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Betty Neumanns 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 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 psychology

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 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
Neumanns 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.

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.

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 (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 balance.

Degree to reaction: - the amount of system instability resulting from stressor invasion of the normal

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.

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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 Neumanns 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 occurs after the system reacts to a stressor and is provided in terms of existing

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 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: o Physiological- Refer of the physicochemical structure and function of the body. o Psychological- Refers to mental processes and emotions. o Socio-cultural- Refers to relationships; and social/cultural expectations and activities.

o Spiritual- Refers to the influence of spiritual beliefs. o 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

persons normal line of defense and so can affect the stability of the system.
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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 NURSING
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 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.

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.

NEUMANNS SYSTEM MODEL FORMAT Neumanns 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.

The data collected are then interpreted to condition and formulate the Nursing diagnosis. Health seeking behaviors. Activity intolerance. Ineffective coping. Ineffective thermoregulation.

In Neumanns systems model the goal is to keep the client system stable.

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

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


Neumanns 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 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

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.

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 masters program because of the universality framework.
Acceptance by the nursing community for education therefore is evident.

A study was published by Riehl and Roy to test the usefulness of the Neumann model in nursing

There were two major objectives of the study. o To test the model/assessment tool for its usefulness as a unifying method of collecting and

analyzing data for identifying client problems.

o 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.

Neumanns 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. NEUMANNS 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.
o The Neumann model represents a focus on nursing interest in the total person approach to the

interaction of environment and health.

o 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 o

Neumanns model in general presents itself as logically consistent.

o 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. o Neumanns model is fairly simple and straightforward in approach. o The terms used are easily identifiable and for the most part have definitions that are broadly

o The multiple use of the model in varied nursing situations (practice, curriculum, and administration)

is testimony in itself to its broad applicability.

o The potential use of this model by other health care disciplines also attests to its generalizability for

use ion practice.

o 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 Neumanns model, due to its high level and breadth of abstraction, lends itself to theory

o 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.

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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.

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Research Articles

Using the Neuman Systems Model for Best Practices--Sharon A. DeWan, Pearl N. UmeNwagbo, 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 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. 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 , 3 rd 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 3 rd 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 Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice, 2nd edition, Thomson, NY, 2002

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