancer: implications for supportive care. J Nurs Scholarsh. 2008;40(1):60–67.
20. Shaha M, Cox CL, Cohen MZ, Belcher AE, Kappeli S. [The contribution of concept development to nursing knowledge? The example of transitoriness]. Pflege. 2011;24(6):361–372.
21. Rodgers BL. Concept analysis: an evolutionary view. In: Rodgers BL, Knafl KA, eds. Concept Development in Nursing: Foundations, Techniques, and Applications. 2nd ed. Philadelphia, PA: Saunders; 2000:77–102.
    22. Shaha M, Pandian V, Choti MA, et al. Transitoriness in cancer patients: a cross-sectional survey of lung and gastrointestinal cancer patients. Support Care Cancer. 2010;19(2):271–279.
    23. Spielberger CD, Reheiser EC. Measuring anxiety, anger, depression and curiosity as emotional states and personality traits with the STAI, STAXI and STPI. In: Hersen M, Hilsenroth MJ, Segal DL, eds. Comprehensive Handbook of Psychological Assessment. Vol 2, Personality Assessment. Hoboken, NJ: John Wiley & Sons; 2003:70–86.
      24. Spielberger CD. State-Trait-Anxiety Inventory (Form Y). Redwood City, CA: Mind Garden; 1983.
        25. Mishel MH. Uncertainty in acute illness. Ann Rev Nurs Res. 1997;15:57–80.
          26. Wallston KA, Stein MJ, Smith CA. Form C of the MHLC scales: a condition-specific measure of locus of control. J Pers Assess. 1994;63(3):534–553.
          27. Canada AL, Murphy PE, Fitchett G, Peterman AH, Schover LR. A 3-factor model for the FACIT-Sp. Psychooncology. 2008;17(9):908–916.
          28. Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy—Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med. 2002;24(1):49–58.
          29. Brooks RG, Rabin R, De Charro F. The Measurement and Valuation of Health Status Using EQ-5D: A European Perspective: Evidence From the EuroQol BIOMED Research Programme. Dordrecht, the Netherlands: Kluwer; 2003.
            30. Shaha M, Bauer-Wu S. Early adulthood uprooted: transitoriness in young women with breast cancer. Cancer Nurs. 2009;32(3):246–255.
            31. Sobral G. Transitoriness: instrument development. In: Zumstein-Shaha M, Cox CL, eds. A Theory of Cancer Care in Healthcare Settings. 1st ed. London: Routledge; 2017:93–108.
            32. Bussy C, Pasche J, Chaudhry-Schaer A-C. [Partial Validation of the Instrument Transitoriness]. Lausanne, Switzerland: Institut universitaire de formation et de recherche en soins IUFRS, University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2018.
            33. Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress. 1996;9(3):455–471.
            34. Schweiger C. Subjektive Todesnähe und psychische Befindlichkeit bei Patienten mit hämato-onkologischen Systemerkrankungen. Tubingen, Germany: Faktultät für Sozial-und Verhaltenswissenschaften, Eberhard-Karl-Universität; 2003.
              35. Vollmer TC, Wittmann M, Schweiger C, Hiddemann W. Preoccupation with death as predictor of psychological distress in patients with haematologic malignancies. Eur J Cancer Care (Engl). 2011;20(3):403–411.
              36. Lo C, Hales S, Zimmermann C, Gagliese L, Rydall A, Rodin G. Measuring death-related anxiety in advanced cancer: preliminary psychometrics of the Death and Dying Distress Scale. J Pediatr Hematol Oncol. 2011;33(suppl 2):S140–S145.
              37. Da Rocha MG. [Determine the Experience of Proximity of Death and the Coping Strategies of Patients With Cancer]. Lausanne, Switzerland: Institut universitaire de formation et de recherche en soins IUFRS, University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2012.
              38. Jalowiec A. The Jalowiec coping scale. In: Strickland O, Diforio C, eds. Measurement of Nursing Outcomes. Vol 3: Self care and coping. New York, NY: Springer; 2003:71–87.
                39. Roos P. In: IUFRS, ed. [Spiritual Needs of Patients With Cancer] [master's thesis]. Lausanne, Switzerland: Institut universitaire de formation et de recherche en soins IUFRS, University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2012.
                40. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9.
                41. Gaillard Desmedt S. [Determine the Level of Well-Being and Coping Strategies in Patients With Cancer] [master's thesis]. Lausanne, Switzerland: Institut universitaire de formation et de recherche en soins IUFRS, University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2013.
                42. Ballif M. [Exploration of the Perception of Spirituality in Relation to Anxiety]. Lausanne, Switzerland: Institut universitaire de formation et de recherche en soins IUFRS. University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2015.
                43. Cudre L. [Comparison of the Coping Strategies of Patients With First-Line Treatments in an Outpatients' Department vs. Patients in a Surgical Department]. Lausanne, Switzerland: Institut universitaire de formation de recherche en soins IUFRS, University of Lausanne, CHUV Centre Hospitalier Universitaire Vaudois, IUFRS; 2016.
                44. Shaha M, Cox CL. The omnipresence of cancer. Eur J Cancer Care (Engl). 2003;7(3):191–196.
                45. Rabow MW. Living with cancer: a step-by-step guide for coping medically and emotionally with a serious diagnosis. J Palliat Med. 2017;20(10):1175.
                46. Shaha M. [The development of a middle-range theory based on phenomenologic research]. QuPuG. 2016;15(1):15–23.
                47. Im EO, Meleis AI. Situation-specific theories: philosophical roots, properties, and approach. Adv Nurs Sci. 1999;22(2):11–24.
                48. Musker KM, Kagan PN. Health as expanding consciousness: implications for health policy as praxis. Nurs Sci Q. 2011;24(3):279–286.
                49. Sethares KA, Gramling KL. Newman's health as expanded consciousness in baccalaureate education. Nurs Sci Q. 2014;27(4):302–307.
                Keywords:

                cancer; Newman's theory of health as expanding consciousness; nursing theory

                © 2020 Wolters Kluwer Health, Inc. All rights reserved.