INTRODUCTION

Betty Neumans system model provides a comprehensive flexible

holistic and system based perspective for nursing.

It focuses attention on the response of the client system to actual

or potential environmental stressors.

And the use of primary, secondary and tertiary nursing prevention

intervention for retention, attainment, and maintenance of optimal
client system wellness.

HISTORY AND BACKGROUND OF THE THEORIST

Betty Neuman was born in 1924, in Lowel, Ohio.

She completed BS in nursing in 1957 and MS in Mental Health

Public health consultation, from UCLA in 1966. She holds a Ph.D.
in clinical psychology

She was a pioneer in the community mental health movement in

the late 1960s.

Betty Neuman began developing her health system model while a

lecturer in community health nursing at University of California,
Los Angeles.

The models was initially developed in response to graduate

nursing students expression of a need for course content that
would expose them to breadth of nursing problems prior to
focusing on specific nursing problem areas.

The model was published in 1972 as A Model for Teaching Total

Person Approach to Patient Problems in Nursing Research.

It was refined and subsequently published in the first edition of

Conceptual Models for Nursing Practice, 1974, and in the second
edition in 1980.

DEVELOPMENT OF THE MODEL

Neumans model was influenced by a variety of sources.

The philosophy writers deChardin and cornu (on wholeness in

system).

Von Bertalanfy, and Lazlo on general system theory.

Selye on stress theory.

Lararus on stress and coping.

BASIC ASSUMPTIONS

Each client system is unique, a composite of factors and

characteristics within a given range of responses contained within
a basic structure.

Many known, unknown, and universal stressors exist. Each differ

in its potential for disturbing a clients usual stability level or
normal LOD

The particular inter-relationships of client variables at any point in

time can affect the degree to which a client is protected by the
flexible LOD against possible reaction to stressors.

Each client/ client system has evolved a normal range of responses

to the environment that is referred to as a normal LOD. The
normal LOD can be used as a standard from which to measure
health deviation.

When the flexible LOD is no longer capable of protecting the

client/ client system against an environmental stressor, the stressor
breaks through the normal LOD

The client whether in a state of wellness or illness, is a dynamic

composite of the inter-relationships of the variables. Wellness is
on a continuum of available energy to support the system in an
optimal state of system stability.

Implicit within each client system are internal resistance factors

known as LOR, which function to stabilize and realign the client
to the usual wellness state.

Primary prevention relates to G.K. that is applied in client

assessment and intervention, in identification and reduction of
possible or actual risk factors.

Secondary prevention relates to symptomatology following a

reaction to stressor, appropriate ranking of intervention priorities
and treatment to reduce their noxious effects.

Tertiary prevention relates to adjustive processes taking place as

reconstitution begins and maintenance factors move the back in
circular manner toward primary prevention.

The client as a system is in dynamic, constant energy exchange

with the environment.

CONCEPTS

Content: - the variables of the person in interaction with the

internal and external environment comprise the whole client
system

Basic structure/Central core: - common client survival factors in

unique individual characteristics representing basic system energy
resources.

The basis structure, or central core, is made up of the basic

survival factors that are common to the species (Neuman,2002).

These factors include:- - Normal temp. range, Genetic structure.Response pattern. Organ strength or weakness, Ego structure

Stability, or homeostasis, occurs when the amount of energy that is

available exceeds that being used by the system.

A homeostatic body system is constantly in a dynamic process of

input, output, feedback, and compensation, which leads to a state
of balance.

Degree to reaction: - the amount of system instability resulting

from stressor invasion of the normal LOD.

Entropy: - a process of energy depletion and disorganization

moving the system toward illness or possible death.

Flexible LOD: - a protective, accordion like mechanism that

surrounds and protects the normal LOD from invasion by
stressors.

Normal LOD: - It represents what the client has become over

time, or the usual state of wellness. It is considered dynamic
because it can expand or contract over time.

LOR: - The series of concentric circles that surrounds the basic

structure.

Protection factors activated when stressors have penetrated the

normal LOD, causing a reaction symptomatology. E.g.
mobilization of WBC and activation of immune system
mechanism

Input- output: - The matter, energy, and information exchanged

between client and environment that is entering or leaving the
system at any point in time.

Negentropy: - A process of energy conservation that increase

organization and complexity, moving the system toward stability
or a higher degree of wellness.

Open system:- A system in which there is continuous flow of

input and process, output and feedback. It is a system of organized
complexity where all elements are in interaction.

Prevention as intervention: - Interventions modes for nursing

action and determinants for entry of both client and nurse in to
health care system.

Reconstitution: - The return and maintenance of system stability,

following treatment for stressor reaction, which may result in a
higher or lower level of wellness.

Stability: - A state of balance of harmony requiring energy

exchanges as the client adequately copes with stressors to retain,
attain, or maintain an optimal level of health thus preserving
system integrity.

Stressors: - environmental factors, intra (emotion, feeling), inter

(role expectation), and extra personal (job or finance pressure) in
nature, that have potential for disrupting system stability.

A stressor is any phenomenon that might penetrate both the F and

N LOD, resulting either a positive or negative outcome.

Wellness/Illness: - Wellness is the condition in which all system

parts and subparts are in harmony with the whole system of the
client.
o

Illness is a state of insufficiency with disrupting needs

unsatisfied (Neuman, 2002).

Illness is an excessive expenditure of energy when more

energy is used by the system in its state of disorganization
than is built and stored; the outcome may be death (Neuman,
2002).

PREVENTION

According to Neumans model, prevention is the primary nursing

intervention. Prevention focuses on keeping stressors and the
stress response from having a detrimental effect on the body.

PRIMARY PREVENTION

Primary prevention occurs before the system reacts to a stressor.

On the one hand, it strengthens the person (primary the flexible
LOD) to enable him to better deal with stressors

On the other hand manipulates the environment to reduce or

weaken stressors.

Primary prevention includes health promotion and maintenance of

wellness.

SECONDARY PREVENTION

Secondary prevention occurs after the system reacts to a stressor

and is provided in terms of existing system.

Secondary prevention focuses on preventing damage to the central

core by strengthening the internal lines of resistance and/or
removing the stressor.

TERTIARY PREVENTION

Tertiary prevention occurs after the system has been treated

through secondary prevention strategies.

Tertiary prevention offers support to the client and attempts to add

energy to the system or reduce energy needed in order to facilitate
reconstitution.

FOUR MAJOR CONCEPTS

PERSON

The focus of the Neuman model is based on the philosophy that

each human being is a total person as a client system and the
person is a layered multidimensional being.

Each layer consists of five person variable or subsystems:

o

Physiological- Refer of the physicochemical structure and

function of the body.

Psychological- Refers to mental processes and emotions.

Socio-cultural- Refers to relationships; and social/cultural

expectations and activities.

Spiritual- Refers to the influence of spiritual beliefs.

Developmental- Refers to those processes related to

development over the lifespan.

ENVIRONMENT

The environment is seen to be the totality of the internal and

external forces which surround a person and with which they
interact at any given time.

These forces include the intrapersonal, interpersonal and extrapersonal stressors which can affect the persons normal line of
defense and so can affect the stability of the system.
o

The internal environment exists within the client system.

The external environment exists outside the client system.

Neuman also identified a created environment which is an

environment that is created and developed unconsciously by
the client and is symbolic of system wholeness.

HEALTH

Neuman sees health as being equated with wellness. She defines

health/wellness as the condition in which all parts and subparts
(variables) are in harmony with the whole of the client (Neuman,
1995).

The client system moves toward illness and death when more
energy is needed than is available. The client system moved
toward wellness when more energy is available than is needed

NURSING

Neuman sees nursing as a unique profession that is concerned with

all of the variables which influence the response a person might
have to a stressor.

The person is seen as a whole, and it is the task of nursing to

address the whole person.

Neuman defines nursing as action which assist individuals,

families and groups to maintain a maximum level of wellness, and
the primary aim is stability of the patient/client system, through
nursing interventions to reduce stressors.

Neuman states that, because the nurses perception will influence

the care given, then not only must the patient/clients perception
be assessed, but so must those of the caregiver (nurse).

The role of the nurse is seen in terms of degree of reaction to

stressors, and the use of primary, secondary and tertiary
interventions

STAGES OF NURSING PROCESS (BY NEUMAN)

NURSING DIAGNOSIS

It depends on acquisition of appropriate database; the diagnosis

identifies, assesses, classifies, and evaluates the dynamic
interaction of the five variables.

Variances from wellness (needs and problems) are determined by

correlations and constraints through synthesis of theory and data
base.

Broad hypothetical interventions are determined, i.e. maintain

flexible line of defense.

NURSING GOALS

These must be negotiated with the patient, and take account of

patients and nurses perceptions of variance from wellness.

NURSING OUTCOMES

Nursing intervention using one or more preventive modes.

Confirmation of prescriptive change or reformulation of nursing

goals.

Short term goal outcomes influence determination of intermediate

and long term goals.

A client outcome validates nursing process.

NeumanS SYSTEM MODEL FORMAT

Neumans nursing process format designates the following categories of

data about the client system as the major areas of assessment.
ASSESSMENT

Potential and actual stressors.

Condition and strength of basic structure factors and energy

sources.

Characteristics of flexible and normal line of defenses, lines of

resistance, degree of reaction and potential for reconstitution.

Interaction between client and environment.

Life process and coping factors (past, present and future) actual
and potential stressors (internal and external) for optimal wellness
external.

Perceptual difference between care giver and the client.

NURSING DIAGNOSIS

The data collected are then interpreted to condition and formulate

the Nursing diagnosis.

Health seeking behaviors.

Activity intolerance.

Ineffective coping.

Ineffective thermoregulation.

GOAL

In Neumans systems model the goal is to keep the client system

stable.

PLANNING

Planning is focused on strengthening the lines of defense and

resistance.

IMPLEMENTATION
The goal of stabilizing the client system is achieved through three
modes of prevention

Primary prevention : actions taken to retain stability

Secondary prevention : actions taken to attain stability

Tertiary prevention : actions taken to maintain stability

EVALUATION

The nursing process is evaluated to determine whether equilibrium

is restored and a steady state maintained.

ACCEPTANCE BY THE NURSING COMMUNITY

Neumans model has been described as a grand nursing theory by

walker and Avant.

Grand theories can provide a comprehensive perspective for

nursing practice, education, and research and Neumans model
does.

PRACTICE

The Neuman systems model has been applied and adapted to

various specialties include family therapy, public health,
rehabilitation, and hospital nursing.

The sub specialties include pulmonary, renal, critical care, and

hospital medical units. One of the models strengths is that it can
be used in a variety of settings

Using this conceptual model permits comparison of a nurses

interpretation of a problem with that of the patient, so the patient
and nurse do not work on two separate problems.

The role of the nurse in the model is to work with the patient to
move him as far as possible along a continuum toward wellness.

Because this model requires individual interaction with the total

health care system, it is indicative of the futuristic direction the
nursing profession is taking.

The patient is being relabeled as a consumer with individual needs

and wants.

EDUCATION

The model has also been widely accepted in academic circles.

It has often been selected as a curriculum guide for a conceptual

framework oriented more toward wellness than toward a medical
model and has been used at various levels of nursing education.

In the associate degree program at Indiana University.

One of the objectives for nursing graduate is to demonstrate ability

to use the Neuman health care system in nursing practice. This
helps prepare the students for developing a frame of reference
centered on holistic care.

At northwestern State University in Shreveport, Louisiana, the

faculty determined that a systems model approach was preferred
for their masters program because of the universality framework.

Acceptance by the nursing community for education therefore is

evident.

RESEARCH

A study was published by Riehl and Roy to test the usefulness of

the Neuman model in nursing practice.

There were two major objectives of the study.

To test the model/assessment tool for its usefulness as a

unifying method of collecting and analyzing data for
identifying client problems.

To test the assessment tool for its usefulness in the

identification of congruence between the clients perception
of stressors and the care givers perception of client
stressors.

Results indicated that the model can help categorize data for
assessing and planning care and for guiding decision making.

Neumans model can easily generate nursing research.

It does this by providing a framework to develop goals for desired

outcomes. Acceptance by the nursing community for research
applying this model is in the beginning stages and positive.

NeumanS AND THE CHARACTERISTICS OF A THEORY

Theories connects the interrelated concepts in such a way as to

create a different way of looking at a particular phenomenon.

The Neuman model represents a focus on nursing interest in the

total person approach to the interaction of environment and health.

The interrelationships between the concepts of person, health,

nursing and society/environment are repeatedly mentioned
throughout the Neuman model and are considered to be basically
adequate according to the criteria.

Theories must be logical in nature

Neumans model in general presents itself as logically

consistent.

There is a logical sequence in the process of nursing wherein

emphasis on the importance of accurate data assessment is
basic to the sequential steps of the nursing process.

Theories should be relatively simple yet generalizable.

Neumans model is fairly simple and straightforward in

approach.

The terms used are easily identifiable and for the most part
have definitions that are broadly accepted.

The multiple use of the model in varied nursing situations

(practice, curriculum, and administration) is testimony in
itself to its broad applicability.

The potential use of this model by other health care

disciplines also attests to its generalizability for use ion
practice.

One drawback in relation to simplicity is the diagrammed

model since it presents over 35 variables and tends to be
awesome to the viewer.

Theories can be the bases for hypotheses that can be tested.

o

Neumans model, due to its high level and breadth of

abstraction, lends itself to theory development.

One are for future consideration as a beginning testable

theory might be the concept of prevention as intervention,
subsequent to basis concept refinement in the Neuman
model.

Theories contribute to and assist in increasing the general

body of knowledge within the discipline through the research
implemented to validate them.
o

The model has provided clear, comprehensive guidelines for

nursing education and practice in a variety of settings; this is
its primary contribution to nursing knowledge.

The concept within the guidelines is clearly explicated and

many applications of the theory have been published, little
research explicitly derived from this model has been
published to date.

Theories can be utilized by the practitioner to guide and

improve their practice.
o

One of the most significant attributes of the Neuman model

is the assessment/intervention instrument together with
comprehensive guidelines for its use with the nursing
process.

These guidelines have provided a practical resource for

many nursing practitioners and have been used extensively
in a variety of setting in nursing practice, education and
administration.

Theories must be consistent with other validated theories, laws

and principles but will leave open unanswered questions that
need to be investigated.
o

In general, there is no direct conflict with other theories.

There is, however, a lack of specificity in systems concepts
such as boundaries which are indirectly addressed
throughout the model.

Research Articles

Using the Neuman Systems Model for Best Practices-Sharon A. DeWan, Pearl N. Ume-Nwagbo, Nursing Science
Quarterly, Vol. 19, No. 1, 31-35 (2006).
o

The purpose of this study was to present two case studies

based upon Neuman systems model; one case is directed
toward family care, and the other demonstrates care with an
individual. Theory-based exemplars serve as teaching tools
for students and practicing nurses.

These case studies illustrate how nurses' actions, directed by

Neuman's wholistic principles, integrate evidence-based
practice and generate high quality care

Melton L, Secrest J, Chien A, Andersen B. A community

needs assessment for a SANE program using Neuman's
model J Am Acad Nurse Pract. 2001 Apr;13(4):178-86.
o

The purpose of the study was to present guidelines for a

community needs assessment for a Sexual Assault Nurse
Examiner (SANE) program using Neuman's Systems Model.

Sexual assault is a problem faced by almost every

community. A thorough community assessment is an
important first step in establishing programs that adequately
meet a community's needs.

Guidelines for conducting such an assessment related to

implementation of a SANE program are rare, and guidelines
using a nursing model were not found in the literature

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