Betty Neuman's Systems Model

"Health is a condition in which all parts and subparts are in harmony
with the whole of the client.”

BIOGRAPHY

1924 - Born in Lowell, a village in Washington County, Ohio, United States, along the Muskingum River

1947 - Obtained her Registered Nurse Diploma from the Peoples Hospital School of Nursing, in Akron Ohio. After that, she went to California where she worked in a hospital as a staff nurse, and eventually became the head nurse. She also explored other fields, and experienced being a school nurse, industrial nurse, and clinical instructor.

1957 - She went to the University of California at Los Angeles (UCLA) and took a double major in psychology and public health. She received her BS Nursing from this institution.

1966 - She completed her Masters degree in Mental Health, Public Health Consultation, also at UCLA. She became recognized as a pioneer in the field of nursing involvement in community mental health.

1970 - Started developing The Systems Model as a way to teach an introductory nursing course to nursing students. The goal was to provide a Holistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings.

1972 - After a two-year evaluation of her model, it was eventually published in Nursing Research.

1985 - She completed her doctorate in Clinical Psychology from Pacific Western University.

1988 - She founded the Neuman Systems Model Trustee Group, Inc. They are dedicated to the support, promotion and integrity of the Neuman Systems Model to guide nursing education, practice and research.

1992 - She was given an Honorary Doctorate of Letters, at the Neumann College, Aston, Pennsylvania.

1993 - Because of her important contributions to the field on Nursing, Dr. Neuman was named Honorary Member of the Fellowship of the American Academy of Nursing.

1998 - Received an Honorary Doctorate of Science from the Grand Valley State University in Michigan. For the past years, Dr. Betty Neuman has continuously developed and made famous the Neuman systems model through her work as an educator, author, health consultant, and speaker. Her model has been very widely accepted, and though it was originally designed to be used in nursing and is now being used by other health professions as well.

As keynote speaker at the University of Maine (2004)

INFLUENCES

Betty Neuman took inspiration in developing her theory from the following theories/ philosophers:

1. Pierre Tielhard deChardin : a philosopher-priest that believed human beings are continually evolving towards a state of perfection – an Omega Point

2. Gestalt Theory : A theory of German origin which proposes that the dynamic interaction of the individual and the situation determines experience and behavior.

3. General Adaptation Syndrome mainly talks about an individual’s reaction to stress on the 3 levels a) alarm b) resistance c) exhaustion

4. General Systems Theory postulates that the world is made up of systems that are interconnected and are influenced by each other.

The Neuman System Model

KEY CONCEPTS

• Viewed the client as an open system consisting of a basic structure or central core of energy resources which represent concentric circles

• Each concentric circle or layer is made up of the five variable areas which are considered and occur simultaneously in each client concentric circles. These are:

1. Physiological - refers of bodily structure and function.
2. Psychological - refers to mental processes, functioning and emotions.
3. Sociocultural - refers to relationships; and social/cultural functions and activities.
4. Spiritual - refers to the influence of spiritual beliefs.
5. Developmental - refers to life’s developmental processes.

Basic Structure Energy Resources

This is otherwise known as the central core, which is made up of the basic survival factors common to all organisms. These include the following:

1. Normal temperature range – body temperature regulation ability
2. Genetic structure – Hair color and bodily features
3. Response pattern – functioning of body systems homeostatically
4. Organ strength or weakness
5. Ego structure
6. Knowns or commonalities – value system

• The person's system is an open system - dynamic and constantly changing and evolving

• 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
  

Flexible Lines of Defense

• Is the outer boundary to the normal line of defense, the line of resistance, and the core structure.

• Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences.

• If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated.
  

Normal Line of Defense

• Represents client’s usual wellness level.

• Can change over time in response to coping or responding to the environment, which includes intelligence, attitudes, problem solving and coping abilities. Example is skin which is constantly smooth and fair will eventually form callous over times.

Lines of Resistance

• the last boundary that protects the basic structure

• Protect the basic structure and become activated when environmental stressors invade the normal line of defense. An example would is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection.

• If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Stressors

• Are capable of producing either a positive or negative effect on the client system.

• Is any environmental force which can potentially affect the stability of the system:

1. Intrapersonal - occur within person, example is infection, thoughts and feelings
2. Interpersonal - occur between individuals, e.g. role expectations
3. Extrapersonal - occur outside the individual, e.g. job or finance concerns

• A person’s reaction to stressors depends on the strength of the lines of defense.

• When the lines of defense fails, the resulting reaction depends on the strength of the lines of resistance.

• As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution.
  

Reconstitution

• Is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors.
• May expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.
• Nursing interventions focus on retaining or maintaining system stability.
• By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system.
  

Prevention

• Is the primary nursing intervention.

• Focuses on keeping stressors and the stress response from having a detrimental effect on the body.

1. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness.
   
2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation.
   
3. Tertiary prevention focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This 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.

Betty Neuman's System Model

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APPLICATION

The main use of the Neuman Model in practice and in research is that its concentric layers allow for a simple classification of how severe a problem is. For example, since the line of normal defense represents dynamic balance, it represents homeostasis, and thus a lack of stress. If a stress response is perceived by the patient or assessed by the nurse, then there has been an invasion of the normal line of defense and a major contraction of the flexible line of defense. Infection or other invasion of the lines of resistance indicates failure of both lines of defense. Thus, the level of insult can be quantified allowing for graduated interventions. Furthermore each person variable can be operationalized and the relationship to the normal line of defense or stress response can be analyzed. The drawback of this is that there is no way to know whether our operationalization of the person variables is a good representation of the underlying theoretical structures.

For example, Eileen Gigliotti published a research article in 1999 based on the Neuman Systems Model. The study investigated the relationship of multiple role stress to the psychological and sociocultural variables of the flexible line of defense. If multiple role stress had occurred, then the normal line of defense had been invaded. Questionnaire instruments were used to operationalize the psychological component with perceived role as a student and as a mother; the sociocultural component with social support, the normal line of defense as perceived multiple role stress.

Upon analysis, no conclusions could be made about the normal line of defense simply on the basis of the psychological component and sociocultural component. By dichotomizing the data by median age, however, a relationship between them could be described. Thus the relationship between the normal line of defense and the psychological and sociocultural components could only be described by taking into account the developmental component. It indicates that the components of the flexible line of defense interact in very complex ways and it may be difficult and dangerous to overgeneralize their interaction.

PERSONAL EXPERIENCES

Experience #1

I’m assigned at the service/charity ward of PDMMMC few months ago. As a staff in the ward of a government hospital, I noticed many weaknesses and shortcomings in the medical management and nursing care as well maybe due to the city government’s not prioritizing health care. They say it is maybe due to “lack of budget” but I really don’t believe in that same old music. I know there is, but the question is where is it going? We are badly lacking of resources, instruments and material so we need to improvise. And most of all, we are under staff so proper nursing care is compromised to every patient plus the fact that the environment is not conducive to the nurses and the patients. At that time, a 25 year old female patient was transferred to our ward from the ICU. The case was PTB advanced and heart problem. I was very curious why? They said that the patient is stable but the catch is she was admitted to the isolation room of the charity ward together with other PTB cases and with minimum nursing care because of the overwhelming census. Based on my own assessment, the patient is not yet stable, I think the true reason for transfer is that the patient can no longer withstand the demands for her medication in ICU because she is the one who is availing that, or maybe there is a much priority patient who will be placed in ICU, because it is only two – bed capacity so they need to manage and decide very well on admissions and discharge. And if they want to transfer the patient post ICU, why in service ward that is not so conducive? Of course the patient is financially incapable to be admitted to pay ward.

The client’s flexible line of defense is compromised here; she had a hard time resting because the temperature in the isolation room is very warm and humid even if she has an electric fan. Her nutritional level is also not good and quantity of stress increases. Her normal line of defense is also unstable, she is not well and we can assess she is not. And her line of resistance is severely debilitated; she has PTB infection and dyspnea. Her environment to isolation room further worsens her condition.

Extrapersonal stressors like the isolation room environment where infection is floating around the room and also the nursing care that nurses wasn’t able to render because of the nurse to patient ratio of 1:30 which is not very ideal. She also has interpersonal stressors like the problem of broking up with his husband and for not having the opportunity to see her son because children are restricted to ward premises especially in isolation room. And her intrapersonal stressors like disturbed emotional status, deteriorating physical ability and financial problems.

These factors disrupted the reconstitution of the patient. In this situation, primary prevention is not given priority, because her admission to charity ward, isolation room increases her risk to infection and stress and limited nursing care. In secondary prevention, we succeed in the first part in ICU but wasn’t able to continue in the ward because of many factors as stated above. Even the prescribed medications are not purchased because of financial constraints. In tertiary prevention, sometimes we nurses do our best, but fate will still prevail. Patient died that evening during endorsement before we receive her case. Nursing goal is not met. And lessons are learned.

Neuman system model is a delicate tool to be used in nursing care especially in identifying the stressors, the interventions, and the affectation in the line of defenses of the client that we must protect to maintain quality of life, reconstitution and optimum level of functioning of our clientele and much better in disease prevention. Holistic care should be given to all of our patients at all times in any setting.

Experience #2

About a week ago I had in my care the wife of the captain of the ill-fated Princess of the Stars. In this case, I was able to identify the following stressors:

1. Psychological-Emotional:

• Anxiety which stemmed from the uncertainty about the fate of her husband.
• A sense of guilt because relatives of the passengers are blaming her husband for the tragedy.
• Ambivalence in the sense that she would be happy if her husband survived and at the same time worried too that if he did survive he would be subjected to court litigation.

2. Financial Stress: Her husband is the breadwinner of the family and in a brood of 5 children, only one is employed; the rest are still in school.

3. Physical Stress manifested as:

a. Insomnia

b. Elevated blood pressure unresponsive to maintenance medications

c. Persistent chest pains

Nursing interventions are carried out on three preventive levels:

• Primary Prevention would not be applicable because the accident causing the stressors has already occurred and the patient has already developed the reactions/symptoms of stress.

• Secondary Prevention is applicable in this case. Because of the persistent elevated blood pressure ( above 200/110) accompanied by severe chest pains, the patient was admitted to the hospital for both diagnostic and therapeutic management. Nursing intervention centered initially on the round the clock monitoring of the blood pressure and giving of the ordered anti- hypertensive drugs. Since the EKG showed ischemia, the patient was closely watched for worsening of the pain because of the possibility of a myocardial infarction. Immediate referral of the patient to the resident physician is to be made if chest pain persisted despite giving isosorbide dinitrate for proper evaluation. Aside from giving anxiolytics to decrease the anxiety of the patient, I have to warn visiting relatives to refrain from talking about the tragedy. Sedatives were given before bedtime to prevent insomnia.

• Tertiary Prevention: Upon discharge, I gave the patient and the immediate family members the following advice:

1. If possible to stay in a relative’s house for a few weeks because they were being hounded by media who were camped outside their home.
2. Regular monitoring of the patient’s blood pressure by a daughter who is a student-nurse who should also monitor her intake of medications as prescribed by the physician.
3. Avoid watching TV shows that mention about the tragedy.
4. Avoid answering the phone.
5. She should have a close relative with her aside from the children who will manage their affairs in the meantime.

Experience #3

In the Community...
In one of the rotations of my students in the community, we encountered this very interesting newly married young couple (both are 18 years old). They have been married only for 3 months, but the supposed to be happy pair is already facing a lot of stressors.

One condition that brings extrapersonal stress is the unemployment of the husband. Their financial source is not enough to meet their needs. The woman somzd enough for her son. This relationship poses as an interpersonal stress to her.

The wife is also pregnant at that time, and her poor nutritional (underweight) and emotional status (sadness and anger at her mother-in-law) create intrapersonal stresses.

We know, based on Neuman’s Systems Model, that the reaction to stressors would depend on the strength of the lines of defense. The woman, due to financial constraints, is suffering from poor nutritional status. She usually lacks enough sleep due to the nature of her work. This creates a breach to her flexible line of defense. The normal line of defense also becomes unreliable because of her uncaring attitude toward her pregnancy and sexual behaviors that predispose her to a lot of possible illnesses. Her coping abilities are also affected because she is sometimes preoccupied with her relationship problems with her mother-in-law.

These conditions put not only our client but also her unborn child on the verge of developing various illnesses. Hence, our interventions focused on restoring system stability, by helping the client’s system adapt to the stressors.

Starting with primary prevention, we tried to educate their family on the importance of having good nutrition. We suggested some nutritious but cheap food choices. We also tried to advice her on possible alternative jobs that would not jeopardize her health and that of her unborn baby.

For the secondary prevention, we advised that she seek pre-natal check-up, and make use of the available services of the nearby health center.

After about 1 month of constant visits to these clients, we really observed noticeable improvements in their health conditions. The woman began to show weight gains consistent with her age of gestation. The couple has also learned to plant and eat nutritious food such as fruits and vegetables. The husband started to work as a production operator in a nearby factory, allowing his wife to take a break from her old job.

Before our duty in the community ended, we were able to initiate tertiary prevention by supporting and commending the positive behavioral changes exhibited by the couple. We also dwelt on strengthening the positive attributes of the family, such as their unwavering faith in God, and their strong devotion to each other. We learned from this experience that no problem is unsolvable with the use of consistent and well-contemplated nursing care.

REFERENCES:

Websites:
http://www. google.com

http://www.neumansystemsmodel.org

http://www.neumansystemsmodel.org/NSMdocs/nsm_powerpoint_overview.htm

http://www.patheyman.com/essays/neuman/index.htm

Patrick Heyman and Sandra Wolfe, University of Florida, April 2000 http://www.patheyman.com/essays/neuman/implications.htm


Books

Añonuevo, C. et. Al (2000). N207 Theoretical Foundations of Nursing. Philippines: UP Open University

Balita, Carlito E. (2005). Ultimate Learning Guide to Nursing Review. Ultimate Learning Series

Kozier, B. et. Al (2004). Fundamentals of Nursing: Concepts, Process, and Practice (4^th ed.) New Jersey: Pearson

Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (2nd edition). St. Louis: Mosby

Octaviano, Eufemia F. and Balita, Carlito E. Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate Learning Series, 2008



CONTRIBUTORS

Reyes, Jose Richard III

Ricana, Ryan

Rico, Ron Paulo

Rimas, Ma. Filipina

Rosales, Ava

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”