THEORIST

The nursing diagnoses and interventions planned are done with consideration of the

community or client as a whole. Using Betty Neuman’s systems theory as a base, the nurse is

able to formulate a framework to address the health care needs of the community. The

interventions are based upon Neuman’s concept of internal and external stressors affecting the

wellness of a client (Haggart, 1993). The goals of Healthy People 2010 are also used by the

nurse in order to prioritize care for the community and determine which health needs are most

pressing. Interventions and diagnoses will correlate closely with the goals set forward in Healthy

People 2010.

Betty Neuman’s model of nursing practice is ideal for use in the community setting

(Haggart, 1993). The Neuman theory provides a concrete framework for community comparison

and evaluation, which can be difficult when performing an assessment over a large area. By

having organized areas to use for comparison, it becomes much easier to assess and compare

data between different clients or client systems.

Betty Neuman’s model is a systems theory (Haggart, 1993). It involves an assessment of

an individual or a group (the client), while considering the impact of the client’s internal and

external environment as well. The ultimate goal is a balance between environments, leading to

overall wellness. When a balance is lacking between the systems, there is an increased risk for

illness or disease.

When applying the system to a community, each individual in the community is a part of

the client system. As stated in Neuman’s model, within each “client” (in this case, the entire

community), there are several parts that interact. These are physiological, psychological,

sociocultural, developmental, and spiritual variables (Haggart, 1993).

Physiological variables in this case become the variables of the entire community,

morbidity, mortality (Haggart, 1993). Psychological variables of the community include the

community’s sense of identity. During the assessment, the nurse asks “Does the community view

themselves as a tightly knit group, with a sense of community verativity?” Sociocultural variables
(Haggart, 1993) include the demographic makeup of the community, as well as the economic

status of the community.

Developmental variables (Haggart, 1993) are harder concept to define in the context of

the community as a client. These can represent by how long the community has been

established. It is important to assess the residents’ whether basic needs are able to be met within

the community. Industrial and technological development can also be considered developmental

variables. Spiritual variables (Haggart, 1993) include the spiritual identity of the community. This

branches out beyond individual Religious practices.

The community has inner lines of defense (Ume-Nwagbo, DeWan, & Lowry, 2006) within

itself that keep the community stabilized: the local police force, health care availability within the

community, support systems within the community, which include family ties and family services

available to families. These lines of defense keep the community stabilized and healthy from an

inner perspective.

The external flexible line of defense senses buffer to protect the entire community. The

flexible line of defense can represent county, state, or national policies and guidelines designed to

support and promote the health of the community. An example of this is the Healthy People 2010

guidelines to improve the nation’s health. At the state level, there is the New York State Oral

Health Plan (2005, p. 11). Policies dealing with insurance and insurance coverage for the poor or

uninsured also help to make up this flexible line of defense.

The community’s forms boundaries its own natural line of defense (Ume-Nwagbo, 2006).

When the flexible line of defense fails to protect the community, the community is left to its own

devices to prevent illness or disease. At this point, a community does not have strong inner

defenses, such as adequate support services for families, then the health and wellness of the

entire community can suffer.

The Neuman systems model offers many advantages when assessing a community

(Haggart, 1993). Once a problem is identified, the intervention can be specifically targeted to the

faculty line of defense in order to alleviate the stressor. It allows a comprehensive look at
community function. Perhaps most importantly, it provides a holistic view of community problems

and allows intervention on the primary level.

The basic Neuman model diagram (see Appendix A) illustrates where community

resources fall. The labels placed on this diagram are specific to the community assessed,

Basom, New York. Basom is 33 miles east of Buffalo, approximately a 40 minute drive and 13.7

miles west of Batavia, New York, approximately a 20 minute drive.

http://www.acsu.buffalo.edu/~lhb/COM.doc

Betty Neuman’s Health Care Systems Model

• Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system
stability.
• Normal line of defense: an adaptational level of health considered normal for an
individual
• Lines of resistance: protection factors activated when stressors have penetrated the
normal line of defense
• Neuman’s model, organized around stress reduction, is concerned primarily with how
stress and the reactions to stress affect the development and maintenance of health.
• The person is a composite of physiologic, psychological, sociocultural, developmental,
and spiritual variables considered simultaneously.
• “Ideally the five variables function harmoniously or are stable in relation to internal and
external environmental stressor influences” (Neuman, 2002).
• A person is constantly affected by stressors from the internal, external, or created
environment.
• Stressors are tension-producing stimuli that have the potential to disturb a person’s
equilibrium or normal line of defense.
• This normal line of defense is the person’s “usual steady state.”
• It is the way in which an individual usually deals with stressors.
• Stressors may be of three types:
1. Intrapersonal: forces arising from within the person
2. Interpersonal: forces arising between persons
3. Extrapersonal: forces arising from outside the person
• Resistance to stressors is provided by a flexible line of defense, a dynamic protective
buffer made up of all variables affecting a person at any given moment the person’s
resistance to any given stressor or stressors.
• If the flexible line of defense is no longer able to protect the person against a stressor, the
stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The
reaction may lead toward restoration of balance or toward death.
• Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal
system stability” (Neuman, 1996).
• Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of
defense, where stressors are successfully overcome or avoided by the flexible line of
defense.
• Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied”
(Neuman, 2002).
 • Illness appears to be a separate state when a stressor breaks through the normal line of
defense and causes a reaction with the person’s lines of resistance.
http://currentnursing.com/nursing_theory/development_of_nursing_theories.htm

The Neuman Systems Model

Betty Neuman developed the Health Care Systems Model as an organizing framework for
students to understand client's needs within a holistic viewpoint (l972). In the Neuman Systems
Model the environment is defined as all internal and external influences surrounding an affecting
the client system. The client's interaction with the environment is reciprocal. This model links
person, environment, health, and nursing. It is an model of an open system in which persons and
their environment are in dynamic interaction (l989). For Neuman optimal system stability is the
best possible health state when all system variables are in balance within the client system. The
major goal of nursing in the Neuman System Model is to keep the client esteem stable through
accurate assessment of actual and potential stressors, followed by implementation of appropriate
interventions. Three intervention modalities are suggested:

Primary Prevention

Secondary Prevention

Tertiary Prevention

These prevention-as-intervention modalities are used to direct nursing actions. Primary

prevention strategies are implemented to strengthen the client's defenses - i.e. might include
giving immunizations, supporting positive coping strategies and providing health education
programs. Secondary prevention strategies are implemented once health problems have
developed, or symptoms have occurred. Early case finding (such as screenings at health fairs)
followed by appropriate referrals, counseling about high-risk behaviors, and the use of
medications and treatments. Tertiary prevention strategies assist clients in rehabilitation. It
provides for readaption, and reeducation. It is initiated after treatment when there is some degree
of system stability. The goal is optimal functioning, given the clients health status.

Caplan (l964) developed guiding principles for community mental health, combining Public Health
principles with Psychiatric principles. This became "Preventive Psychiatry. Just as in the
theoretical frameworks you have just read, Caplan saw the community as the client rather than
the individual, and the focus of practice is promoting mental health. Caplan used the terms
primary prevention, secondary prevention and tertiary prevention when identifying mental
health activities in the community.

In Preventive psychiatry:

Primary Prevention: refers to activities directed at reducing the incidence of mental disorder
within a population. Aggregates (population groups) at risk of developing an identified mental
disorder and environmental factors that may contribute to that risk are targeted. Population-
focused practice refers to the target population to which the intervention is directed . Primary
prevention does not seed to prevent a specific person from developing a mental disorder. Rather,
it reduces the risk for aggregates within a population through health promotion. Examples of
primary prevention would be:

Teaching classes on stress management to factory workers.

Conducting support groups for children moving from a small elementary

School to a large consolidated high school

Secondary Prevention: refers to activities directed at reducing the prevalence of mental

disorders by shortening the duration of a sufficient number of established cases (You may want to
skip forward to the Epidemiology module for the definitions of incidence and prevalence). This
reduction is achieved by encouraging early referrals, decreasing barriers to early diagnosis and
providing effective, timely treatment. Examples are:

Staffing a women's crisis center hotline

Screening clients with chronic, debilitating physical illness for depression.

Tertiary Prevention: activities are aimed at reducing the residual defects that are associated with
mental disorders. Sometimes this might be referred to as psychiatric rehabilitation services.
Examples are:

Medication management groups for Seriously Mentally Ill clients.

Monitoring the effectiveness of aftercare services in community mental health centers.

The services provided in this public health model are based on community needs assessment.
Local community mental health centers regularly collect data on the people they serve. This data
is used to identify and determine priorities for high-risk aggregates and to design and implement
appropriate interventions.

In the Levels of Prevention exercise, there are several mental health related items, so you can
apply Caplan's theoretical framework.

Open this link to Betty Neuman's site for more information about her model.

http://jan.ucc.nau.edu/~d-ctel/nur/nur425_jones/class/framework/framework/lesson2-1-1.html