Guest Contributor: Raymond R. Romano, III

Health as Expanding Consciousness (HEC) transformed nursing’s understanding of health by reframing disease as manifestations of an evolving life pattern.¹ The theory has generated decades of scholarship and insights into practice. Newman’s greatest insight may have been that consciousness is revealed through pattern.² If patterns can emerge not only within persons but also within networks of relationships, then consciousness itself may need to be examined at levels beyond the individual.

Consider a woman living with early Alzheimer’s disease. Questions about treatment decisions, future planning, daily functioning, identity, and meaning are rarely navigated alone. Over time, her husband begins managing medications, her daughter maintains the calendar, a neighbor notices changes in her routine, and a nurse helps the family navigate care. In dementia care, experiences unfold within networks of relationships.^3,4 Some capacities necessary for living have become distributed across relationships, people, objects, and environments.^5,6 Other disciplines have wrestled with this idea. Theories of extended mind, distributed cognition, and transactive memory suggest that remembering, planning, and problem-solving can occur across people and environments.^5–7

Dementia scholars have similarly challenged assumptions that cognitive decline necessarily means the loss of agency, identity, or selfhood.⁸ These perspectives raise a common question: Is the individual always the appropriate boundary around the phenomenon we are trying to understand? HEC already rejects a strict separation between person and environment.^9,10 Yet in research and clinical care, we routinely return to individual variables: the patient’s cognition, the caregiver’s burden, the individual’s quality of life. Even relationships are often treated as something external that acts upon the person rather than as part of the phenomenon itself.

Perhaps the next evolution of HEC is not deeper exploration of individual consciousness, but examination of consciousness as an emergent pattern of interaction within complex social networks. A network consciousness could describe the awareness, pattern recognition, and meaning-making that emerge through interactions among interconnected individuals. No single person possesses the entire pattern. Rather, understanding develops through the integration of perspectives distributed across patients, families, clinicians, and communities. In this view, consciousness is not merely shared; it is emergent.

Dementia care provides a compelling example. Spouses preserve autobiographical history. Children coordinate appointments. Friends maintain social identities. Clinicians carry information between settings. Nurses connect people and resources. These relationships do more than provide support. They carry information, preserve identity, enable action, and help express preferences.¹¹ Unlike the abstract concept of pattern, networks can be observed. Social network analysis allows us to examine who is connected to whom, where information travels, whether responsibilities are concentrated in one overwhelmed caregiver, and how these structures reorganize over time.¹²

This raises an intriguing possibility for HEC. Imagine that cognitive decline continues while a person’s network becomes better able to understand her preferences, distribute responsibilities, maintain meaningful activities, and support participation in decisions. The disease has progressed, yet the person-environment system has developed new possibilities for action. Could that be one observable manifestation of expanding health? If pattern is the manifestation of consciousness, and patterns can emerge at the level of social networks, then consciousness itself may possess emergent properties that cannot be reduced to any single individual.

This perspective also offers a way to address a longstanding challenge facing highly abstract nursing theories: What evidence could prove our interpretation wrong? Rather than attempting to measure expanding consciousness directly, HEC could generate testable propositions.

For example:

• Does pattern recognition in one family member influence pattern recognition in others?
• Do family narratives converge over time following a dementia diagnosis?
• Does network capacity predict decision quality better than cognitive status alone?
• Do highly connected care networks demonstrate greater adaptation than fragmented networks?

Such questions move HEC beyond interpretation and toward empirical examination. The implications for nursing practice are equally important. If health experiences unfold across networks, nursing assessment may need to extend beyond the individual and consider the health of the care network itself. Questions about connection, shared understanding, value alignment, and collective adaptation may become as important as questions about symptoms and functioning. If HEC challenged nursing to view health and disease as manifestations of a larger pattern, perhaps the next challenge is to ask where that pattern resides. Is it contained within a single person? Or does it emerge through the relationships that surround and sustain that person? The question for nursing scholars may no longer be: How does consciousness expand within a person? But rather: How does consciousness expand across a network of persons experiencing illness together? Perhaps Newman’s emphasis on pattern was preparing us for this question all along.

References:

1. Newman MA. Transforming Presence: The Difference That Nursing Makes. F.A. Davis; 2007.
2. Pharris MD. Margaret A. Newman’s Theory of Health as Expanding Consciousness. Nurs Sci Q. 2011;24(3):193-194. doi:10.1177/0894318411409437
3. Wang J, Liu W, Li X, et al. Examining the Social Networks Types and Their Effects on Caregiving Experience of Family Caregivers for Individuals With Dementia: A Mixed-Methods Study. Innov Aging. 2024;8(6):igae040. doi:10.1093/geroni/igae040
4. Informal Caregiving Networks of Older Adults With Dementia Superimposed on Multimorbidity: A Social Network Analysis Study | Innovation in Aging | Oxford Academic. Accessed August 13, 2026. https://academic.oup.com/innovateage/article/7/4/igad033/7125940
5. Distributed Cognition – an overview | ScienceDirect Topics. Accessed August 13, 2026. https://www.sciencedirect.com/topics/social-sciences/distributed-cognition
6. Clark A, Chalmers D. The Extended Mind. Analysis. 1998;58(1):7-19.
7. Wegner DM. Transactive Memory: A Contemporary Analysis of the Group Mind. In: Mullen B, Goethals GR, eds. Theories of Group Behavior. Springer; 1987:185-208. doi:10.1007/978-1-4612-4634-3_9
8. Kontos PC. Embodied selfhood in Alzheimer’s disease: Rethinking person-centred care. Dementia. 2005;4(4):553-570. doi:10.1177/1471301205058311
9. Newman MA. Health as Expanding Consciousness. Jones & Bartlett Learning; 1999.
10. Marchione J. Margaret Newman: Health As Expanding Consciousness. SAGE Publications, Incorporated; 1992. Accessed August 16, 2023. http://ebookcentral.proquest.com/lib/vand/detail.action?docID=1598477
11. Friedman EM, Kennedy DP. Typologies of Dementia Caregiver Support Networks: A Pilot Study. Gerontologist. 2021;61(8):1221-1230. doi:10.1093/geront/gnab013
12. Wang J, Liu W, Li X, et al. Examining the Social Networks Types and Their Effects on Caregiving Experience of Family Caregivers for Individuals With Dementia: A Mixed-Methods Study. Innov Aging. 2024;8(6):igae040. doi:10.1093/geroni/igae040

About Raymond Romano

Raymond Romano is a family nurse practitioner with experience in research and quality improvement. His focus is on health services research, and his specific interests are in the detection, diagnosis, and care of dementia in the primary care setting. He earned his bachelor’s degree in biology at Marymount Manhattan College, his master’s degree in public health from Boston University, and his master’s degree in nursing from Vanderbilt University. He completed his PhD at the University of Tennessee Health Science Center. He currently works at the Vanderbilt Memory and Alzheimer’s Center, where he conducts clinical assessments for the Center’s longitudinal studies and supports outreach, recruitment, and community engagement. He is the director of the Tennessee Dementia ECHO program, a provider education program aimed at bringing quality dementia care to every corner of Tennessee.