Using the Neuman Systems Model for Best Practices

Pearl N. Ume-Nwagbo, RN; MSN

Assistant Professor, East Tennessee State University, Johnson City, Tennessee

Sharon A. DeWan, RN; MSN

Family Practitioner, Tarpon Springs, Florida

Lois W. Lowry, RN; DNSc

Professor, East Tennessee State University, Johnson City, Tennessee
Human beings with unmet needs related to their health and illnesses are the central focus of the domain of nursing.
It is proposed in this column that nurses who conduct their practice from a nursing theory base, while assisting individuals and families to meet their health needs, are more likely to provide comprehensive, individualized care that
exemplifies best practices. The Neuman systems model has been widely acclaimed to guide practice, yet specific examples are few in the published literature. The purpose of this column is to present two case studies based upon
Neuman systems model; one case is directed toward family care, and the other demonstrates care with an individual. Theory-based exemplars serve as teaching tools for students and practicing nurses. These case studies illustrate how nurses actions, directed by Neumans wholistic principles, integrate evidence-based practice and
generate high quality care.

The primary emphasis in healthcare today is to provide the

highest quality care, based on the best and latest evidence, delivered by knowledgeable and caring practitioners. This is a
tall order, and one that must be examined to determine the
most adequate means to achieve the goal. For example, practice grounded in research findings alone, may de-emphasize
the importance of the individual needs of the client and the experiential knowledge of the caregiver. Likewise, a primary focus on professional judgment gained through experience may
overlook the importance of the theoretical underpinnings that
provide the perspective and framework for delivering comprehensive, individualized care. Thus, it is the intention of the
current authors to demonstrate how quality nursing care can
be delivered by integrating theory-guided perspectives with
individualized patient needs, based on current evidence, and
clinical expertise.
When considering the domain of nursing, human beings
who have unmet needs related to their health or illness status
are the central focus. The domain of nursing focuses on nursing therapeutics directed toward meeting human needs to promote health and well-being. Theory and research are the processes by which the domain of nursing is developed,
validated, and communicated. Theories that conceptualize
the goal of nursing as bringing back balance and stability and
preserving energy, focus on interventions that will attain,
maintain, and retain client system stability (Neuman, 1996).
These principles are exemplified within the Neuman systems
Nursing Science Quarterly, Vol. 19 No. 1, January 2006, 31-35
DOI: 10.1177/0894318405284125
2006 Sage Publications

modela model that provides a unifying focus for a wide

range of nursing concerns. Whereas general guidelines exist
to assist the practitioner in using the model, few specific examples are available in the published literature. Thus, each
practitioner must dwell with the model to learn the concepts,
definitions, and philosophic approach to care prior to creatively thinking and synthesizing the information for application. One excellent learning tool for practitioners is to study
cases that are assessed and implemented according to the
Neuman systems model perspective.
The purpose here is to introduce the reader to the critical
concepts of the Neuman systems model (Neuman, 1996); and
then, present two case studies that are analyzed and interpreted using the Neuman systems model as the guide to care
delivery. In case study 1, a newly wed couple experiencing
marital stressors is the focus of the care. In case study 2, an individual client who requires coronary bypass surgery is
presented.
Neuman Systems Model
The Neuman systems model is predominantly wellnessoriented and wholistic. It is based on concepts of stress and reaction to stress within the total environment of the defined client as an open system. Clients may be one person, or a group
of peoplemeaning a family, a community, or a society
(Neuman & Fawcett, 2002). Each client system consists of

Keywords: Neuman systems model, nursing theoryguided practice

Downloaded from nsq.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 8, 2015

32

Nursing Science Quarterly, 19:1, January 2006

five interacting variables: physiological (bodily structure and

internal function), psychological (mental processes and interactive environmental effects, both internally and externally),
sociocultural (combined effects of social-cultural conditions
and influences), developmental (age-related development
processes and activities), and spiritual (spiritual beliefs and
influences) (Neuman & Fawcett, 2002, pp. 16-17).
The Neuman systems model (Neuman & Fawcett, 2002)
diagram illustrates the client system as an open circle surrounded by several concentric circles. The central circle is described as the basic structure, which consists of factors common to all persons, such as blood pressure, temperature,
innate or genetic features, and strengths and weaknesses of
the system organs. The basic structure is surrounded by several circles representing lines of resistance (LOR), whose
function is to protect the system against stressors and maintain a healthy existence (Neuman & Fawcett, 2002). Examples include the bodys mobilization of white blood cells, activation of the immune system mechanisms, and social and
psychological supports. Surrounding the LOR there are two
circles. The outside one is the flexible line of defense (FLD),
which serves as the protective buffer to prevent or impede
stressors from invading the system. The FLD is said to be
accordion-like in function. When it expands away from the
system, it provides greater protection, and as it draws nearer
to the normal line of defense (NLD), the second outer line,
less protection is provided (Neuman & Fawcett, 2002). Conditions such as fatigue, poor nutrition, and daily stress can
cause the FLD to move closer to the NLD because its buffering power is compromised. The NLD, protected by the FLD,
represents the usual wellness level of the client system. The
NLD develops over time and is influenced by system variables such as coping patterns, lifestyle factors, developmental, spiritual, and cultural influences. When the NLD is
penetrated by environmental stressors, the LOR are activated
to protect the basic structure (Neuman & Fawcett, 2002).
Neuman (Neuman & Fawcett, 2002) proposed that nurses
enter into the clients world to promote stability and balance.
This is achieved by accurate assessment of the possible effects of internal and environmental stressors, and then, to assist the client/client system to readjust so that an optimal
wellness state can be attained. In Neumans (1996) model,
The nursing process is described as the three-step format of
nursing diagnosis, nursing goals, and nursing outcomes
(p. 69). The nurse approaches the patient by way of three preventions as intervention: primary, secondary, and tertiary
(Neuman, 1996; Neuman & Fawcett, 2002).
Primary prevention strategies are used to maintain the
state of wellness, by strengthening the FLD of the client system, through stress prevention and reduction of risk factors.
Secondary prevention strategies are used after stressors have
invaded the NLD and there are signs of illness. The goal is to
diagnose these stressors and intervene so that the LOR are
strengthened. Appropriate treatment at this time will assist
the client system to regain stability. Finally, tertiary preven-

tion strategies are instituted through support and education so

that the client can readapt and resume the road to healthy
functioning (Neuman & Fawcett, 2002).
Stressors are described as tension-producing stimuli or
forces occurring within the internal and external environmental boundaries of the client system (Neuman & Fawcett,
2002, p. 21). Stressors disrupt client systems, sometimes
causing physical illness or emotional and social crises. The
role of the nurse is to assess the stressor reaction in all five
variables, as well as the perception of the client of the stressors. Nurse and client then negotiate goals and formulate strategies to meet the goals. In the first case presented below, the
client is a married couple experiencing system instability.
Marriage is both a maturational and situational crisis, both of
which have the capability to produce stress.
Case Example of Marital Stressors
The nurse guided by the Neuman systems model (Neuman
& Fawcett, 2002) met Jane and Joey when their marriage was
threatened by stressors. The nurse assessed the couple and
learned the following details. Jane and Joey were high school
sweethearts. They grew up in the same neighborhood, and
went to the same grade school. It was not until high school
that they fell in love with each other. They knew that they
would eventually marry. The families were acquainted and
supported the plan for their children to marry after college.
Jane was a quiet, tall, slim, good-looking girl, but not what
one would call beautiful. She was friendly, well-liked by her
classmates, and always tried to make peace among her
friends. She hated to quarrel and would do everything in
her power to avoid any kind of misunderstanding between her
and anybody else. Joey, on the other hand, was outgoing, very
talkative, and popular. He was the basketball star in their
school, and girls were always trying to get dates with him; but
for some reason he fell for quiet Jane.
Jane and Joey went to the same undergraduate and graduate schools. Jane graduated with a masters degree in accounting, and was working as an accountant in a bank. Joey earned
a masters degree in chemical engineering and was working
in a chemical company.
Prior to the marriage, the couple attended a 10-week premarriage counseling, conducted by Joeys minister and his
wife. The premarriage counseling included topics meant to
help the couple to better understand each other. The counseling included topics such as communication skills, listening
skills, anger management, financial management, and meditation. From the perspective of Neumans model, the premarriage counseling can be viewed as a primary prevention as
intervention to strengthen the couples FLD.
Following marriage, Jane and Joey did almost everything
together. They shared housework, cooking, shopping, and
cleaning almost equally, and spent their quiet time together.
They left for work together, and when they got back from
work they prepared dinner, ate, relaxed, and went to bed to-

Downloaded from nsq.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 8, 2015

Practice Applications
gether. They hardly ever went out except for occasional movies and dining. They were both vigilant to detect when their
relationship was not as healthy as they would like it, and they
would make time to talk and pray for guidance, thus were able
to settle their differences. Jane and Joey utilized the knowledge that they gained from the premarriage counseling to
strengthen the FLD whenever they noticed that their marriage
was confronted by stressors.
One year after their marriage, Jane observed that Joey was
less talkative and more moody. When asked, Joey claimed
that nothing was wrong. After constant questioning, he admitted that he missed hanging out with his men friends as
he used do to before he got married. He stated that he felt
caged in. The couple agreed that they would spend two
nights a week with their individual friends. This arrangement
seemed to suit Joey well. He was his old self, and consequently, they started communicating more effectively.
Three months following this arrangement, Joey stopped
helping Jane with any of the housework, remarking that none
of his friends did any housework in their respective homes.
Jane tried to get Joey to talk with her to air this problem, but
Joey refused, insisting that he was the man of the house, and
should not be expected to do a womans job. By trying to get
Joey to discuss their problem, Jane was seen by the Neuman
nurse as trying to bolster their FLD, so that the NLD would
not be penetrated.
In a continued attempt to protect the NLD, Jane suggested
that they should schedule and attend marriage counseling.
Joey refused. Meanwhile, their communication and the
whole relationship began to suffer. It took pleadings from
Joeys parents to get him to agree to go to the marriage
counseling.
The nurse, guided by the Neuman systems model, understood that the breakdown in the couples relationship represents the breakdown in the FLD, leading to a breakdown of
the NLD. Marriage counseling, if instituted, represents a secondary prevention as intervention. If the marriage counseling
is successful, the NLD would be repaired, and the marriage
would be strengthened. Joey did attend the marriage counseling, and their marriage relationship resumed to what it was
soon after their wedding.
This renewed relationship did not last long. Jane introduced another stressor by telling her husband that she would
like to have a baby. Joey did not receive this news well at all.
He did not think it would be wise to bring any child into this
world that was full of evil. He strongly believed that bringing a child into this world would not be fair to that child. This
issue soon began to be a point of very bitter argument. Even
interventions by their minister and their parents did not help
to bring an agreement between the couple. As the arguments
became worse, Joey stopped helping Jane with housework
and started staying out late with his friends.
With continued quarrellings, Joey moved out of their
house. Jane made several attempts to get Joey to agree to
counseling in order to rescue their marriage. Joey said he was

33

not interested. He maintained that as far as he was concerned

the marriage was over. At this point, both the NLD and the
FLD had been penetrated, and the LOR were activated. At
this time, the nurse was thinking that if tertiary prevention as
intervention, in the form of readapting and reeducating the
couple to the present reality of their marriage, would be initiated successfully, then the NLD and the FLD could be
mended and the marriage retained. This level of intervention
is the most challenging because it requires learning and implementing new behaviors that can alter the NLD, hopefully,
toward more optimal system stability.
Over the next months, Jane made it a point to be polite to
Joey each time they ran into each other, although Joey chose
to ignore her. Six months after Joey moved out, Jane received
a telephone call from him requesting that she go out with him
for a cup of coffee. She accepted the invitation, and they had a
pleasant visit. Soon after this, they were dating on a regular
basis. Joey was the one who suggested that they should give
their marriage another chance, and suggested that they should
look into counseling sessions. During the sessions, they relearned how to communicate, listen, and relate to each other.
During one session, Joey apologized to Jane about his reaction to her desire to have children. He explained that his negative reaction to that wish was because he was very unhappy at
that time. Since that situation had now changed, he would
consider having children. Jane was overjoyed. Joey soon
moved back in with his wife, and they established a different
NLD that better reflected their actual life together.
The nurses diagnosis for this case was, a change in the
couples established patterns of living lead to unhealthy disagreements, that penetrated the FLD and NLD, activating the
LOR, causing the need for three preventions as interventions.
Interventions included secondary prevention of marriage
counseling to repair the NLD. Tertiary preventions of reeducation and readaptation to establish new guidelines for their
life together, provided the support to begin again. In the 2
years following the counseling, a baby boy was born whom
they adore. The couples acceptance of the three interventions
has strengthened their family FLD and NLD so that they are
better able to withstand stressors.
In the case study presented above, the nurse guided by the
Neuman systems model was able to conduct assessments that
informed interventions and that assisted the couple to resolve
the stressors of their marriage to regain stability and health.
The model also provides clear direction when used with an individual with an acute healthcare problem as shown in the
next case study.
Case Example of an Individual Client
With a Physiological Stressor
In this application of the Neuman systems model, the client is a 60-year-old man, who is scheduled for coronary artery
bypass graft (CABG) in 1 week. During his preoperative
visit, assessment reveals a good ejection fraction (50%), a his-

Downloaded from nsq.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 8, 2015

34

Nursing Science Quarterly, 19:1, January 2006

tory of a small anterior wall infarct, and three vessel disease.

The man is considered by the cardiothoracic surgeons to be a
good candidate for surgery. However, he does have history of
mild chronic obstructive pulmonary disease due to a 20 year
history of smoking. Before beginning the 3 steps of
Neumans nursing process, the nurse practitioner (NP) assessed the client as an open system in total interface with the
environment (Neuman & Fawcett, 2002), whose risk of postsurgical complications is dependent on the strength of the
FLD and NLD, and the ability of the LOR to maintain the client in a stable state. All three preventions as interventions
(primary, secondary, tertiary) will be considered for this
patient in order to ensure a rapid uncomplicated recovery.
In formulating a diagnosis, the NP concludes the first step
of the nursing process with a nursing diagnostic statement,
and the formulates prioritized goals and interventions
(Neuman & Fawcett, 2002). The diagnosis included data
about each of the patients five variables: physiological, psychological, sociocultural, developmental, and spiritual variables. During the process of diagnosis, the NP included the
patients perceptions of the effect of his illness on the five
variables; particularly, the physiological and psychological.
In assessment of the physiological variable, in relation to
the basic core energy resources, heredity factors, genetic factors, and organ strengths or weaknesses were considered.
Common client survival factors related to system variables
as well as unique individual characteristics (Neuman &
Fawcett, 2002, p. 17) make up the basic structure energy resources. Therefore, the patients myocardial damage was
considered as well as the heart muscles contractibility. An
electrocardiogram, stress test, and echocardiogram were
evaluated to determine the patients left ventricular function.
His chronic obstructive lung disease was assessed and the
ventilation profusion ability of the pulmonary membrane was
assessed through pulmonary function tests and blood gases.
The integrity of the harvest saphenous veins was also assessed, along with the patients family history of heart
disease, stroke, diabetes, lung disease, and hyperlipidemia.
LOR surround and protect the basic structure energy resources and provide internal protection factors when stressors have penetrated the NLD, causing reactions or symptoms.
Factors that included the LOR assessment were the patients
white blood cell count, hemoglobin, hematocrit, platelets,
skin integrity at the sternal site, the patients cardiac output,
myocardial contractive ability (stroke volume), blood pressure, lung cilia, and pulmonary ventilation and perfusion capabilities. The ability of the sympathetic and parasympathetic
systems to compensate postoperatively, the respiratory rate,
phagocytic function, oxygen availability, maximum pulmonary inspiratory and expiratory forces, and the accessory
muscle capacity of the client were also noted. A complete
blood count with differential, a chemistry profile, liver enzymes, chest x-ray, urinalysis, clotting studies, and medication assessment were required to determine the protective
ability of the NLD in defending the basic core structure.

The FLD in relation to the physiological assessment included the intact intrapleural space that prevents the lungs
from collapsing, the skin integrity and its ability to be the first
line of defense against infection; the perfusion capability of
the coronary arteries, which will prevent myocardial
ischemia; the force of contraction of the heart; and serum osmotic pressure, which will maintain glomerular filtration
rate, optimal urinary output, and peripheral perfusion.
In assessing the psychological variable, the basic genetic
psychological health of the patient and his ego strength were
included. In relation to the LOR, the psychological assessment included the patients values and the ability to perceive
and react to stressors, the patients past experiences with a
surgical procedure, his strength of coping mechanisms, and
perception of wellness. The ability of the NLD to deflect
stressors is dependent upon communication and decisionmaking patterns, change mechanisms, and present support
systems. In assessing the FLD, the NP and the patient considered daily decision-making capabilities, his ability to manage
stress and communicate needs, his general sense of wellbeing, and his expression of a positive, hopeful outlook. This
type of assessment can be seen as the personality characteristics that influences emotional sensitivity to role stressors in
the objective environment (Gigliotti, 1999).
The developmental assessment variable included agerelated developmental skills, developmental tasks, age-related
values, the ability to function as a dependent person immediately postoperative, the ability to perceive appropriate pain
management, and the clients ability to express his needs and
concerns. The sociocultural assessment included financial resources, cultural or ethnic practices, roles and rules, use of
healthcare system, resource allocation, financial expectations, and personal obligations. Spiritual assessment included
daily spiritual practices, religious beliefs, spiritual values,
and source of power and strength.
The main stressor in this case is the surgical procedure and
postoperative mechanical ventilation. According to Neuman
(Neuman & Fawcett, 2002), stressors have the potential to
cause system instability leading to either a positive or negative outcome. A CABG procedure is a major physiological
stressor that will either benefit or potentially harm the client
system in the postoperative or intraoperative arena. If the
stressor becomes an uncomplicated operative procedure,
the stressor will benefit the patient by sufficiently oxygenating the myocardium and preventing further ischemia. The
nursing diagnosis reflected the patients ability to overcome
the stress of open heart surgery. The nursing diagnosis was,
the potential for postoperative entropy, resulting in illness,
requiring the optimization of the clients lines of defense and
resistance in relation to the physiological, developmental,
spiritual, psychological, and sociocultural variables; thus
achieving reconstitution.
Although all variables require goals, interventions, and
evaluation, the focus here included interventions pertaining
to the physiological variable in relation to the actual model.

Downloaded from nsq.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 8, 2015

Practice Applications
Based on the assessment, the NP considered primary, secondary, and tertiary interventions. Primary intervention included
patient teaching, iron and vitamin supplements, immunizations as needed, high protein diet, electrolyte and hydration
maintenance, discontinuing medications that would potentially affect clotting studies, inotropic medications to maintain cardiac output, nitroglycerine to prevent myocardial infarction, and bronchodilators to enhance oxygenation.
Secondary preventative measures attempted to maintain system stability once reaction to stressors occurred postoperatively. Secondary interventions focused on the immediate
postoperative period, namely, ventilator control, administration of blood products and clotting factors as necessary, monitoring and replacing chest tube output, potassium infusions,
transfusions as necessary, maintenance of endotrachial
intubation, ordering ventilatory changes, maintenance of
chest tube patency, the evaluation of cardiac indexes and
systemic vascular resistances every 1 to 2 hours and ordering
inotropic agents as necessary.
Tertiary interventions during the rehabilitative period that
occurred 1 week to 6 months postoperatively included physical therapy, client-system stability, and wellness assessment
maintained every 1 to 2 months, and medications continued
as needed. The final step included the evaluation to determine
goal attainment, or to guide goal reformulation. This client
had an uneventful postoperative recovery and was continually evaluated for optimal system stability every 6 months.
Balance and health will persist if he follows a healthy lifestyle
and is able to identify stressors that can affect his health.
Conclusions
Through these two cases, the Neuman systems model
(Neuman, 1996; Neuman & Fawcett, 2002) has provided a
theoretical framework for assessing both individual and fam-

35

ily needs, and a plan for delivering care in a knowledgeable

way that honors and respects the client system. The systematic use of the Neuman model permits nurses to collect data
for research studies that will add to nursing knowledge and
provide for evidence-based outcomes.
The Neuman systems model (Neuman, 1996; Neuman &
Fawcett, 2002) provides the nurse with a basic wholistic system required to explore nursing goals and interventions. It is
comprehensive and flexible enough to provide a basis for all
nursing inquiry, and it also promotes individual interpretation. In fact, Neuman encouraged nurses to be creative in their
application to prevent the model from becoming stagnant
(Neuman & Fawcett, 2002). The focus on prevention is congruent with the goals of Healthy People 2010 and can be incorporated with United States Preventative Service Task
Force recommendations to improve health and reduce
mortality.
This process of caring leads to optimal client outcomes because the Neuman systems model focuses on client systems
in terms of stressors, variables, and lines of defense, rather
than relying on medical diagnoses or surgical procedures. Although the scientific method enables professionals to seek the
ultimate diagnostic quest for answers, it has the potential to
leave nursing expertise behind. The use of theoretical underpinnings, such as the Neuman systems model, ensures integrity of care by focusing on wholistic, individualized
perspectives of each client system.
References
Gigliotti, E. (1999). Womens multiple role stress: Testing
Neumans flexible line of defense. Nursing Science Quarterly,
12, 36-44.
Neuman, B. (1996). The Neuman systems model in research and
practice. Nursing Science Quarterly, 9, 67-70.
Neuman, B., & Fawcett, J. (2002). The Neuman systems model (4th
ed.). Upper Saddle River, NJ: Prentice Hall.

Downloaded from nsq.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 8, 2015