Summary

Betty Neuman was born in rural Ohio in 1924. She graduated from a nursing diploma program at
Peoples Hospital in Akron in 1947, received her B.S. in public health in 1957 and earned an M.S. as a
public health-mental health nurse consultant in 1966. After graduating, Neuman became faculty chair of
the M.S. program she graduated from at University of California, Los Angeles. She began developing her
theory in as a teaching aid for an introductory course in said program and continued to develop it after
multiple evaluations.
Neuman systems theory seeks to identify positive and negative stressors and determine how they can
disrupt the system. The theory uses variables that pertain to spiritual, developmental, and psychological
aspects of the body system, among other variables, to define how stressors affect the body system.
Neumans theory sees the person as an open system in conjunction with the environment. The
environment is used to explain how external factors can bring about stress. Health is considered a line of
defense against stress and may be impacted by stress. Nursing is used to intervene between stressors
and the body system through the nursing process.
The Neuman systems model combats system stressors by adapting the nursing process into 3 steps:
diagnosis, goal setting, and outcome planning. The system also uses prevention of a stressor as an
intervention.



Early Life and Nursing Education
Betty Neuman was born in 1924 on a farm in rural Ohio. She was the second of three children and the
only girl in her family. Her mother worked as a rural midwife while raising Neuman and her siblings. Her
father passed away of chronic renal disease when she was eleven years old.
Neuman attributes her desire to join the nursing field to her father's high esteem of his nurses and her
mother's work. When she graduated high school, however, Neuman could not afford a nursing
education. She worked three jobs to raise money for school and help care for her mother and younger
brother. She also joined the Cadet Nurse Corps Program, which accelerated her acceptance into nursing
school. She graduated from Peoples Hospital's (now Akron General Medical Center) diploma program in
1947. In 1957, she received a Bachelors in Public Health Nursing from the University of California in Los
Angeles. She earned a masters degree in Public Health/Mental Health Services Consultation from the
University of California, Los Angeles in 1966.
Six months after receiving her masters degree, she became a faculty chair of her graduate program. She
created the Neuman Systems Model in response to a request of graduate students in the University of
California, Los Angeles nursing program. These students wanted, "an introductory course that would
provide an overview of the physiological, psychological, sociocultural, and developmental aspects of
human beings." (Neuman, 2002a, p.325-396) The model was developed as a way to integrate all of these
aspects into a holistic, teachable format.


The following is an interview in which Neuman discusses the development of her theory.
https://www.youtube.com/watch?v=UilhyIGg8jA

Besides working as the faculty chair of University of California, Los Angeles' graduate program and
developing her model, Neuman has also worked as a mental health consultant. She was also one of the
first nurses licensed as a marriage and family counselor in the state of California, is a clinical fellow of
the American Association of Marriage and Family Therapists, maintains her own private counseling
practice. She also attained the honor of becoming a fellow in the American Academy of Nursing in 1993.
Neuman has received two honorary doctorates, as well: one from Grand Valley State University in
Allendale Michigan, and one from Neumann College in Aston, Pennsylvania. She is also a licensed real
estate agent and has a private pilot's license. (George, 2010, p. 338-339)

Nursing Theory, Concepts, and Propositions
The Neuman Systems Model is based on stress and the reaction/ potential reaction to stress, with a
philosophical basis in wholeness, wellness, client perception and motivation, energy, and environmental
interaction (George, 2011, p. 341). In the Neuman Systems Model (NSM), it is considered ideal to
achieve a stable system. Once stability is achieved, a revitalization occurs (George, 2011, p. 341).
Neuman identifies stressors as forces that seek to disrupt the systems stability. Neuman views stressors
as either a positive or negative effect on the system (George, 2011).


Basic Structure
The central focus of the Neuman Systems Model is basic survival factors. Neuman defines basic survival
factors as system variables, genetic features, and strengths and weaknesses of the system. System
variables refer to the physiological, psychological, sociocultural, developmental, and spiritual variables
of a species.
Other Components of the Neuman Systems Model
Client Variables
Neuman views that individual client wholistically and considers five variables simultaneously and
comprehensively (George, 2011, p. 342). Physiological variables include the structure and
internal/external functions of the body. Psychological variables are the mental processes and
relationships. Sociocultural variables are the functions that relate to social/cultural expectations,
activities, and influences. Developmental variables are processes related to human development.
Spiritual variables are those that influence spiritual beliefs (George, 2011).
Lines of Resistance
The lines of resistance protect the basic structure and become activated when the normal line of
defense is invaded by environmental stressors (George, 2011, p.343). The lines of resistance are the
last boundary to protect the basic structure (Reyes, Ricana, Rico, Rimas, & Rosales, 2008). If the lines of
resistance are effective, the system will rebuild but if the lines of resistance prove to be ineffective,
death may occur (George, 2011).
Normal/Flexible Lines of Defense
The normal lines of defense indicate the systems stability over time whereas the flexible lines of
defense represent the initial response to system stressors. Any stressor may invade the normal line of
defense when the flexible line of defense offers inadequate protection (George, 2011, p.343). The
normal lines of defense represent the clients typical wellness level. The flexible lines of defense
(reaction to stressors) is dependent upon the amount of sleep, nutritional status, *and+ the quality and
quantity of stress experienced (Reyes et al., 2008).




Environment
The environment in the Neuman Systems Model includes any internal/external factors that impact the
client. The environment has the potential to be positive or negative and can affect the clients reaction
to stress. George (2011) gives an example of individuals that are sleep deprived and experience a higher
susceptibility to the common cold. The sleep deprivation would be an internal factor and the common
cold would be an external factor.

Stressors
Stressors, in the Neuman Systems Model, are stimuli that produce tensions and *may cause+ system
instability (George, 2011, p.344). In this model, stressors are neutral; the clients perception of the
stressors determines whether they are positive or negative. Stressors can be intrapersonal (within the
system boundary), interpersonal (outside the system boundary), or extrapersonal (outside the system
boundary at a greater distance). An example of an intrapersonal stressor is the clients autoimmune
response. Interpersonal may include role expectations of the client. Extrapersonal could include social
policy that affects the client.
Health/Reaction
Neuman identifies health as complete system stability or harmony among the five variables (George,
2011, p. 345). As the client moves towards illness and death, entrophy, or a need for more energy,
occurs. As the client moves towards wellness, negentrophy, or excess energy, occurs. Reaction can be
positive or negative and is impacted by entrophy and negentrophy (George, 2011).
Prevention-as-Intervention
There are three forms of prevention-as-intervention: primary, secondary, and tertiary. Primary
prevention occurs prior to the systems reaction to a stressor (health promotion and wellness
maintenance). Secondary prevention occurs after the system reacts to a stressor (provided based upon
existing symptoms). Tertiary prevention begins after the system is treated (maintain wellness after
treatment through secondary prevention) (George, 2011).
Reconstitution
Reconstitution is initiated after the treatment for stressors begins. It can be viewed as the return to and
maintenance of system stability (George, 2011, p.346). Reconstitution may improve, return to, or
decrease the previous level of wellness (George, 2011).
Nursing
The Neuman Systems Model addresses nursing as a means to help the client system attain, maintain, or
retain system stability (George, 2011, p.346). This can be done by adjusting the prevention-as-
intervention methods (primary, secondary, and tertiary) to fit the needs of the client. The nurse is the
link between client system, environment, health, and nursing (George, 2011, p. 346).

Application of Meta-Paradigms to Neuman's Theory

A meta-paradigm is a set of concepts that describe the reasoning behind a certain discipline. The four
main links in a meta-paradigm include the person, environment, health, and nursing (Potter & Perry,
2012, pg. 40).

The person is whoever is receiving the nursing care. The person can be a single individual, or even a
whole community. Environment relates to any condition affecting the person. The person is directly
related to the environment that they are within. The health of a person is always changing. The nurse
must make sure to provide patient-centered, high quality care (Potter & Perry, 2012, pg. 40-
41). According to the American Nurses Association,nursing is the "...diagnosis and treatment of human
responses to actual or potential health problems..." (American Nurses Association, 2010).

Using Betty Neuman's theory, the four major concepts in the nursing meta-paradigm are applied below.
Neuman sees the person as an open system that works with the environment. The human being is
constantly changing, either in positive or negative ways. The client's system mechanisms can be viewed
using the diagram below. The line of resistance protects the core and consists of what would be the
immune response and basic physiological mechanisms. The next part, the normal line of defense,
represents how the person has changed over time. This includes what they have learned, their attitudes
developed, and their abilities (Knight, 1990, pg. 449). Lastly, there is the flexible line of defense. The
flexible line of defense depends on present day contributions such as sleep, nutrition, and social activity
(Ross & Bourbonnais, 1985, pg. 200-201). A person is subject so stress both in internally and externally,
and people react to this stress in either learned or natural ways. A person's perception of a stressor-
whether it's important or not, the intensity, and the timing all impact how a person will react to a
certain type of stress (Knight, 1990, 449). Each person also has different variables. The variables are
physiological, sociocultural, psychological, developmental, and spiritual (Reed, 1993, pg. 10-11).

The environment is an important factor to the system; it includes internal, external, and created
environments. The internal environment of a person includes such things as smoking, infection, or
disease (Ross & Bourbonnais, 1985, pg. 201). The external environment brings about stress related
interpersonally, or with other people. This can be seen in role changes, such as when a child now has to
care for an older parent. A person can also find resources such as gaining education, family support, or
community help within their environment to help relieve some of the stressors (Knight, 1990, pg. 449).
The last type of environment is the created environment, which is unconsciously created by the person.
In a created environment, a person unconsciously does certain acts to reduce stress. An example would
be rearranging furniture in an old, familiar way when moving to a new home (Reed, 1993, pg. 12).
Health is looked at as a continuum from optimal health to illness (George, 2011, p. 348). Optimal health
occurs when all system needs are tended to, while illness will occur when needs are not tended to. In
regards to the person, wellness is defined as the flexible line of defense preventing anything from
harming the normal line of defense. Illness occurs whenever the normal line of defense is hindered and
needs are not met (Knight, 1990, pg. 449).
Nursing defines the action in certain situations that are stress induced or related to reactions of the
client. This is where nursing interventions come into play- to help restore stability and reduce stress.
When using the nursing process of assessment, diagnosis, planning, intervention, and evaluation; the
nurse must communicate thoroughly with the patient throughout the entire process. Neuman stated
that the nursing interventions can be implemented whenever a stressor is occuring, or whenever it is a
potential risk for occuring (Knight, 1990, pg. 450). The interventions that can take place include primary,
secondary, and tertiary prevention.

Theory's Implication to Nursing Practice, Education, and Research
The Nursing Process
The nursing process is implemented in the Neuman systems model in an altered format. The
Neuman systems model follows the nursing process, initially, by utilizing the assessment phase. The
nurse can assist the patient in regaining optimal wellness by assessing the actual and potential effects of
stressor invasion and helping the client to implement necessary changes (George, 2011). The nurse
supports system stability by utilizing primary, secondary, and tertiary and by linking the client system to
the environment, health, and nursing (George, 2011).
The Neuman systems model used in clinical practice consists of a three-step process: nursing
diagnosis, nursing goals, and nursing outcomes. The first step is nursing diagnosis. This involves utilizing
databases to identify alterations in wellness and development compared to correlations and constraints
(George, 2011). It is organized according to client system, level of response, client subsystem
responding to the stressor (i.e. psychological, physiological, etc.), the source of the stressor, and the
type of stressor (George, 2011). Data is collected, prioritized, and compared to theories that are able to
explain the clients condition (George, 2011). Any factor out of the norm is included as a risk factor,
whether it is an intra-, inter-, or extrapersonal factor.
The next step of the process is nursing goals. This consists of caregiver-client oriented strategies
agreed upon to attain, maintain, or retain system stability (George, 2011). Goals need to be negotiated
upon and accepted by the patient to be effective. There are two parts to the goal process: expected
outcomes and planned interventions (Knight, 1990). The goal of the nurse should be to maximize the
clients energy conservation while also using the clients energy to improve their condition (George,
2011). The goals are based on the needs of the client and the resources available.
The final step of the Neuman systems model in practice is nursing outcomes, which begins with
interventions. The interventions portion of the outcomes stage consists of the prevention-as-
intervention stages mentioned previously (George, 2011). Each prevention-as-intervention (whether
primary, secondary, or tertiary) are followed-up by an evaluation (George, 2011).
Below are pictures illustrating the nursing process. The photo on left is a picture of the traditional
nursing process. The photo on the right is the Neuman systems model of the nursing process. Both
utilize the same factors, however, the Neuman systems model consolidates outcome identification and
planning into goals and implementation and evaluation into outcomes.

Prevention-as-Intervention
Primary prevention consists of: preventing the invasion of a stressor, providing information to
promote the strengths of the client, support positive actions, eliminate possible stressors, promote
wellness, incorporating theories and epidemiological input, education, and utilizing stress as a positive
intervention strategy (George, 2011). Secondary prevention includes: protection from stressors after
invasion, optimizing resources (internal and external) to maximize energy conservation, controlling the
reaction to stressors, further education of clients toward health and wellness goals, encouraging positive
wellness, and providing primary prevention as needed (George, 2011). Tertiary prevention occurs after
undergoing treatment from secondary prevention. Tertiary prevention consists of: attaining and
maintaining optimal wellness and stability post-treatment, reeducating and adapting to changes,
supporting the client towards implemented goals, implementing health service resources, and following-
up with primary prevention as needed (George, 2011).
In Research and Education
The flexibility of the Neuman systems model makes it ideal for utilization in research and
education. This is due to the fact that the model works with open-system characteristics, it incorporates
time as a variable, and it incorporates major client variables which are unique to specific situations,
regardless of complexity and unpredictability (Knight, 1990). A major client variable that the model
focuses on in research is perception. This allows the researcher to focus on the client's feelings,
attitudes, and beliefs that could affect the nature of the disease process (Knight, 1990).
In education, the Neuman systems model's versatility, once again, plays a major role. It can be
used for many levels of education such as continuing education programs, baccalaureate, or
masters (Bourbonnais & Ross, 1985). The model can be used in various types of settings such as public
health, hospitals, and daycares and also for the invdividual, family, or community client (Bourbonnais &
Ross, 1985). As mentioned above, the model can be used to maintain health, promote health, or restore
health (Bourbonnais & Ross, 1985). The extent of the type of care the Neuman systems model can be
used for varies from managing pain, rehabilitation, acute or chronic care and more (Bourbonnais & Ross,
1985).

References
American Nurses Association. (2010c). Nursings social policy statement: The essence of the profession
(2010 Reissue). Silver Spring MD: Author.
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implementation. Journal of Advanced Nursing, 10, 117-123.
George, J. B. (2011). The Neuman systems model. In M. Connor (Eds.) Nursing theories (pp. 338-384).
New Jersey: Pearson Education, Inc.
Knight, J.B. (1990). The Betty Neuman Systems Model applied to practice: a client with multiple
sclerosis. Journal of Advanced Nursing, 15(4), 447-455. doi:10.1111/1365-2648.ep8530016
Neuman, B. (2002a) Appendix B: Betty Neuman's autobiography and chronology of the development
and utilization of the Neuman Systems Model. In B. Neuman & J. Fawcett (Eds.) The Neuman
Systems Model (4th Ed., pp. 325-396) Upper Saddle River, NJ: Prentice Hall.
Potter, P.A., & Perry, A.G. (2012). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby Elsevier.
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