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Nursing Theories

Nursing Theories


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Published by: Dennis Nabor Muñoz, RN,RM on Jan 03, 2009
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Betty Neumann’s 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.


Betty Neumann 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

She was a pioneer in the community mental health movement in the

late 1960s.

Betty Neumann began developing her health system model while a
lecturer in community health nursing at University of California, Los

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


Neumann’s model was influenced by a variety of sources.

The philosophy writers deChardin and cornu (on wholeness in


Von Bertalanfy, and Lazlo on general system theory.

Selye on stress theory.

Lararus on stress and coping.


Each client system is unique, a composite of factors and
characteristics within a given range of responses contained within a basic

Many known, unknown, and universal stressors exist. Each differ in
it’s potential for disturbing a client’s 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.


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

The basis structure, or central core, is made up of the basic survival
factors that are common to the species (Neumann,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

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


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

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.


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).


According to Neumann’s 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 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


Primary prevention includes health promotion and maintenance of



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


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


The focus of the Neumann 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:


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.


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 extra-
personal stressors which can affect the person’s normal line of defense and
so can affect the stability of the system.

The internal environment exists within the client system.

The external environment exists outside the client system.

Neumann also identified a created environment which is an
environment that is created and developed unconsciously by the
client and is symbolic of system wholeness.


Neumann 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 (Neumann, 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


Neumann sees nursing as a unique profession that is concerned with
all of the variables which influence the response a person might have to a

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 nurse’s perception will influence the
care given, then not only must the patient/client’s 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


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.


These must be negotiated with the patient, and take account of
patient’s and nurse’s perceptions of variance from wellness.


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.


Neumann’s nursing process format designates the following categories of data
about the client system as the major areas of 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.


The data collected are then interpreted to condition and formulate

the Nursing diagnosis.

Health seeking behaviors.

Activity intolerance.

Ineffective coping.

Ineffective thermoregulation.


In Neumann’s systems model the goal is to keep the client system



Planning is focused on strengthening the lines of defense and



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

Primary prevention : actions taken to retain stability

Secondary prevention : actions taken to attain stability

Tertiary prevention : actions taken to maintain stability


The nursing process is evaluated to determine whether equilibrium is
restored and a steady state maintained.


Neumann’s 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 Neuman’s model does.


The Neumann 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 model’s strengths is that it can be used
in a variety of settings

Using this conceptual model permits comparison of a nurse’s
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.


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 Neumann 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
master’s program because of the universality framework.

Acceptance by the nursing community for education therefore is



A study was published by Riehl and Roy to test the usefulness of the
Neumann 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 client’s perception of
stressors and the care giver’s perception of client stressors.

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

Neumann’s 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.


Theories connects the interrelated concepts in such a way as
to create a different way of looking at a particular phenomenon.


The Neumann model represents a focus on nursing interest in
the total person approach to the interaction of environment and


The interrelationships between the concepts of person, health,
nursing and society/environment are repeatedly mentioned
throughout the Neumann model and are considered to be basically
adequate according to the criteria.

Theories must be logical in nature


Neumann’s model in general presents itself as logically



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.


Neumann’s model is fairly simple and straightforward in



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.


Neumann’s 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.


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.


One of the most significant attributes of the Neumann 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.


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

1.“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).


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
2.Melton L, Secrest J, Chien A, Andersen B. “A community
needs assessment for a SANE program using Neuman's model”
Am Acad Nurse Pract. 2001 Apr;13(4):178-86.

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


Timber BK. Fundamental skills and concepts in Patient Care, 7th

edition, LWW, N

George B. Julia , Nursing Theories- The base for professional Nursing

Practice , 3rd

ed. Norwalk, Appleton and Lange.

Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.

Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development &

Progress 3rd

ed. Philadelphia, Lippincott.

Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th
ed. Philadelphia, Lippincott.

Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –
Concepts Process & Practice 3rd

ed. London Mosby Year Book.

Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15

Reed PG, The force of nursing theory guided- practice. Nurs Sci Q.

2006 Jul;19(3):225

Cheng MY. Using King's Goal Attainment Theory to facilitate drug
compliance in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.

Delaune SC,. Ladner PK, Fundamental of nursing, standard and
practice, 2nd edition, Thomson, NY, 2002

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