BETTY NEUMAN

SYSTEM MODEL

Born on a farm on Lowell, Ohio in 1924.

She received her BS in Nursing in 1957 at People's Hospital, Ohio. Her MS in Mental Health, Public Health Consultation from UCLA in 1966 and she holds a PhD in clinical psychology. Her teaching experience includes mental health, consultation and organization, leadership, and counseling. As a mental health counselor, she developed her nursing model of the whole person approach based on a system adaptation framework.

NEUMANS SYSTEM MODEL

The model was initially developed in response to graduate nursing students expression of a need for course content that would expose them to a breadth of nursing problem prior to focusing on specific nursing problem areas. The model was published in 1972 as a Model for Teaching Total Person Approach to Patient Problem, in Nursing Research. It was later refined and was published in the first edition of Conceptual Models for Nursing Practice in 1974.

Neuman described her model as comprehensive and dynamic. The model is multidimensional view of individual, groups (families), and communities, who are in constant interaction with environmental stressors. Essentially, the model focuses on the clients reaction to stress and the factors of reconstitution or adaptation. It is considered an appropriate model not only for nursing but also for all health professions. Neumans conceptual approach is the result of synthesis of knowledge from several theoretical sources, including: de Chardin, Marx, Gestalt, Selye, von Bertalanffy, and Caplan.

NEUMAN'S THEORY AND THE FOUR MAIN CONCEPT

1. INDIVIDUAL/ HUMAN - focused on the philosophy that each human is a total person as a client and that this is multidimensional, a composite of physiological, psychological, sociocultural, developmental and spiritual variables. The interaction of theses variable with the lines of normal defense and flexible resistance, combined with multiple stressors, provide the essence of total person approach.

2. SOCIETY/ENVIRONMENT the concept on which humans are in constant interaction with their environment. It is defined as those internal and external forces surrounding the human at any given point in time. The created environment is intra-, inter- and extrapersonal.

Stressors: More than one stressors can occur at a time

Extrapersonal forces that occur outside the system Interpersonal forces occurring between one or more individuals Intrapersonal forces that occur within the individual

3. HEALTH/WELLNESS Neuman does not define health but stated that through an interaction/adjustment process, a person retains varying degree of balance and harmony between internal and external environments.

WELLNESS is equated with optimal stability of the normal line of defense; state of saturation; of inertness free; and of disruptive needs ILLNESS state of insufficiency; disruptive needs are yet to be satisfied. RECONSTITUTION can be equated with moving from variances from wellness to desired wellness levels and client stability which is viewed holistically.

4. NURSING is a unique profession that concerns itself with all the variables affecting human response to stressors, with a primary concern for the total person. Its goal is the retention and attainment of client system stability. Neuman has systematized the nursing process into three categories of nursing diagnosis, nursing goals, and nursing outcomes.

 Reaction: can begin at any point at which a stressor is either expected or identified. Primary Prevention If a reaction had not occurred, the intervention would enter at the primary level. Its goal is to prevent the stressor from penetrating the normal line of defense or lessen the degree of reaction by reducing the possibility of encounter with stressors and by strengthening the line of defense.

 Secondary Prevention If primary prevention is not possible and a reaction has occurred, intervention would begin at the secondary prevention. Deals mainly with early case finding, early treatment of symptoms and attempts to strengthen the internal lines of resistance to reduce reaction. Nursing interventions at this level can begin at any point where stress reaction is recognized. It may progress beyond or below the usual level of wellness or line of defense.

 Tertiary prevention is the intervention that follows that active treatment plan when reconstitution or some reasonable degree of stabilization has occurred. The goal is to maintain this adaptation in strengthening the lines of resistance, thus preventing future occurrences and by optimum use of the system's total resources, including the internal and external environment.

PERSONAL EXPERIENCES Experience #1 Im assigned at the service/charity ward of PDMMMC few months ago. As a staff in the ward of a government hospital, I noticed many weaknesses and shortcomings in the medical management and nursing care as well maybe due to the city governments not prioritizing health care. They say it is maybe due to lack of budget but I really dont believe in that same old music. I know there is, but the question is where is it going? We are badly lacking of resources, instruments and material so we need to improvise. And most of all, we are under staff so proper nursing care is compromised to every patient plus the fact that the environment is not conducive to the nurses and the patients. At that time, a 25 year old female patient was transferred to our ward from the ICU. The case was PTB advanced and heart problem. I was very curious why? They said that the patient is stable but the catch is she was admitted to the isolation room of the charity ward together with other PTB cases and with minimum nursing care because of the overwhelming census. Based on my own assessment, the patient is not yet stable, I think the true reason for transfer is that the patient can no longer withstand the demands for her medication in ICU because she is the one who is availing that, or maybe there is a much priority patient who will be placed in ICU, because it is only two bed capacity so they need to manage and decide very well on admissions and discharge. And if they want to transfer the patient post ICU, why in service ward that is not so conducive? Of course the patient is financially incapable to be admitted to pay ward.

The clients flexible line of defense is compromised here; she had a hard time resting because the temperature in the isolation room is very warm and humid even if she has an electric fan. Her nutritional level is also not good and quantity of stress increases. Her normal line of defense is also unstable, she is not well and we can assess she is not. And her line of resistance is severely debilitated; she has PTB infection and dyspnea. Her environment to isolation room further worsens her condition. Extrapersonal stressors like the isolation room environment where infection is floating around the room and also the nursing care that nurses wasnt able to render because of the nurse to patient ratio of 1:30 which is not very ideal. She also has interpersonal stressors like the problem of broking up with his husband and for not having the opportunity to see her son because children are restricted to ward premises especially in isolation room. And her intrapersonal stressors like disturbed emotional status, deteriorating physical ability and financial problems. These factors disrupted the reconstitution of the patient. In this situation, primary prevention is not given priority, because her admission to charity ward, isolation room increases her risk to infection and stress and limited nursing care. In secondary prevention, we succeed in the first part in ICU but wasnt able to continue in the ward because of many factors as stated above. Even the prescribed medications are not purchased because of financial constraints. In tertiary prevention, sometimes we nurses do our best, but fate will still prevail. Patient died that evening during endorsement before we receive her case. Nursing goal is not met. And lessons are learned. Neuman system model is a delicate tool to be used in nursing care especially in identifying the stressors, the interventions, and the affectation in the line of defenses of the client that we must protect to maintain quality of life, reconstitution and optimum level of functioning of our clientele and much better in disease prevention. Holistic care should be given to all of our patients at all times in any setting.

Experience #2

About a week ago I had in my care the wife of the captain of the ill-fated Princess of the Stars. In this case, I was able to identify the following stressors:
1. Psychological-Emotional: Anxiety which stemmed from the uncertainty about the fate of her husband. A sense of guilt because relatives of the passengers are blaming her husband for the tragedy. Ambivalence in the sense that she would be happy if her husband survived and at the same time worried too that if he did survive he would be subjected to court litigation. 2. Financial Stress: Her husband is the breadwinner of the family and in a brood of 5 children, only one is employed; the rest are still in school.

3. Physical Stress manifested as: a. Insomnia b. Elevated blood pressure unresponsive to maintenance medications c. Persistent chest pains

Nursing interventions are carried out on three preventive levels: Primary Prevention would not be applicable because the accident causing the stressors has already occurred and the patient has already developed the reactions/symptoms of stress. Secondary Prevention is applicable in this case. Because of the persistent elevated blood pressure ( above 200/110) accompanied by severe chest pains, the patient was admitted to the hospital for both diagnostic and therapeutic management. Nursing intervention centered initially on the round the clock monitoring of the blood pressure and giving of the ordered anti- hypertensive drugs. Since the EKG showed ischemia, the patient was closely watched for worsening of the pain because of the possibility of a myocardial infarction. Immediate referral of the patient to the resident physician is to be made if chest pain persisted despite giving isosorbide dinitrate for proper evaluation. Aside from giving anxiolytics to decrease the anxiety of the patient, I have to warn visiting relatives to refrain from talking about the tragedy. Sedatives were given before bedtime to prevent insomnia. Tertiary Prevention: Upon discharge, I gave the patient and the immediate family members the following advice: If possible to stay in a relatives house for a few weeks because they were being hounded by media who were camped outside their home. Regular monitoring of the patients blood pressure by a daughter who is a student-nurse who should also monitor her intake of medications as prescribed by the physician. Avoid watching TV shows that mention about the tragedy. Avoid answering the phone. She should have a close relative with her aside from the children who will manage their affairs in the meantime.

Experience #3 In the Community... In one of the rotations of my students in the community, we encountered this very interesting newly married young couple (both are 18 years old). They have been married only for 3 months, but the supposed to be happy pair is already facing a lot of stressors. One condition that brings extrapersonal stress is the unemployment of the husband. Their financial source is not enough to meet their needs. The woman somzd enough for her son. This relationship poses as an interpersonal stress to her. The wife is also pregnant at that time, and her poor nutritional (underweight) and emotional status (sadness and anger at her mother-in-law) create intrapersonal stresses. We know, based on Neumans Systems Model, that the reaction to stressors would depend on the strength of the lines of defense. The woman, due to financial constraints, is suffering from poor nutritional status. She usually lacks enough sleep due to the nature of her work. This creates a breach to her flexible line of defense. The normal line of defense also becomes unreliable because of her uncaring attitude toward her pregnancy and sexual behaviors that predispose her to a lot of possible illnesses. Her coping abilities are also affected because she is sometimes preoccupied with her relationship problems with her mother-in-law. These conditions put not only our client but also her unborn child on the verge of developing various illnesses. Hence, our interventions focused on restoring system stability, by helping the clients system adapt to the stressors. Starting with primary prevention, we tried to educate their family on the importance of having good nutrition. We suggested some nutritious but cheap food choices. We also tried to advice her on possible alternative jobs that would not jeopardize her health and that of her unborn baby. For the secondary prevention, we advised that she seek pre-natal check-up, and make use of the available services of the nearby health center. After about 1 month of constant visits to these clients, we really observed noticeable improvements in their health conditions. The woman began to show weight gains consistent with her age of gestation. The couple has also learned to plant and eat nutritious food such as fruits and vegetables. The husband started to work as a production operator in a nearby factory, allowing his wife to take a break from her old job. Before our duty in the community ended, we were able to initiate tertiary prevention by supporting and commending the positive behavioral changes exhibited by the couple. We also dwelt on strengthening the positive attributes of the family, such as their unwavering faith in God, and their strong devotion to each other. We learned from this experience that no problem is unsolvable with the use of consistent and well-contemplated nursing care.