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

• Neumann’s 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

• 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 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.
  • 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.

• 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 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.

• 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 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 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.

• 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 stable.

• Planning is focused on strengthening the lines of defense and resistance.

• 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 evident.

• 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 health.
  • 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 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.
  • Neumann’s 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.
  • 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.

• “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  
• 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

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