Neuman Systems Model in Nursing Practice
Kathleen M. Flaherty
The philosophic base of the Neuman Systems Model encompasses wholism, a wellness orientation, client perception and motivation, and a dynamic systems perspective of energy and variable interaction with the environment to mitigate possible harm from internal and external stressors, while caregivers and clients form a partnership relationship to negotiate desired outcome goals for optimal health retention, restoration and maintenance.
History and Background
The Neuman Systems Model was first developed in 1970 to assist graduate students to consider patient needs in wholistic terms (Neuman, 1974, 2011).∗ “Helping each other live” is Neuman’s basic philosophy (Neuman, 2011, p. 333) and the Neuman Systems Model is a synthesis of systems thinking and wholism that provides a comprehensive systems approach for wellness-focused nursing care. Neuman’s model has been developed and influenced by personal experiences, open systems theories (Lazarus, 1981, 1999; von Bertalanffy, 1968), Selye’s (1950) construct of environmental stressors, holism (Cornu, 1957; de Chardin, 1955), gestalt theories of environment and person interaction (Edelson, 1970), and Caplan’s (1964) concept of prevention interventions, among others (Neuman, 2011).
Neuman developed the current conceptual model over almost four decades (Neuman, 1974, 1980, 1982a, 1989a, 1990, 1995a, 1996, 2002, 2011; Neuman & Young, 1972). Since 1980, a special nursing process format has been developed to facilitate model use in practice, the concept of environment has been expanded and clarified, a distinct spiritual variable has been added and explicated, the use of the term client has replaced patient, and clarifications of model componentsand relationships among these components have been provided (Neuman, 2011). The most recent publication of the Neuman Systems Model text uses the original diagram and presents the model components within the nursing metaparadigm of person, environment, health, and nursing (Neuman, 2011). This publication also provides guidelines for implementation of the model in clinical practice, nursing research, nursing education, and nursing administration, in addition to current and anticipated future applications (Neuman & Fawcett, 2011). Enhanced understanding of model components—client, reconstitution, and created environment—are provided (de Kuiper, 2011; Gehrling, 2011; Jajic, Andrews, & Jones, 2011; Tarko & Helewka, 2011).
In 1988, Neuman established the Neuman Systems Model Trustees Group to “preserve, protect, and perpetuate” the use of the model (Neuman & Fawcett, 2011, p. 355). The trustees established the Institute for Study of the Neuman Systems Model to provide support in the origination and testing of middle-range theories developed from the model (Neuman & Fawcett, 2011). Nurses continue to test and apply the Neuman Systems Model in nursing research, clinical practice, education, and administration. The utility of the model in each area is evidenced within Neuman’s books (Neuman, 1982b, 1989b, 1995b; Neuman & Fawcett, 2002, 2011). Fawcett compiled a bibliography of Neuman Systems Model applications. Scholars, practitioners, and students can access this bibliography, updated through July 2011 (an ongoing project), at the Neuman Systems Model website (http://neumansystemsmodel.org). Recent literature describes use of the Neuman Systems Model in research and praxis in a variety of applications. Some of these treatments include use of the model for evidence-based practice development (Breckenridge, 2011); Merks, Verbeck, de Kuiper, et al., 2012), promoting student coping and success (Das, Nayak, & Margaret, 2011; Pines, Rauschhuber, Norgan, et al., 2012; Yarcheski, Mahon, Yarcheski, et al., 2010), family participation in critical care (Black, Boore, & Parahoo, 2011), spirituality in adults (Cobb, 2012; Lowry, 2012), nurse stress in emergency care (Lavoie, Talbot, & Mathieu, 2011), and application in nursing administration (Shambaugh, Neuman & Fawcett, 2011).
Neuman considers “client” to be an individual, a group, a family, or a community system. Each client is viewed with five variables that interact synergistically in relation to each other and reciprocally with the internal, external, and created environments in which the client exists. The five client variables essential to the Neuman model are physiological, psychological, developmental, sociocultural, and spiritual. Intrapersonal, interpersonal, or extrapersonal environmental stressors can affect potential or actual reactions within the client system.
A continuum of increasing wellness to increasing illness, and even death, is the basis by which wellness is understood. Whenever the system has more energy stored than needed, the client is considered within the range of wellness. Conversely, whenever system energy depletion occurs, variances from wellness (illness) are exhibited in clients. In the Neuman model, optimal system stability is the greatest degree of client wellness. Consequently, the major goal of nursing is to assist the client in achieving system stability through the attainment, retention, and maintenance of optimum health. Accordingly, it is the nurse who creates the connections among the client, environment, health, and nursing that lead to systemstability. Nurses practicing according to the Neuman model promote system stability through primary, secondary, or tertiary prevention-as-interventions.
Client system stability is significantly affected by clients’ perceptions that in turn have a significant effect on the increase or decrease in energy available to them. Therefore, if the nurse is to facilitate energy use in wellness promotion, accurate appreciation of the client’s perception of the health care situation is essential (Neuman, 2011).
Neuman uses the term wholism to reference biological and philosophical concepts “implying relationships and processes arising from wholeness, dynamic freedom, and creativity in adjusting to stressors in the internal and external environments” (Neuman, 2011, p. 10). The Neuman Systems Model incorporates the structure and process components of open systems models (Sohier, 2002). Such incorporation of open systems models to her conceptual framework is demonstrated by Neuman’s technical use of the word wholism as opposed to holism. The “homologous” (Neuman, 2011, p. 9) nature of open systems, the model and nursing concepts empowers the nurse using the Neuman Systems Model to fulfill two concurrent responsibilities inherent to the model. First, Neuman’s emphasis on wholism motivates nurses to view the client as an interrelated whole different from and greater than the sum of the parts. Second, nurses using the Neuman model are able to focus on a particular subpart of a client situation without neglecting the interrelatedness of the system.
Overview of Neuman Systems Model
The aim of the Neuman model “is to set forth a structure that depicts the parts and subparts and their interrelationship for the whole of the client as a complete system” (Neuman, 2011, p. 12). As depicted in Figure 11-1, and beginning from the center of the figure, the Neuman model identifies a basic structure of energy resources, variables, system boundaries, and the environment as the core subparts of the system.
At the core of the diagram, energy resources are noted. A constant energy exchange occurs between the client system and environment. The client maintains and augments system stability by using energy, regarded as a positive force available to the system. As such, stability is not static but adaptive and developmental in nature because the client system is considered an open system in a state of constant change.
A series of protective rings encircle the center structure and protect the system from environmental stressors. Each system component is intersected by five variables (physiological, psychological, sociocultural, developmental, and spiritual). These five variables interact synergistically and wholistically within all parts of the client system (Neuman, 2011).
As noted, Neuman considers “client” to be an individual, a group, a family, or a community system. Accordingly, the substance of each of the five variables depends on which client system is being considered. For example, the physiological variable is defined as “body structure and internal function” (Neuman, 2011, p. 16). Therefore, circulation could be considered a physiological variable for anindividual. Objective data that reflect the physiological variable of circulation would include vital signs, peripheral pulses, and heart sounds. However, for a community system, the physiological variable could include vital statistics, morbidity, mortality, and general environmental health (Hassell, 1998, Jajic, et al., 2011). Psychological variables include “mental processes and interactive environmental effects…” (Neuman, 2011, p. 16). For example, self-esteem and its effect on relationships for the individual and communication patterns for a family could be considered components of the psychological variable. The developmental variable refers to life developmental processes and/or developmental tasks that relate to life changes (e.g., individual adjustment to aging parents or “empty nest syndrome” for a couple). The combination of social and cultural functions or influences defines the sociocultural variable. Both ethnic cultural practices and health belief practices are examples and important components of this variable regardless of how the client system is defined. Client belief influence is exhibited in the spiritual variable. As an example, spiritual factors could include a person’s worldview and perceived sources of strength or hope, or the predominant religious culture of a community system (Hassell, 1998). Neuman proposes each of these five variables as system subparts that are open, with energy exchange existing within and between the client system and the environment (Neuman, 2011). As noted in Figure 11-1, these five variables are considered simultaneous influences on the system.
At the center of the diagram is the client’s basic structure composed of energy resources that Neuman calls “survival factors” (Neuman, 2011, p. 16). Within the basic core, the five interacting variables (physiological, psychological, developmental, sociocultural, and spiritual) contain commonly known norms (Neuman, 2011). For example, the individual as client possesses common resources such as organ structure and function, mental status, and coping mechanisms that are integral to core system stability. Alternatively, the client as family has a basic structure that includes specific roles, attitudes, and cultural beliefs that provide energy resources and stability.
Lines of resistance protect the client’s basic structure. These are defenses activated by the client when internal or external environmental factors stress the client system. Broken lines that circle the basic structure diagrammatically represent these lines of resistance. The internal immune system is an example of a physiological variable activated within the lines of resistance when infection invades an individual. The client system restabilizes for wellness/energy conservation (reconstitution) whenever these lines of resistance effectively mobilize internal and external resources. Energy depletion and ultimately death occur whenever the lines of resistance are ineffective (Neuman, 2011). Ineffective lines of resistance can be seen when an individual has had extensive chemotherapy (an external stressor), with the result of the immune system being severely compromised. This compromise of the immune system is an example of system energy depletion. Mobilization of external resources (transfusion) helps the client’s internal resources and strengthens the lines of resistance. The outcome of these added external resources is a more physiologically stable client.
Neuman regards the normal line of defense as the usual or standard client level of wellness that protects the basic structure as the client system reacts to stressors. A solid line that circles the lines of resistance and basic structure represents this protection. The standard level of wellness is achieved by the interaction of the five variables over time. Clients’ usual level of wellness (the normal line of defense) is maintained, increased, or decreased as stressed clients react to a stressor encounter (Neuman, 2011).
The normal line of defense is encircled by the flexible line of defense, represented by broken lines that suggest the constant interaction of the environment and the open nature of the system. The flexible line of defense expands and contracts depending on the protection available to the client at any point in time. For example, healthy lifestyles and effective coping mechanisms function as possible expanders of the flexible line of defense. Stressors may invade the client/client system but are buffered by this line, thereby freeing clients from reactions to those stressors. The protection of the client system is proportionate to the distance between the flexible line of defense and the normal line of defense (Neuman, 2011).
Neuman has clarified and expanded the concept of environment to include three discrete yet interactive environments that influence the system. Neuman’s most recent publication (2011) describes how the internal and external factors that interact with the client/client system are considered part of the environment. The intrapersonal environment is the internal environment that includes influences within the system. The external environment is considered both interpersonal andextrapersonal in nature. The created environment is the third distinct aspect of Neuman’s construct of environment. Neuman describes this created environment as unconsciously developed by the client system and as “a symbolic expression of system wholeness” as it mobilizes all system components towards wellness (Neuman, 1989, p. 32; 2011, p. 20).
The maintenance of purposeful system stability involves constant energy interchange with the internal, external, and created environments. The manner in which the individual client processes a life event such as pain is based on past experiences with pain. This is an example of the interaction of internal, external, and created environments. The client’s past experiences with pain and the elicited coping mechanisms and outcomes result in the creation of a perceptual reality for the interpretation of the current situation. This created perceptual reality (created environment) influences the client’s response to the painful situation (de Kuiper, 2011).
Client system stability can be affected by internal or external environmental factors, which Neuman defines as stressors. Neuman considers the effect of these stressors, whether they are positive or negative, to be dependent on the client’s perception of the stressor. When stressors penetrate the flexible and normal lines of defense and the lines of resistance are activated, energy depletion and system instability occur. However, system stability may be maintained when stressors are deflected or modulated by the interaction of the five system variables within the flexible and normal lines of defense and the lines of resistance (Neuman, 2011).
Stressors that can influence client system stability are classified in three ways: intrapersonal, interpersonal, and extrapersonal. First, internal stressors that occur within the client system boundary are classified as intrapersonal. Atherosclerosis and resultant hypertension are examples of an individual client’s intrapersonal stressors. Second, stressors that occur in the external environment outside but proximal to the client system boundaries are classified as interpersonal. The individual client’s role in the family, perceptions of caregiver, and friend relationships are examples of these forces. Third, extrapersonal stressors are those that occur distally to the client boundary. Community resources, financial status, and employment of the individual client are examples of extrapersonal stressors. Because of the complexity of human beings, all three stressors may be exhibited in clients and observed by nurses in any nursing situation (Neuman, 2011).
Application of the Neuman Systems Model in nursing praxis can occur in any setting. In each nursing situation, the nurse completes a wholistic assessment of actual or potential stressors, client variables, and boundary impact. The nurse determines the client’s perspective before the analysis and synthesis of the objective and subject data collection. In addition, client strengths, weaknesses, and resources are considered.
Identification and differentiation of both nurse and client perceptions in the health care situation are required by the Neuman Systems Model. This requirement is rooted in the understanding that client stability and optimal health outcomes can be compromised by incongruities between nurse and client perceptions. These incongruities can be avoided by developing a partnership between the nurse and the client, with care based on their complementary perceptual understandings. The result of such a complementary partnership is joint planning of care based on goalclarification. Because perception can influence client response and resistance to a stressor, resolving the potential perceptual differences for nurses and clients is essential within the Neuman model. Neuman has provided a formalized nursing process that includes specific subjective data gathering about the client perspective (Neuman, 2011). Once data collection is complete, the nurse analyzes and synthesizes the data and in conjunction with the client determines nursing diagnoses, goals, outcomes, and interventions.
There are three different intervention modalities or nursing actions specific to the actual or potential stressor response from the client system described by Neuman. These interventions are dynamic and cyclical in nature and are labeled as primary, secondary, and tertiary prevention-as-interventions. Nurses may use the three intervention modalities concurrently to achieve a synergistic effect. Optimal client wellness or system stability is the ultimate goal of these three interventions. Primary interventions retain, secondary interventions attain, and tertiary interventions maintain system energy (Neuman, 2011).
Before the client system reacts to stressors and to prevent a stressor invasion, nursing actions should be implemented as primary prevention interventions to strengthen the flexible line of defense. This preemptive nursing act promotes the retention of client system wellness (Neuman, 2011). Nursing actions such as instituting a wellness program that integrates healthy nutrition and exercise would be an example of primary prevention-as-intervention.
Nursing actions necessary for the client system to attain restabilization (reconstitution) through energy conservation and the use of internal and external resources are considered secondary preventions. These interventions protect the basic structure of the system. The nurse implements secondary prevention actions whenever stressor reactions occur and symptoms are present. Symptom treatment of hypertension is an example of secondary intervention. Dynamic system stability is achieved and the basic structure is protected whenever the lines of resistance are strengthened. “Reconstitution may be viewed as feedback from the input and output of secondary intervention” (Neuman, 2011, p. 29). If secondary preventions are not successful in reconstituting client system energy to counterbalance system reaction, death can occur (Neuman, 2011).
After a therapeutic modality and reconstitution, the maintenance of client system stability is achieved by tertiary prevention-as-interventions (Neuman, 2011). Nursing actions such as education and reinforcement about nutrition, exercise, and medications that can maintain the reconstitution of the client with hypertension are examples of tertiary prevention. Applications of the Neuman Nursing Process Format to specific client situations are provided later in this chapter.
Critical Thinking in Nursing Practice with Neuman’s Model
The Neuman Systems Model provides a structure for critical thinking in several ways. As a systems-based model, conceptualization of clinical nursing phenomena can be approached wholistically while appreciating the interaction of the part and subpart components of the system that adapt synergistically and developmentally to promote system persistence (Fawcett, 2005; Neuman, 2002). In addition, thissystems-based model allows for reconceptualization when clinical situations undergo rapid change. In such rapid change situations, the Neuman Systems Model allows for the identification of interrelationships between identified systems, parts, subparts, and the environment, leading to consequent and rational nursing actions. Therefore, this conceptualization of nursing phenomena promotes efficacious critical thinking processes such as application, analysis, synthesis, and evaluation. The Neuman Systems Model nursing process categories of nursing diagnoses, nursing goals, and nursing outcomes create a format for purposeful critical thinking and problem solving that translates to action (Freese, Neuman, & Fawcett, 2002; Freiburger, 2011).
Freese and colleagues (2002) identify guidelines for Neuman Systems Model–based clinical practice using Neuman’s Nursing Process Format. These guidelines include the process of praxis, diagnostic taxonomy, typology of clinical interventions, and typology of outcomes (p. 38). The Neuman Systems Model–based clinical practice guidelines are congruent with the current standards of nursing practice articulated by the American Nurses Association (2004) as the nursing process. Both depictions of the nursing process are construed as iterative and overlapping subprocesses of thought rather than a linear process. Table 11-1 presents the relationship between critical thinking and the Neuman Systems Model nursing process.
TABLE 11-1
Critical Thinking and the Neuman Systems Model Nursing Process
Data from Fawcett, J. (2005). Neuman’s systems model. In Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (2nd ed.), Philadelphia: F. A. Davis; Freese, B. T., Neuman, B., & Fawcett, J. (2002). Guidelines for Neuman systems model–based clinical practice. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 37-42). Upper Saddle River, NJ: Prentice Hall; Neuman, B. (2011). The Neuman systems model. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (5th ed., pp. 3-33; 338-348). Upper Saddle River, NJ: Prentice Hall; Paul, R. W., & Elder, L. (2002). Critical thinking: Tools for taking charge of your professional & personal life. Upper Saddle River, NJ: Prentice Hall.
Comprehensive assessment based on the Neuman Systems Model requires a conceptualization of each model component (client perspective, variables, basic structure, environmental stressors, and boundaries) by the nurse and is essential to determine current client status accurately. The nurse-client relationship begins at first contact and is conceived as an ongoing partnership between the nurse and client. Through this partnership, the nurse purposefully discovers the client’s perspective and resolves any perceptual discrepancies between the nurse and client. Maintenance of this relationship throughout each phase of the nursing process requires reflective, thoughtful, interactive communication by the nurse. Systematic data collection that considers the potential or actual effect of environmental stressors on the client system is accomplished through interview and physical assessment (Neuman, 2011).
The Neuman Systems Model guidelines give a framework for the development of comprehensive diagnoses, determination of appropriate interventions, and evaluation of outcomes. For example, the nurse-client partnership identifies a stressor that may penetrate the flexible line of defense and lead to a variance from wellness. The nurse considers the application of relevant nursing and related theories and in conjunction with the client develops diagnoses, interventions, and goals to prevent or ameliorate stressor impact on the client system. Logical outcomes are then formulated to measure client system reconstitution (Neuman, 2011).
Neuman directs the nurse to use model concepts for the determination of nursing diagnoses (Neuman, 2011). Authors have suggested several approaches to this application. Ziegler (1982) describes a taxonomy derived from the Neuman model. Newman (2002) further adapted this taxonomy to include evolutionary model changes (Freese, et al., 2002; Russell, 2002). Neuman and Martin (1998) suggest that the Neuman Systems Model and the Omaha System are complementary. Others have used the Neuman Systems Model and the North American NursingDiagnosis Association (NANDA–International, 2007) diagnostic taxonomy linking model concepts and nursing diagnoses (Gigliotti, 1998, 2002; McHolm & Geib, 1998). Although Neuman (2011) cautioned lack of congruency between the model and the NANDA nomenclature, earlier Neuman guidelines for use of the model in clinical practice stipulated that the diagnostic taxonomy reflected the model in the following categories: (1) client system (individual, family, group, community); (2) response level (primary, secondary, tertiary); (3) subsystem response (five variables); (4) stressor source (intrasystem, intersystem, extrasystem); and (5) stressor type (five variables) (Freese, et al., 2002, p. 38). It seems clear that the synthetic use of the Neuman Systems Model and nursing process facilitates enhanced critical thinking by the nurse.
Nursing Care of Debbie with Neuman’s Model
Table 11-2 presents an application of the Neuman Systems Model to the care of Debbie. As stated, the nurse-client relationship is paramount to determine wholistic client needs accurately (Neuman, 2011). Although the case studypresents some information about Debbie and her situation, gathering further data about client strengths, resources, and interpersonal relationships would be necessary. Stressor occurrences at the system boundaries (e.g., between Debbie and her children, husband, and mother) could cause family system disequilibrium. In addition, needed information about strengths and resources could provide support to client/client family system stability. For example, if Debbie is interested in spiritual matters and has contacts with a local congregation, her flexible line of defense could be strengthened by her beliefs and congregational support. Neuman provides possible questions to obtain the client’s perception of major stress areas, changes in patterns of living, previous coping patterns, and current coping behaviors as well as the client’s anticipated consequences and expectations in the current situation (Neuman, 2011). Therefore, the nurse informed by the Neuman Systems Model would extend and clarify the assessment data. Answers to each of these questions help contribute to a wholistic database that identifies the perceptions of both the client and the nurse. This type of wholistic database is a hallmark of the Neuman model.
TABLE 11-2
Application of the Neuman Systems Model to the Care of Debbie
| Model Component | Application to Debbie |
| Nurse-client relationship | Mutual partnership has been developed during initial assessment. Nurse perceives physiological stressors as being very important. However, Debbie’s perceptions of her psychological, developmental, sociocultural, and spiritual stressors may be most important to her. Throughout process of care planning, nurse assesses for possible discrepancies in perceptions. |
| Physiological | Stressors Intrapersonal: Cancer, radiation therapy planned, nausea, pain, urinary retention, weight loss, smokes, compromised immune system, new medications Interpersonal: Self-catheterization Extrapersonal: Effect of situational stress (finances, home situation) on system |
| Psychological | Stressors Intrapersonal: Fear of future, crying Interpersonal: Fear about children’s future, lack of support from husband, relationship with mother Extrapersonal: No mention of additional emotional support |
| Developmental | Stressors Intrapersonal: 29-year-old female, 2 children, first pregnancy at 16 years of age Interpersonal: Mother of one teen (13), one preteen (11), questionable unmet relational intimacy needs Extrapersonal: No mention of friends at same life stage |
| Sociocultural | Stressors Intrapersonal: Eighth-grade education, fear of smoking effects Interpersonal: At times abusive, unsupportive husband Extrapersonal: Husband unemployed, lives with mother, limited income, unsanitary environment |
| Spiritual | Stressors Intrapersonal: Fears illness is punishment Interpersonal: No mention of assistance in processing current situation Extrapersonal: No mention of congregational support |
| Affected boundaries | Debbie’s flexible and normal lines of defense have been penetrated, and her lines of resistance have been activated. Thus all secondary and tertiary modes of prevention-as-interventions will be implemented to meet her needs. In addition, family members’ flexible line of defense enhancement will be evaluated. |
| Nursing process | Nursing Diagnoses Deficient Knowledge (new medication regimen, planned radiation therapy, postoperative symptom management, self-catheterization, lifestyle changes) related to lack of exposure Fear related to unknown future, “punishment” Interrupted Family Processes related to shift in health status, developmental and situational crises, family economics Nursing Goals Promote wellness and sense of control over life events through education and open family communication Nursing Outcomes Debbie’s reaction to prevention-as-interventions is evaluated for level of flexible line of defense enhancement, reconstitution of normal line of defense, and needed goal reformulation |
| Examples of prevention-as-interventions for identified stressors | Primary prevention: Teach children about smoking and cancer Secondary prevention: Teach about medications, postoperative symptom management Teach clean-technique self-catheterization Provide for nutritious meals Teach husband about Debbie’s illness Explore counseling between Debbie and husband Tertiary prevention: Teach breast self-examination Establish cancer support group connections Provide support for smoking cessation Explore means to reduce fear of “punishment” Referral to home health agency, social services |
Data from North American Nursing Diagnosis Association (NANDA-International). (2012). Nursing diagnoses: Definitions & classification 2012-2014. Philadelphia: NANDA-International; Newman, D. M. (2005). Complex patient needs? Nursing models can help! Journal of Christian Nursing 22(1), 33.
Debbie and Neuman’s Nursing Process Format
Neuman describes the importance of conceptualizing the client as an open, wholistic system because “the various interrelationships of the parts and subparts must be appropriately identified and analyzed before relevant nursing action can be taken” (Neuman, 2011, p. 10). Once Debbie’s stressors, strengths, and resources are identified, the nurse can analyze the data, identify what system boundaries were affected, and prioritize nursing diagnoses. For example, assessment data may reveal multiple new stressors within Debbie’s physiological variable that she has never before experienced and are related to her medical diagnosis of cervical cancer. Using theNeuman Systems Model, the nurse would recognize that the wholistic nursing focus should be Debbie’s ongoing responses to her life changes, not her disease. Debbie’s acute need for information, her expressed fears regarding her children and future, and the interrupted family processes in a previously tenuous family situation have penetrated her already compromised flexible line of defense and invaded her normal line of defense (usual state of health). The assessment data reveal that these strong interpersonal and intrapersonal stressors have already penetrated Debbie’s lines of resistance. However, this analysis would be tentative until confirmation of client perception is made and the nurse-client partnership agrees on Debbie’s needs and the priority of proposed prevention-as-interventions. For example, the nurse’s priority might be to first implement nursing interventions to address Debbie’s knowledge deficit. However, if Debbie’s external environmental stressor of family relationship needs precludes her from learning because she is so concerned about her children, then her interpersonal needs would become a priority.
Table 11-2 presents several broad nursing diagnoses that depict Debbie’s intrapersonal and interpersonal stressors, followed by resultant nursing goals and outcomes. Although Debbie’s health situation is serious, Neuman’s model would suggest the hope that Debbie can develop system stability through energy input. Therefore, nursing interventions derived from the nursing diagnoses–related factors would be focused on supporting the lines of resistance and enhancing the flexible line of defense. Secondary nursing interventions would be developed to support Debbie’s lines of resistance within each of the five variables. Tertiary nursing interventions would be developed to strengthen her flexible line of defense, to assist reconstitution of her normal line of defense, and to promote optimal wellness. The nurse would also consider the importance of the setting (environment) of the nursing care. If the initial contact were in an acute care facility, the focus would include discharge and referral for seamless care. If the contact were in an outpatient or home health care setting, the nursing actions would be accordingly modified. In either case, the whole family must be considered in the plan of care. Informed use of the Neuman Systems Model easily facilitates such wholistic considerations and strategic primary, secondary, and tertiary prevention-as-interventions.
Nursing Care of Mary with Neuman’s Model
As stated, application of the Neuman Systems Model in nursing praxis enhances conceptual flexibility in rapidly changing situations. Initially, Mary’s admission and planned discharge seemed a relatively predictable event. However, with the changes Mary is experiencing, the nursing care must also change. The following is a chronological flow of the critical thinking that would be employed by the nurse who is applying the Neuman Systems Model in a rapidly changing situation. An overview of the Neuman Nursing Process Format for Mary is provided in Table 11-3.
TABLE 11-3
Application of the Neuman Systems Model to the Care of Mary
| Model Component | Application to Mary |
| Nurse-client relationship | Mutual partnership has been developed during initial and ongoing assessment. Nurse perceives physiological stressors as a priority to prevent further energy depletion but recognizes importance of effect of Mary’s perceptions of her psychological, developmental, sociocultural, and spiritual stressors on her status. Synthesis of ongoing assessment data provides nurse meaningful information to create wholistically effective care. Throughout process of care planning, nurse assesses for possible discrepancies in nurse-client perceptions. |
| Physiological | Stressors Intrapersonal: Post-PTCA, hypertension, COPD, obesity, feels tired, episodic depression, dyspneic, edematous, ventilation-perfusion imbalance, chest x-ray pathology, cardiac status stable, new medications Interpersonal: States diet is “tasteless,” pulls off bi-PAP mask Extrapersonal: Effect of situational stress (pathology, current fears, future concerns, discharge) on physiological system |
| Psychological | Stressors Intrapersonal: Feels claustrophobic on bi-PAP mask, fear of death, future lifestyle changes, states that she wants to go home Interpersonal: Asks for daughter, possible dysfunctional grieving for loss of husband Extrapersonal: Physical separation from support systems while hospitalized |
| Developmental | Stressors Intrapersonal: 76 years old, high school GED completion because education is important, asks if she is going to die Interpersonal: Widow of 10 years, 1 married adult child, generativity vs. stagnation issues Extrapersonal: Possible loss of autonomy in relationships |
| Sociocultural | Stressors Intrapersonal: Retired factory worker Interpersonal: Frequent interaction with daughter, telephone calls from friends while in hospital, weekly social activities Extrapersonal: Fixed income, Medicare, lives in retirement community, drives self short distances |
| Spiritual | Stressors Intrapersonal: Finds meaning in attending church, speaks of God and prayer Interpersonal: Active in local parish, priest involved Extrapersonal: Unknown future transportation needs |
| Affected boundaries | Mary’s flexible and normal lines of defense have been penetrated, and her lines of resistance have been activated. If prevention interventions are not effective, system disequilibrium will cause death. Thus secondary interventions will be implemented to strengthen her lines of resistance and tertiary interventions will be implemented to strengthen her flexible line of defense. |
| Nursing process | Nursing Diagnoses Fear related to sensory impairment (ventilation-perfusion imbalance), hospital procedures, separation from support system, acute health changes∗ Impaired Gas Exchange related to ventilation-perfusion imbalance, feelings of claustrophobia (mask removal)∗ Risk for Decreased Cardiac Output related to increased pulmonary vascular resistance (altered afterload)∗ Deficient Knowledge (new medication regimen, lifestyle changes) related to lack of exposure Risk for Spiritual Distress (unknown future, periods of depression, possible unresolved grief) Risk for Activity Intolerance (cardiovascular and oxygenation status) Nursing Goals Promote reconstitution (ventilation-perfusion balance) and sense of control over life events through prescriptions, education, lifestyle changes, and spiritual support to attain highest level functioning Nursing Outcomes Mary’s reaction to prevention-as-interventions is evaluated for level of reconstitution of normal line of defense stability, enhancement of flexible line of defense, and needed goal reformulation |
| Examples of prevention-as-interventions for identified stressors | Secondary prevention: Monitor and intervene for cardiac dysrhythmias, vital signs, PTCA site bleeding, blood laboratory results, and oxygenation Teach about medications, importance of needed lifestyle changes Explore family-friend support during immediate discharge Support spirituality Tertiary prevention: Contact priest and support spirituality Reinforce teaching Referrals to cardiac-pulmonary rehabilitation, social services for possible visiting nurse support, registered dietitian for heart-healthy diet and weight-loss planning, resource for depression evaluation, and parish nurse for discharge plan and follow-up |
∗Data from Mosca, L. et al. (2011). Effectiveness-based guidelines for cardiovascular disease prevention in women: 2011 update (AHA Guidelines), Circulation, 123, 1243-1262; North American Nursing Diagnosis Association (NANDA-International). (2012). Nursing diagnoses: Definitions & classification 2012-2014. Philadelphia: NANDA-International; Newman, D. M. (2005). Complex patient needs? Nursing models can help! Journal of Christian Nursing, 22(1), 33.
Mary’s Care and Neuman’s Nursing Process Format
Before Mary’s acute change in status, the nurse partnered with Mary to ascertain both present and future concerns. The nurse and Mary developed rapport and beganto address each other on a first-name basis. The nurse assessed the client in each variable for Mary’s intrapersonal, interpersonal, and extrapersonal stressors. After gathering assessment data in each of the five variables, the nurse focused on the physiological variable while wholistically conceptualizing the interrelationships important for a client experiencing cardiac disease. This dual perspective of wholism and subpart kept the nurse from neglecting a wholistic view of the client and minimizing the importance of the client’s perspective. While spending time with Mary, the nurse used the Neuman system to assess Mary’s personal perception of potentialor actual stressors. The nurse asked questions to determine Mary’s primary concerns. Mary spoke about her new diet and how she felt tired. Mary stated concerns about whether she would be able to continue to drive, meet with friends, and go to church. She also spoke about how she did not like to take medicine and wondered whether all the medications were necessary. The nurse also explored how Mary had handled the stress of her husband’s death and created an independent life. Mary talked about how, even after 10 years, she would sometimes hear his voice or think that she had seen her husband. The nurse asked Mary what she would do when these things happened, and Mary said that she would sometimes cry but that usually she would ask God to help her, although at times she would just wish to go “home.” When the nurse asked what Mary anticipated would happen when she returned to the retirement community, Mary said, “I don’t know, I guess that I will do the best I can.”
The nurse recognized that the physiological cardiopulmonary and nutritional stressors and Mary’s episodic depression had penetrated Mary’s flexible and normal lines of defense. The nurse then reflected on the data and current research about women and cardiovascular disease. The nurse remembered that, as in Mary’s case, women tend to delay seeking treatment for symptoms of acute myocardial infarction, support persons are less likely to recognize symptoms are cardiac related, and the American Heart Association has provided specific prevention guidelines for women (Hermann, 2008; Mosca, Benjamin, Bara, et al., 2011). However, in conjunction with Mary’s weaknesses, the nurse also considered Mary’s strengths and resources during the assessment phase. One of Mary’s strengths discovered in the sociocultural variable was her solid network of personal relationships. And strength emerged in the spiritual variable when Mary identified her faith as one of her major sources of strength. When the nurse interviewed Mary to determine her psychological variable, Mary revealed a third strength when she indicated a desire to learn about her needed lifestyle changes. The nurse integrated these three discovered strengths and realized that Mary’s flexible line of defense could be enhanced. The nurse identified three nursing diagnoses that identified Mary’s stressors (see Table 11-3): (1) deficient knowledge, (2) risk for spiritual distress, and (3) risk for activity intolerance.
Primary prevention-as-intervention modalities could enhance Mary’s flexible line of defense and would include supporting her spiritual worldview and independence. In addition, the nurse identified secondary interventions that could help Mary’s reconstitution from the cardiac event. These interventions could include education about needed lifestyle changes and exploration of family-friend support systems during immediate discharge. Tertiary interventions could include referrals for other health care support systems as listed in Table 11-3. The nurse proposed that prevention-as-intervention might promote a satisfactory level of wellness for Mary. Before implementing this plan of care, the nurse would have discussed these initial perceptions with Mary to determine perceptual congruency between the nurse and client and to establish appropriate goals and outcomes. However, before the nurse had time to discuss the plan of care with Mary, the client developed complications that required the nurse to change the focus of care.
As the case history describes, Mary is experiencing the onset of an additional physiological stressor, impaired gas exchange. The nurse recognizes the need for reassessment of Mary’s variables and her created environment to evaluate Mary’sresponse to current stressors within her lines of resistance. The nurse uses the Neuman Systems Model to reorganize and reprioritize nursing care in order to meet the client’s immediate needs, without neglecting Mary’s future discharge planning needs.
Reassessment for Stressors, Strengths, and Resources Within the Variables
Physiological
The nurse reassesses Mary’s physiological respiratory variable and recognizes the acute nature of the situation. Mary’s physiological variable assessment data reveal both hypoxemia and hypercapnia with attendant signs. Both findings are negatively influencing her system stability. The nurse recognizes that although Mary’s cardiac status is stable, the subparts of the system (her cardiac and respiratory status) are interacting synergistically and can be further compromised. Mary’s physiological change in oxygenation is the most obvious stressor. This stressor is permeating the client’s flexible line of defense, the normal line of defense, eliciting a stressor response in the lines of resistance (hyperventilation), and potentially causing enough energy depletion to cause death. However, the nurse also recognizes that Mary is greater than the sum of her parts and therefore reassesses the other four variables.
Psychological
The nurse listens as Mary talks about her fears of dying and states that she wants to go home. When Mary becomes agitated, pulling off the bi-PAP mask and refusing treatment, the nurse recognizes the importance of the variable interactions in the client’s lines of resistance. Although the nurse recognizes that clients who have hypoxemia and are hypercapnic are very anxious, the nurse also explores Mary’s concern about tubes. Mary talks about her near-drowning experience as a child and how the mask makes her feel like she is drowning. She also tells the nurse that she does not want to be connected to one of those machines and that her daughter knows this.
Developmental
The nurse also remembers that Mary has a high school GED and needs basic explanations about what is happening to her.
Sociocultural
The nurse calls the daughter to inform her of her mother’s change in status and current anxieties. Mary’s daughter explains that during her mother’s last hospitalization her mother needed bi-PAP treatments and had similar concerns. The nurse and daughter agree to form a partnership to replicate a previously successful approach to Mary’s care.
Spiritual
The nurse recognizes that the current situation could overwhelm Mary’s spiritual resources in her flexible line of defense that are protecting her normal line of defense. The nurse asks Mary whether prayer might help calm her. Mary affirms this and says that praying always gives her hope. Mary also asks to see the priest again.
The nurse weighs the strengths, weaknesses, and resources in each of the variables and considers the wholistic nature of Mary’s perceptions and situation. In addition, Mary’s created environment is especially important because although Mary has an acute physiological need, the synergistic interaction of the variables is compounding the physiological problem. The nurse recognizes that Mary’s fears and current coping mechanisms must be addressed before interventions for her ventilation-perfusion needs can be successfully implemented. Therefore, the nurse reflects and synthesizes the information and develops two actual nursing diagnoses to direct the care. A third nursing diagnosis that reflects a possible stressor is also identified. The following three priority nursing diagnoses are also listed in Table 11-3:
1. Fear related to sensory impairment (ventilation-perfusion problems), hospital procedures, support system separation, and acute health changes
2. Impaired Gas Exchange related to ventilation-perfusion imbalance and feelings of claustrophobia
The flexibility inherent in the Neuman Systems Model enables the nurse responsively to change the focus from discharge planning to secondary prevention-as-interventions with the goal of system reconstitution. The necessary client outcomes are now decreased anxiety and balanced ventilation-perfusion. The following seven nursing actions will specifically assist in mitigating the stressors of fear and impaired gas exchange within the client’s lines of resistance, thus promoting reconstitution:
1. Provide an environment conducive for Mary to pray before and during bi-PAP treatment.
3. Arrange for a family member or friend to be available as possible during bi-PAP treatments.
4. Give Mary a list of treatment times so that she can anticipate and prepare herself.
5. Collaborate with the physician for a prescription for antianxiety medications, and chart Mary’s desire that no pulmonary resuscitation should occur (do not resuscitate [DNR]).
6. Reinforce Mary’s past effective coping mechanisms during needed hospitalization and bi-PAP therapy.
7. Monitor for signs and symptoms of decreased cardiac output.
The nurse explains the plan of care to Mary and verifies their individual perceptions. Mary agrees, seems somewhat less anxious, and states that she now thinks she can complete the treatments. In addition, the nurse charts the complete plan of care to promote continuity of care for Mary among staff members 24 hours a day. The initial client needs that were identified and the plan of care related to discharge will need to be modified depending on Mary’s ongoing needs. However, the individualized plan of care as described in Table 11-3 becomes the working map based on the Neuman model. This exemplar exhibits how the professional nurse can implement the Neuman Systems Model to exhibit effective, wholistic nursing care in rapidly changing situations.