Nursing Theory :

Betty Neuman’s

By:
Harpreet Kaur
M.Sc. 1st year
Biographical Information

1924 Born near Lowell, Ohio.

1947 Received RN Diploma from Peoples Hospital
School of Nursing, Akron, Ohio
Moved to California and gained experience as
a hospital, staff, and head nurse; school nurse
and industrial nurse; and as a clinical
instructor in medical-surgical, critical care
and communicable disease nursing.
1957 Attended University of California at Los
Angeles (UCLA) with double major in
psychology and public health.
Received BS in nursing from UCLA.
1966 Received Masters Degree in Mental Health, Public
Health Consultation from UCLA.
Recognized as pioneer in the field of nursing
involvement in community mental health.
Began developing her model while lecturing in
community mental health at UCLA.
1972 Her model was first published as a 'Model for
teaching total person approach to patient
problems' in Nursing Research.
1985 Received doctorate in Clinical Psychology from
Pacific Western University.
1998 Received second honorary doctorate - this one
from Grand Valley State University, Allendale,
Michigan.
Introduction

The Neuman System Model provides a comprehensive, flexible,

holistic, and systems-based perspective for nursing. This conceptual
model of nursing focuses attention on the response of the client
system to actual or potential environment stressors, and the use of
primary, secondary, and tertiary nursing prevention interventions for
retention, attainment, and maintenance of optimal client system
wellness.
- Betty Neuman (1996)
The Neuman Systems Model is a unique, systems-based
perspective that provides a unifying focus for approaching a wide
range of nursing concerns. The Neuman Systems Model is a
comprehensive guide for nursing practice, research, education, and
administration that is open to creative implementation… (And) has
the potential for unifying various health-related theories, clarifying
the relationships of variables in nursing care and role definitions at
various levels of nursing practice. The multidimensionality and
holistic systemic perspective of the Neuman Systems Model is
increasingly demonstrating its relevance and reliability in a wide
variety of clinical and educational settings throughout the world.
 The Neuman Systems Model was originally developed in
1970 at the University of California, Los Angeles, by Betty
Neuman, Ph.D., RN. The model was developed by Dr.
Neuman as a way to teach an introductory nursing course to
nursing students. The goal of the model was to provide a
holistic overview of the physiological, psychological, socio-
cultural, and developmental aspects of human beings. After a
two-year evaluation of the model, it was published in Nursing
Research (Neuman & Young, 1972).
INFLUENCES

Neuman's model was influenced by a variety of sources, but most

particularly:
The philosophy of writers such as
• deChardin
• Gestalt theory Hans Selye's
• General Adaptation Syndrome
• General Systems Theory
Pierre Tielhard deChardin was a Catholic priest and
scientist who is credited with first proposing the idea of
spiritual evolution. He believed that spiritually, humans are
evolving toward an ultimate perfection that he called the
Omega Point. He is most often associated with the idea of
a mind mesh, the interconnectedness of human spirit and
mind, similar to Carl Jung's collective unconscious.
Gestalt Theory is a theory of German origin that centers
around the concept of the Gestalt or the whole. It
emphasizes the primacy of the phenomenal (the perceived),
asserting that the human world of experience is the only
immediately given reality. The dynamic interaction of the
individual and the situation determines experience and
behavior (meaning that no two interactions will ever be the
same and we should not simplistically over generalize).
The General Adaptation Syndrome is quite pervasive and even
taught to high schoolers in their health class. It postulates that there
is a nonspecific response to stress involving three stages: 1) alarm,
2) resistance, 3) exhaustion. In the first stage, the body gears up in
preparation to deal with the stressor. In the second stage, the body
seeks to return to homeostasis-a resting state. If stressors are not
removed, then the body will not return to homeostasis, but will
enter the third stage, exhaustion, in which the body function begins
to breakdown.
General Systems Theory grew out of the field of Thermodynamics, a
branch of physics, chemistry and engineering. Thermodynamics is the
study of the flow of energy from one system to another. General systems
theory posits that the world is made up of systems that are interconnected
and are influenced by each other; systems can also be concentric with
smaller systems forming a larger system. Two key assumptions are that
energy is needed to maintain a high organizational state and that a
dysfunction in one system will affect other systems, particularly if the
dysfunctional system is a subsystem of a larger system.
Basic Assumptions
Though each individual client or group as a client system is unique,
each system is a composite of common known factors or innate
characteristics within a normal, given range of response contained
within a basic structure.
Many known, unknown, and universal environment stressors exist.
Each differs in its potential for disturbing a clients usual stability level,
or normal line of defense. The psychological, sociocultural,
developmental, and spiritual – any point in time can affect the degree
to which a client is protected by the flexible line of defense against
possible reaction to a single stressor or a combination of stressors.
Each individual client/client system, overtime, has evolved a normal
line of defense, or usual wellness/stability state.
When the cushioning, accordion like effect of the flexible line of defense is
no longer capable of protecting the client/client system against
environment stressor, the stressor breaks through the normal line of
defense. The interrelationships of variables – physiological, psychological,
sociocultural, developmental, and spiritual- determine the nature and
degree of the system reaction or possible reaction to the stressors.
The client, whether in a state of wellness or illness, is a dynamic composite
of the interrelationships of variables – physiological, psychological,
sociocultural, developmental, and spiritual. Wellness is on a continuum of
available energy to support the system in its optimal state.
Implicit within each client system is a set of internal resistance
factors known as lines of resistance, which function to stabilize
and return the client to the usual wellness state (normal line of
defense) or possibility to a higher level of stability following an
environmental stressor reaction.
Primary prevention relates to general knowledge that is applied
in client assessment and intervention in identification and
reduction or mitigation of risk factors associated with
environmental stressors to prevent possible reaction.
Secondary prevention relates to the symptomatology
following a reaction to stressors, appropriate ranking of
intervention priorities, and treatment to reduce their noxious
effects.
tertiary prevention relates to the adjustive process taking
place ass reconstitution begins and maintenance factors
move the client back in a circular manner toward primary
prevention.
The client is in dynamic constant energy exchange with the
environment.
 THE SYSTEM MODEL
Neuman's model is just that-a model, not a full theory. It is a conceptual framework, a
visual representation, for thinking about humans and nurses and their interactions. The
model views the person as a layered, multidimensional whole that is in constant dynamic
interaction with the environment. The layers represent various levels of defense
protecting the core being. The two major components in the model are stress reactions
and systemic feedback loops. Client reacts to stress with lines of defense and resistance
(Neuman, 1995). Continuous feedback loops fine-tune the lines of defense and resistance
so as to achieve maximal level of stability. The client is in continuous and dynamic
interaction with the environment. The exchanges between the environment and the client
are reciprocal (each one is influenced by the other). The goal is to achieve optimal system
stability and balance. Prevention is the main nursing intervention to achieve this balance.
Primary, secondary, and tertiary prevention activities are used to attain, retain, and
maintain system balance (George, 1996
Each layer, or concentric circle, of the Neuman model is made up of the
five person variables. Ideally, each of the person variables should be
considered simultaneously and comprehensively.
Physiological - refers of the physicochemical structure and function of
the body.
Psychological - refers to mental processes and emotions.
Sociocultural - 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.
CONCENTRIC CIRCLE OF NEUMAN’S MODEL

Central Core: Basic survival factors

Flexible Lines of Defense: outer barrier

Normal Line of Defense: stability in the system

Lines of Resistance : protect the basic structure

 Central Core
The basic structure, or central core, is made up of the basic survival factors that are
common to the species (Neuman, 1995, in George, 1996). These factors include:
system variables, genetic features, and the strengths and weaknesses of the system
parts. Examples of these may include: hair color, body temperature regulation
ability, functioning of body systems homeostatically, cognitive ability, physical
strength, and value systems. The person's system is an open system and therefore is
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
The flexible line of defense is the outer barrier or cushion to the
normal line of defense, the line of resistance, and the core structure.
If the flexible line of defense fails to provide adequate protection to
the normal line of defense, the lines of resistance become activated.
The flexible line of defense acts as a cushion and is described as
accordion-like as it expands away from or contracts closer to the
normal line of defense. The flexible line of defense is dynamic and
can be changed/altered in a relatively short period of time.
 Normal Line of Defense

The normal line of defense represents system stability

over time. It is considered to be the usual level of stability
in the system. The normal line of defense can change
over time in response to coping or responding to the
environment. An example is skin, which is stable and
fairly constant, but can thicken into a callus over time.
 Lines of Resistance
The lines of resistance protect the basic structure and
become activated when environmental stressors invade the
normal line of defense. Example: activation of the immune
response after invasion of microorganisms. 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.
 Reconstitution
Reconstitution is the increase in energy that occurs in
relation to the degree of reaction to the stressor.
Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution 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.
 Stressors
The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors).
Stressors are capable of having either a positive or negative effect on the
client system. A stressor is any environmental force which can potentially
affect the stability of the system: they may be:
• Intrapersonal - occur within person, e.g. emotions and feelings
• Interpersonal - occur between individuals, e.g. role expectations
• Extra personal - occur outside the individual, e.g. job or finance pressures
 Prevention
Primary
Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the
person (primarily the flexible line of defense) to enable him to better deal with stressors, and on the
other hand manipulates the environment to reduce or weaken stressors. Primary prevention
includes health promotion and maintenance of wellness.
Secondary
Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing
systems. Secondary prevention focuses on preventing damage to the central core by strengthening
the internal lines of resistance and/or removing the stressor.
Tertiary
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.
 BASIC STRUCTURE
PRIMARY PREVENTION BASIC FACTORS
REDUCE POSSIBILITY COMMON TO ALL
OF ENCOUNTER WITH ORGANISM i.e.
STRESSORS NORMAL TEMP. RANGE
STRENGTHEN FLEXIBLE STRESSORS STRESSOR GENETIC STRUCTURE
LINE IDENTIFIED RESPONSE PATTERN
CLASSIFIED AS TO KNOWS STRESSOR ORGAN STRENGTH
OR POSSIBILITIES i.e. WEAKNESS
LOSS EGO STRUCTURE
PAIN KNOWNS OR
SENSORY DEPRIVATION COMMONALITIES
CULTURAL CHANGE

INTRA
INTER PERSONAL
SECONDARY EXTRA FACTORS
PREVENTION Basic
EARLY CASE FINDING
TREATMENT OF Structure
SYMPTOMS Energy
REACTION sources
REACTION

reconstitution
INDIVIUAL INTERVENING
VARIABLES, i.e.
BASIC STRUCTURE
IDIOSYNCRASIES
NATURE AND LEARNING
RESISTANCE
TIME OF ENCOUNTER WITH
TERTIARY PREVENTION STRESSOR
READADAPTATION STRESSORS
REEDUCATION TO INTRA MORE THAN ON STRESSORS
PREVENT FUTURE INTER PERSONAL COULD OCCUR
OCCURENCES EXTRA FACTORS SAME STRESSORS COULD VARY
MAINTENANCE OF AS TO IMPACT OR REACTION
STABILITY NORMAL DEFENSE LINE VARIES
INTERVENTIONS WITH AGE AND DEVELOPMENT
CAN OCCUR BEFORE OR AFTER
RESISTANCE LINES ARE RECONSTITUTION
RECONSTITUTION PHASES COULD BEGIN AT ANY DEGREE
INTERVENTIONS ARE BASED ON: OR LEVEL OF REACTION
DEGREE OF REACTION RANGE OF POSSIBILITY MAY
RESOURCES EXTEND BEYOND NORMAL LINE
GOALS OF DEFENSE
ANTICIPATED OUTCOME
INTRA
INTER PERSONAL
EXTRA FACTORS
 META PARADIGM
Person
The person is a layered multidimensional being. Each layer
consists of five person variables or subsystems:
• Physical/Physiological
• Psychological
• Socio-cultural
• Developmental
• Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense. The
basic core structure is comprised of survival mechanisms including: organ
function, temperature control, genetic structure, response patterns, ego, and
what Neuman terms knowns and commonalities. Lines of resistance and two
lines of defense protect this core. The person may in fact be an individual, a
family, a group, or a community in Neuman's model. The person, with a core
of basic structures, is seen as being in constant, dynamic interaction with the
environment. Around the basic core structures are lines of defense and
resistance (shown diagrammatically as concentric circles, with the lines of
resistance nearer to the core. The person is seen as being in a state of constant
change and-as an open system-in reciprocal interaction with the environment.
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 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.
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)". As the person is in a constant interaction with the
environment, the state of wellness (and by implication any other state) is in dynamic
equilibrium, rather than in any kind of steady state. Neuman proposes a wellness-
illness continuum, with the person's position on that continuum being influenced by
their interaction with the variables and the stressors they encounter. The client system
moves toward illness and death when more energy is needed than is available. The
client system moves 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 actions 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 perceptions be assessed,
but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degrees
of reaction to stressors, and the use of primary, secondary and tertiary interventions.
 Neuman envisions a 3-stage nursing process:
• Nursing Diagnosis - based of necessity in a thorough
assessment, and with consideration given to five variables in
three stressor areas.
• Nursing Goals - these must be negotiated with the patient, and
take account of patient's and nurse's perceptions of variance
from wellness
• Nursing Outcomes - considered in relation to five variables,
and achieved through primary, secondary and tertiary
interventions.
 NEUMAN’S WORK AND THE
CHARACTERISTICS OF A THEORY
o Theories can interrelate concepts in such a way as to create a different way of
looking at a particular phenomenon.
o Theories must be logical in nature
o Theories should be relatively simple yet generalizable.
o Theories can be bases for hypotheses that can be tested.
o Theories contribute to and assist in increasing the general body of knowledge
with the discipline through the research implemented to validate them.
o Theories can be utilized by the practitioners to guide and improve their practice.
o Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated