Roline Campbell Roxy Johanning Tracy Hill Neuman Systems Model Roline Campbell Roxy Johanning Tracy Hill

Presentation Objectives: Introduce Betty Neuman Overview of the Neuman Systems Model (NSM) it’s concepts and principles Evaluate the NSM nursing theory using Fawcett’s criteria Compare the NSM with two other nursing theories Discuss and analyze the use of the NSM

Meet Betty Neuman Born in 1924 on a farm near Lowell, Ohio. Completed initial nursing education Then moved to Los Angeles Worked in a variety of nursing roles - always with an interest in human behavior. She attended UCLA 1957: Completed bachelor’s degree with a double major in Public Health & Psychology. Helped her husband to establish and manage his medical practice.

Career advances 1966: Master’s degree in Mental Health, Public Health Consultation from UCLA. Pioneer of nursing involvement in mental health. Late 1960’s: Teaching and practice model for mental health consultation. Requests from UCLA graduate students prompted the design of a conceptual model for nursing in 1970. First published in 1972 in an article entitled “A Model for Teaching Total Person Approach to Patient Problems” (Neuman & Young, 1972). 1974 – 2002: Further development and refinement of the NSM. (First called “The Neuman Systems Model” in 1985 – retained the same title since then.) 1985: Doctoral degree in Clinical Psychology from PWU. In 1966 she received her Master’s degree in Mental Health, Public Health Consultation, from UCLA. She was now considered a pioneer of nursing involvement in mental health. In the late 1960’s she developed her first teaching and practice model for mental health consultation. Requests from UCLA graduate students prompted Betty Neuman to design a conceptual model for nursing in 1970. This was followed by the first publication of The Neuman Systems Model in 1972 in an article entitled “A Model for Teaching Total Person Approach to Patient Problems” (Neuman & Young, 1972). She began developing her health system model while a lecturer

Recent years Maintained involvement in variety of professional and international activities Moved back to Watertown, Ohio and practiced as a licensed clinical marriage and family therapist. Founder/Director of the Neuman Systems Model Trustees Group, Inc. Holds two Honorary Doctorates 1992: Honorary Doctorate of Letters (Neuman College) 1998: Honorary Doctorate of Science (Grand Valley State University) Fellow of the American Academy of Nursing (1993) Maintains involvement in variety of professional and international activities Numerous publications Paper presentations Consultations Lectures Conferences. Moved back to Ohio and practiced as a licensed clinical marriage and family therapist. Maintains leadership role in the Neuman Systems Model Trustees Group

“It is important to state that neither was I knowledgeable about nursing models nor had a clear trend yet begun in nursing for developing models. The Neuman Systems Model was developed strictly as a teaching aid” - Betty Neuman, 2002 Betty Neuman as keynote speaker at the University of Maine, Fort Kent in 2004.

An Overview of the Neuman Systems Model

Philosophical Claims Wholism Wellness orientation Client perception and motivation Dynamic systems perspective of energy & variable interaction with the environment Client & caregiver in partnership “ 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. This philosophic base pervades all aspects of the model.” Neuman, 2002

Classified according to the applicable metaparadigm forerunner. Key Concepts Classified according to the applicable metaparadigm forerunner. Human Beings Client/Client System Interacting Variables Basic Structure Flexible line of Defense Normal line of Defense Lines of Resistance Environment Internal Environment External Environment Created Environment Stressors Health Health/Wellness/ Optimal Client System Stability Variances from Wellness Illness Reconstitution Nursing Prevention as Intervention Metaparadigm concepts - human beings, - environment, - health & - nursing are evident in the concepts of the NSM. Client/client system as four dimensions : * individual, *family, *community & *social issue Interacting Variables has five dimensions: *physiologic, *psychological variable, *sociocultural variable, *developmental variable, *spiritual variable. Unidimensional concepts: Basic structure, Flexible Line of Defense, Normal line of defense, Lines of resistance.

Client/Client System Viewed as open system Repeated cycles of input, process, output & feedback Thus a dynamic organizational pattern Can be Individual Family Group Community Aggregate (Social Issue)

Interacting Variables Spiritual Psychological Physiological Socio-cultural Developmental Consider these simultaneously & comprehensively Present in each type of client

Basic survival factors Central Core Basic survival factors Normal temp range Genetic Structure Response pattern Organ strength/weakness Ego structure

Flexible Line of Defense (FLD) Outer barrier (protective buffer) Dynamic – can be altered in relatively short period of time Prevents stressor invasion of the client system Flexible Line of Defense Outer boundary of defined client system Protective buffer system for client’s normal or stable state Ideally, prevents invasions of the client system – keeping it free from stressor reactions or symptomatology Protects the Normal Line of Defense / usual wellness condition Flexible (accordion-like in function) expands = greater protection, contracts = less protection Dynamic rather than stable: Can be rapidly altered over a relatively short period of time Or in a situation like a state of emergency Or condition like undernutrition, sleep loss, dehydration

Normal Line of Defense (NLD) Client’s normal wellness level What client has become / evolved into over time Defines the stability & integrity of client system Standard from which to measure health deviation Normal Line of Defense: Client system’s normal or usual wellness level Evolved over time. Normal range of response to the environment – aka usual wellness/stability state (represents change over time through coping) = What client has become / state to which client evolved / usual wellness level Result of adjustment to environmental stressors AND result of previous behavior Defines the stability & integrity of the client system & it’s ability to maintain stability & integrity Used as standard form to measure health deviation Dynamic Can contract and expand over time Ability to become and remain stabilized to deal with stresses over time (protecting basic structure & integrity) Expansion = enhanced wellness state Contraction = diminished state of wellness

Lines of Resistance Protective mechanism Attempts to stabilize the client system (support return to wellness) Supports the basic structure & normal line of defense Contains resource factors Lines of Resistance The protective mechanism which attempt to stabilize the client & foster return to usual wellness level Contain know and unknown internal and external resource factors which support the basic structure and the Normal Line of Defense Implicitly found within each client system (internal resistance factors) Functions to stabilize & return client to usual wellness level or to a higher level of stability following environmental stressor reaction Protects the basic structure & support return to wellness Within Lines of Defense & Lines of Resistance is the 5 interacting variables. These must be considered simultaneously in each client concentric circle.

Forces & interactive influences confined within client system Internal Environment Forces & interactive influences confined within client system Intrapersonal Stressors

External Environment Forces & interaction influences existing outside the client system Interpersonal stressors Extra-personal stressors

Created Environment Extra-personal Intrapersonal Interpersonal Symbolic expression of system wholeness Unconscious mobilization of all system variables Extra-personal Intrapersonal Interpersonal

Wellness and Illness Optimal Wellness System stability Greatest possible degree of system stability at a given point in time Illness State of insufficiency Disrupting needs are unsatisfied Excessive expenditure of energy Variance from Wellness Varying degrees of system instability Difference from the normal or usual wellness condition.

Prevention as Intervention Basis for health promotion Nursing is prevention as intervention Three dimensions Primary prevention Secondary prevention Tertiary prevention

Primary Prevention Health promotion & Maintenance of wellness Occurs before the system reacts to a stressor Strengthens the client / client system to better deal with stressors (FLD) May also try to manipulate the environment to reduce or weaken stressors

Secondary Prevention Focus on preventing damage to the Central Core Occurs after the system reacts to a stressor Aims to strengthen the Lines of Resistance May also try to remove the stressor

Tertiary Prevention add energy to the system or Occurs after the client/client system has been treated through secondary prevention strategies Offers support to the client Attempts to: add energy to the system or reduce energy needed in order to facilitate reconstitution

Reconstitution The determined energy increase related to the degree of reaction to a stressor Represents the return and maintenance of system stability following treatment May be viewed as feedback from the input/output of secondary prevention Complete reconstitution may occur Level beyond the initial Normal Line of Defense Same level of wellness prior to illness Lower level where system stability is re-defined

Evaluation of the Neuman Systems Model Jacqueline Fawcett and Betty Neuman at the 8th Neuman Systems Model Symposium - Salt Lake City, 2001

Jacqueline Fawcett on Betty Neuman’s System Model Theory: Neuman System Model Trustee since: 1988  Areas of Consultation with the Neuman Systems Model: Serve as a mentor and consultant for students, post-doctoral fellows, faculty, and clinicians interested in using nursing models and theories to guide their research and practice, including the Neuman Systems Model.

Selected Neuman Systems Model Publications Fawcett, J., Carpenito, L. J., Efinger, J., Goldblum‑Graff, D., Groesbeck, M. J., Lowry, L. W., McCreary, C. S., & Wolf, Z. R. (1982). A framework for analysis and evaluation of conceptual models of nursing with an analysis and evaluation of the Neuman Systems Model. In B. Neuman (Ed.), The Neuman Systems Model. Application to nursing education and practice (pp. 30‑43). New York: Appleton‑Century‑Crofts. Fawcett, J. (1989). Analysis and evaluation of Neuman's systems model. In B. Neuman (Ed.), The Neuman Systems Model. Application to nursing education and practice (2nd ed., pp. 65- 92). Norwalk, CT: Appleton and Lange. Fawcett, J. (1995). Constructing conceptual-theoretical-empirical structures for research: Future implications for use of the Neuman systems model. In B. Neuman, The Neuman Systems Model (3rd ed., pp. 459-471). Norwalk, CT: Appleton and Lange. Beynon, C.E., Chadwick, P.L., Chang, N.J., Craig, D.M., Fawcett, J., Freese, B.T., Hinton-Walker, P., & Neuman, B. (1997). The Neuman systems model: Reflections and projections. Nursing Science Quarterly, 10, 18-21. Fawcett, J. (2001). The nurse theorists: 21st century updates—Betty Neuman. Nursing Science Quarterly, 14, 211-214. Fawcett, J., & Giangrande, S.K. (2001). Neuman Systems Model-based research: An integrative review project. Nursing Science Quarterly, 14, 231-238.   Fawcett, J., & Gigliotti, E. (2001). Using conceptual models of nursing to guide nursing research: The case of the Neuman Systems Model. Nursing Science Quarterly, 14, 339-345.

Selected Neuman Systems Model Publications (cont.) Neuman, B., Aylward, P.D., Beynon, C., Breckenridge, D.M., Fawcett, J., Fields, A., Lowry, L., Memmott, R.J., & Toot, J. (2001). The Neuman systems model: A futuristic care perspective. In N. L. Chaska (Ed.), The nursing profession: Tomorrow and beyond (pp. 321-330). Thousand Oaks, CA: Sage. Neuman, B., & Fawcett, J. (Eds.). (2002). The Neuman systems model (4th ed.). Upper Saddle River, NJ: Prentice Hall.  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.  Louis, M., Neuman, B., & Fawcett, J. (2002). Guidelines for Neuman systems model-based nursing research. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 113-119). Upper Saddle River, NJ: Prentice Hall.  Fawcett, J., & Giangrande, S.K. (2002). The Neuman systems model and research: An integrative review. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 120-149). Upper Saddle River, NJ: Prentice Hall.  Gigliotti, E., & Fawcett, J. (2002). The Neuman systems model and research instruments. In B. Neuman & J. Fawcett (Eds.). The Neuman systems model (4th ed., pp. 150-175). Upper Saddle River, NJ: Prentice Hall.  Newman, D.M.L., Neuman, B., & Fawcett, J. (2002). Guidelines for Neuman systems model- based education for the health professions. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 193-215). Upper Saddle River, NJ: Prentice Hall.  Shambaugh, B.F., Neuman, B., & Fawcett, J. (2002). Guidelines for Neuman systems model- based administration of health care services. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 265-270). Upper Saddle River, NJ: Prentice Hall.

Fawcett’s Criteria to Evaluate Nursing Theory Significance Internal Consistency Parsimony Testability Empirical Adequacy Pragmatic Adequacy

Significance - Meets Metaparadigm concepts & propositions are explicitly stated All philosophical claims are addressed Support of colleagues and the influence of other scholars & adjunctive disciplines are acknowledged (Psychology & Philosophy) Special contributions made by NSM to discipline of nursing are identified Usefulness in Education, Research, Practice & Administration of Health Care Services All of Neuman’s philosophical claims are addressed: Human beings - client as an open system. Environment - contains both internal and external stressors (neutral) and resistance factors (determined by client to be + or -). client => energy exchange <= environment Health – represents a usual dynamic stability state of the normal line of defense; stressors penetrate normal line of defense, causing illness. Nursing - goal is optimal client system stability or wellness; perceptual distortions are mutually negotiated and resolved. Prevention as intervention. Neuman acknowledged the support of colleagues and the influence of other scholars on the development of the NSM, as well as adjunctive disciplines. UCLA

Internal Consistency - Meets Neuman values a holistic (“wholistic”), systems-based approach to the care of clients. Revisions and refinements indicates Neuman’s responsiveness to critiques. The basic intent, meaning, and purpose of the model have been retained.

Parsimony - Meets NSM is sufficiently comprehensive with regard to depth of content. The revisions and refinements in Neuman’s (2002d) current version have clarified several areas of confusion found in earlier versions and have improved the adequacy of concept definitions and descriptions (Fawcett, 2005). Confusion still remains in the Family, Community, and Social Issue dimensions of the Client/Client System – these dimensions require definitions or descriptions that go beyond being described as kinds of groups. Is the theory content clearly stated?

Testability - Meets The guidelines for research based on NSM are clearly defined and are congruent with the theory (Optimal Client System Stability). Research and practice are linked: Problems encountered in practice give rise to new research questions (Fawcett, 2005). NSM based research continues to increase. Is there research methodology developed? Is it congruent with the theory?

Empirical Adequacy – Partially met The content of the NSM is not completely logically congruent. Additional research is clearly warranted (Varying statistical significance). Neuman considers her model to be appropriate for use by members of all health-care disciplines. Are study findings congruent with the concepts and principles? Are theoretical assertions congruent with empirical evidence?

Pragmatic Adequacy - Meets Extensive study of the concepts of the NSM and relevant theories from nursing and adjunctive disciplines is required before knowledgeable application in nursing research, education, administration, and practice. The content of the NSM comprises many terms, but most are familiar words; therefore, use of the model does not require mastery of an extensive vocabulary. The success of the NSM as a guide for nursing curricula and for delivery of nursing services is documented in several reports (Fawcett, 2005). Special training required? Has it been used in “real world” practice? Effectiveness measurable? Comparisons in situations with and without theory use?

Comparison of NSM with two other nursing theories / models

Comparison Rogers (1970) Science of Unitary Human Beings Neuman (1970) Neuman’s System Model Roy (1970) Roy’s Adaptation Model

Contemporaries of one another Martha Rogers Betty Neuman Sister Callista Roy

Each Define the Metaparadigm Concepts: Person Environment Health Nursing

Each Used in Nursing: Practice Administration Education

Theories derived from: Martha Rogers Six Grand theories and 12 Middle-range theories based on SUHB (Fawcett, 2005, p. 332-333) Betty Neuman Two Grand Theories and Three Middle-range theories based on NSM (Fawcett, 2005, p. 184) Sister Callista Roy One Grand theory and Nine Middle-range theories based on RAM (Fawcett , 2005, p. 389, 392-93)

Goal of Nursing To Promote Human Betterment wherever People Are, on Planet Earth or in Outer Space. (Fawcett, 2005, p. 316) To Facilitate Optimal Wellness for the Client Through Retention, Attainment, or Maintenance of Client System Stability. (Fawcett, 2005, p. 167) To Promote Adaptation for Individuals and Groups in the Four Adaptive Modes, Thus Contributing to Health, Quality of Life, and Dying with Dignity by Assessing Behavior and Factors That Influence Adaptive Abilities and by Intervening to Expand those Abilities and to Enhance Environmental Interactions (Fawcett,2005, p. 365)

Overview Focus is on unitary, irreducible human beings & their environments. (Fawcett, 2005, p. 315) Focus is on wellness of client system in relation to environmental stressors and reactions to the stressors. (Fawcett, 2005, p. 166) Focus is on human adaptive system responses and environmental stimuli, which are constantly changing. (Fawcett, 2005, p. 365)

Worldview Reflects the simultaneous action worldview Reflects the reciprocal interaction worldview

Reciprocal Interaction Worldview This worldview is a synthesis of elements from the organismic, simultaneity, totality, change, persistence and interactive-integrative world views: Human beings are holistic; parts are viewed on the context of the whole Human beings are active, and interactions between human beings and their environments are reciprocal Change is a function of multiple antecedent factors, and may be continuous or may be only for survival Reality is multidimensional, context dependent, and relative (Fawcett, 2005, p.12-13)

Simultaneous Action World View This world view combines elements of the organismic, simultaneity, change and unitary- transformative world views: Unitary human beings are identified by pattern Human beings are in mutual rhythmical interchange with their environments Human beings change continuously, unpredictably and in the direction of more complex self- organization The phenomena of interest are personal knowledge and pattern recognition (Fawcett, 2005, p. 13)

Meets Fawcett’s Criteria for Evaluation of Nursing Models Rogers Roy Neuman (Fawcett 2005, p. 57-58)

Selection Rationale Rogers Roy Neuman

Discussion of the Nurse as the Client Galloway (1993) offered an informative NSM-based self- analysis of her practice with a mentally and physically impaired infant. She stated: “Through analyzing my role as a student nurse in a difficult clinical situation, I learned that I not only adapted well but also experienced personal growth. I did not avoid the reality of my situation; rather, I worked within the difficulties it presented. Understanding the importance of identifying and expressing emotions, I did not deny my positive and negative feelings. By using effective coping mechanisms and introducing alternative methods as necessary to deal with stressors, I achieved a positive result. Although my flexible line of defense contracted slightly due to the influence of specific negative variables, it buffered effectively so that my underlying normal line of defense was not penetrated (p. 36).” (Fawcett, 2005, p. 206)

Discussion Points

Steps taken to ensure the Continued Evolution of the NSM Establishment of the NSM Trustees Group Support & promote the NSM through scholarly work & professional forums Establisment of the NSM Archives at Neumann College in Aston, Pennsylvania Facilitates access to important documents Establishment of the Neuman Institute Enhance continuation of NSM-based scholarly work