MRU The Jefferies Family as Client Under the Neuman System Model Case Study
Individuals and a Family as a Client
Mila Jefferies is a recently widowed 36-year-old mother of two children and the daughter of two aging parents in the southeastern United States. She and her children have recently relocated from an urban neighborhood to a rural town to care for her parents, Robert and Susan. The move involved a job change for Elizabeth, a change in schools for the children, and an increased distance from the family of the children’s deceased father. Mila’s older child is a 5-year-old daughter, recently diagnosed with autism spectrum disorder and dyslexia. The younger of the two children is a 3-year-old boy with asthma that has been difficult to control since the move. Robert is a 72-year-old Methodist minister who recently suffered a stroke, leaving him with diminished motor function on his left side and difficulty swallowing. Susan is 68 years old and suffers from fibromyalgia, limiting her ability to assist with the daily care of her husband. She has experienced an increase in generalized pain, difficulty sleeping, and worsening fatigue since her husband’s stroke.
Use the Neuman systems model as a conceptual framework to respond to the following:
Describe the Jefferies family as a client Isystem using each of the five variables. What actual and potential stressors threaten the family? Which stressors are positive, and which are negative? Separate the actual and potential stressors that threaten the individual members of the family. Which of the stressors are positive, and which are negative? What additional nursing assessment data are needed considering Robert’s medical diagnoses? What additional data would be helpful for Susan’s medical diagnoses? What about each of the children? What levels of prevention intervention(s) are appropriate for the Jefferies family? Propose potential prevention intervention(s) for each member of the family.
• Identify your nursing priorities if you were providing care to this family.
Betty Neuman’s Systems Model
Unique focus of Neuman systems model
according to Betty Neuman, (2001)
“The Neuman system model reflects nursing’s interest in well and ill
people as holistic systems and in environmental influences on
health. Clients’ and nurses’ perceptions of stressors and resources are
emphasized, and clients act in partnership with nurses to set goals and
identify relevant prevention interventions. The individual, family or
other group, community or social issues, all are client systems which
are viewed as composites of interacting physiological, psychological,
sociocultural, developmental and spiritual variables” (p. 322).
What shaped Betty Neuman
Born in 1924 on a farm in rural Ohio – this background helped her
develop compassion for those in need.
• 1947- RN from diploma
program in OH
• 1957-BSN, UCLA mental
health & public health
• 1966-MSN, UCLA
• 1967-1973, UCLA faculty.
• Developed first community
mental health program for
graduate students at UCLA.
• 1985- PhD Western Pacific
History of the Neuman’s Systems Model
• Developed in 1970 as a teaching
tool to integrate four variables of
• 1974 – published and classified as a
systems model called “The Betty
Neuman Health-Care Systems
Model: A Total Approach to Patient
• Published first book detailing NSM in 1982. Notable change:
“patient” now referred to as “client”
• The Neuman Systems Model, 2nd ed.,1989. Spiritual variable
added to diagram as fifth variable.
• 3rd, 4th & 5th editions of The Neuman Systems Model published
in 1995, 2002 & 2010
Who and what influenced the NSM?
• The writings of philospher de Chardin on the wholeness
• Marxist Cornu’s views on the oneness of man and
• Gestalts theories on the interaction between man and the
• Von Bertalannfy’s, Emery’s and Lazarus’ views on
• Selye’s concept of stress and Caplan’s levels of
Fawcett, J. (2001). The nurse theorists: 21st-century updates-Betty Neuman.
Nursing Science Quarterly, 14(3), 211-214.
More on the origins of NSM
“The development of the wholistic systemic perspective of the
Neuman systems model was motivated by my own basic philosphy of
helping each other live, many diverse observations and clinical
experiences in teaching and encouraging positive aspects of human
variables in a wide variety of community settings, and theoretical
perspectives and stress related to the interactive, interrelated,
interdependent, and wholistic nature of systems theory. The
significance of perception and behavioral consequences [also] cannot
be overestimated” (p. 675-676)
Neuman, B. (1995). The Neuman systems model (3rd ed.). Norwalk, CT:
Appleton and Lange.
Key Concepts of the Neuman Systems
Each client system is made up of 5 variables
o bodily structure & function
o mental processes & relationships
o social & cultural funtions
o developmental processes of life
o continuum of spirituality – from complete
unawareness to full spiritual understanding.
Client system as a core
Flexible line of defense:
-The outermost ring of
defense, prevents invasion
Normal line of defense:
– Represents the client
systems normal or usual
Lines of resistance:
– Involuntarily activated
when a stressor invades
normal line of defense.
Environment and Stressors
Internal environment-all forces or influences internal to or
contained within the boundaries of the defined client system, the
source of intrapersonal stressors.
External environment-all forces or
influences external to or outside the client
system, the source of interpersonal and
developed by the client as a symbolic
expression of system wholeness. Acts as
a safety mechanism to block the reality
of the environment and health experience.
Supercedes the internal and external
Variance from wellness & illness according to
Variance from wellness
• Varying degrees of system
• The difference from the
usual or normal wellness
• Illness is a state of
insufficiency with disrupting
• Illness is an excessive
expenditure of energy…
when more energy is used by
the system in its state of
disorganization than is built
and stored, the outcome may
Nursing implications of the NSM
Neuman’s Systems Model Nursing Process Format
1. Nursing diagnosis: determined on the basis of assessment of
the variables and lines of defense and resistance that make up
the specific client system.
2. Nursing goals: determined with the client for desired
prescriptive changes to correct variances from wellness.
3. Nursing outcomes: Nursing interventions are implemented
using one or more of the prevention as intervention methods.
How it’s done: Prevention as Intervention
Primary prevention as intervention- nursing actions
preventing stressor invasion; providing resources to retain or strengthen existing
client/client system strengths; supporting positive coping and functioning; motivating the
client system toward wellness; educating the client system
• Secondary prevention as intervention-nursing actions
protecting the client system’s basic structure; mobilizing and optimizing the client
system’s internal and external resources to attain stability and energy conservation;
facilitating purposeful manipulation of stressors and reactions to stressors; motivating,
educating, and involving the client system in mutual establishment of health care goals;
facilitating appropriate treatment and intervention measures
Tertiary prevention as intervention-nursing actions
attaining and maintaining the highest possible level of client system wellness and stability
during reconstitution; educating, reeducating, and/or reorienting the client system as
needed; supporting the client system toward appropriate goals; coordinating and
integrating health services resources; providing primary and/or secondary preventive
intervention as required. The nurse evaluates the outcome goals by: confirming
attainment of outcome goals with the client system and reformulating goals as necessary
with the client system
“A total person approach to viewing patient problems”
(Neuman and Young, 1972)
Human being- The client. Viewed as a whole, dynamic. Individuals
interact with their environment, and everything in the environment
relates to the individual.
Environment- Both external and internal. Environment is dynamic,
and this influences the client.
Health- The result of clients interaction with their environment.
Maintained by lines of defenses within the client.
Nursing- Focuses on all aspects of life and problem solving for
clients using one of three levels of prevention while viewing the client
as an integrated being. (Bott, Duke, Marett & Memmott, 2000)
What’s the point? Was she just another
Neuman System Model grew out of a movement in the 1970’s and
1980’s that began to recognize the patients as whole systems. With the
growing complexity of medicine, health care became more
fragmented (Bott, et al).
This is where Betty comes in. Her views were shaped by the
emerging health care practices at the time, which included taking a
broader look at patients and their needs. Also around this time the
hospice movement took place.
Neuman System Model has been criticized for being to complicated,
broad and abstract. With increasing complexity of our health and
managing major illnesses, this model is becoming more relevant in
the 21st century (Bott, et al).
So what do we do with it?
Neuman System Theory has a way of mashing all the global concepts
together. You really have to look at the individual situation to define
the concepts for that specific situation. They will change every time;
they are dynamic.
This model can be used for any situation at any given time. It is broad
and abstract, but relevant and applicable.
This system seems to be particularly useful for hospice and case
management nursing. It is well suited to not only serve an individual
client, but also families, groups and communities because of its
Nursing and Beyond
Betty Neuman’s theory was designed for nursing, but now other parts
of the interdisciplinary health care team are beginning to use her
Members of the interdisciplinary health care team may include:
▪ physical therapy
▪ occupational therapy
▪ respiratory therapy
▪ speech therapy
▪ lab, x-ray
What/Who Influenced Betty Neuman?
The influences of this model are deeply rooted in both philosophy and
psychology as they pertain to client health and well being
The influences of Betty Neuman were:
▪ Pierre Tielhard deChardin
▪ Gestalt Theory
▪ General Adaptation Syndrome
▪ General Systems Theory
Are the Global Concepts Represented?
The overall contributions of the model to the discipline of nursing are
summarized by Neuman:
▪ “The Neuman’s System Model fits well with the wholistic
concept of optimizing a dynamic yet stable
interrelationship of spirit, mind, and body of the client in
a constantly changing environment and society” (Neuman
& Young, 1972).
Betty Neuman designed her model around the idea that it is universal
and can be adapted to many situations involving a client and the
client’s stress and their reaction to it.
This model can be used in the OB and OR situation. The client, as
well as their families, have much stress in both situations. The nurse
will be able to implement the three levels of prevention:
1. Protects the normal line and strengthens the flexible line of defense
2. Strengthens the internal lines of resistance
3. Readapt, stabilizes, and protects the client’s return to wellness after
Practice Situation #1
Below are slides in which the Neuman model was used by a nurse to
care for a client. The information was taken from
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
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
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
employed; the rest are still in school.
3. Physical Stress manifested as:
b. Elevated blood pressure unresponsive to maintenance medications
c. Persistent chest pains
(continued on next slide)
Practice Situation #1
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
1. If possible to stay in a relative’s house for a few weeks because they were being hounded by media
who were camped outside their home.
2. Regular monitoring of the patient’s blood pressure by a daughter who is a student-nurse who
should also monitor her intake of medications as prescribed by the physician.
3. Avoid watching TV shows that mention about the tragedy.
4. Avoid answering the phone.
5. She should have a close relative with her aside from the children who will manage their affairs in
Practice Situation #2
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 Neuman’s 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.
Practice Situation #2
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 client’s 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
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 wellcontemplated nursing care.
Sally, a nurse for community mental health is caring for 3 clients
today. First, she meets Sam. Sam has been admitted to a psychiatric
unit with a diagnosis of psychosis and schizophrenia. Sally provides
Sam with appropriate interventions to help stabilize his condition,
monitors his compliance with medication and conducts therapy
1. Sally is using what level of prevention according to the Neuman
2. Give a few examples of nursing actions using Tertiary preventions
Bott, R., Duke, L., Marett, K., Memmot, R. (2002). Use of the
Neuman Systems Model for interdisciplinary teams. Online
Journal of Rural Nursing and Health Care. 1(2) 35-43.
Fawcett, J. Appendix N1: Conceptual models and theories
of nursing. (n.d.). In Tabers Cyclopedic Medical Dictionary
Retrieved from STAT!ref.
Kozier, B. et. Al (2004). Fundamentals ofNursing:Concepts,Process,
and Practice (4th ed.) New Jersey: Pearson
Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (2nd
edition). St. Louis: Mosby
Neuman, B., & Fawcett, J. (Eds.). (2011). The Neuman systems
model (5th ed.). Upper Saddle River, NJ: Pearson.
Neuman, B., & Young, R.J. (1972). A model for teaching total
person approach to patient problems. Nursing Research 21,
KING’S GENERAL SYSTEMS
IMOGENE KING, RN, MSN, EDD, FAAN
• Born: January 30, 1923 in West
• The youngest of three children
• Died: December 24, 2007 in Saint
Petersburg two days after
suffering from a stroke. ¹
IMOGENE KING’S EDUCATION
• 1945-Completed her diploma in nursing education at St. John’s Hospital in St. Louis,
• 1948-Received her BS in Nursing from St. Louis University
• 1957-Obtained her MS in Nursing from St. Louis University
• 1961-Obtained her Doctorate in Education(Ed.D.) from Teacher’s College in
Columbia University, N.Y.¹
• 1971- Published “Toward a theory of nursing: general concepts of human
• 1980-Honoary Ph. D from Southern Illinois University
• Postdoctoral study in research design, statistics and computer²
• Practiced as an office nurse, staff nurse, school nurse, nurse educator, and
• Administrator at Ohio State University
• Educator at St. John’s Hospital School of Nursing, Loyola University, and the
University of South Florida
• Adult Medical-Surgical Nursing Practitioner
• Assistant chief of the Research Grants Branch, Division of Nursing,
Department of Health, Education and Welfare
• Professor emeritus at the University of South Florida³
IMOGENE KING CONT’D
• Formulated her theory while she was an associate professor at Loyola
University in Chicago³
“A search for literature in nursing and other behavioral science fields,
discussion with colleagues, attendance at numerous conference,
inductive and deductive reasoning, and some critical thinking about
the information gathered, lead me to formulate my own theoretical
• During this time nursing was emerging as a profession and some sought to
challenge the existing role of nurses.
JOURNEY TOWARDS THE THEORY
• According to King humans have
three fundamental needs
• Information on health that can be
accessed and utilized
• Care that aims to prevent illness
• Care in times of need or illness²
• In 1981 King refined her concepts into a
nursing theory that consisted of:
• 1. An open system framework as the
basis of goal attainment
• 2. Nursing as a major system within
the health care system
• 3. Nursing process emphasis on
• Used a “systems” approach in the
development of her Dynamic
Interacting Systems Framework and in
her subsequent goal attainment theory.
• Interacting Systems Framework
included three systems:
• Personal System-the individual
• Interpersonal System -individuals
interacting with one another
• And Social system-groups of people
in a community or society sharing
common goals, interests and
• King studied the systems as a whole
rather than as isolated parts
• The three systems included:
• Personal system concepts includes: coping, spirituality, perception, self, body
image, growth and development
• Interpersonal system concepts includes: interaction, communication,
transaction, role, stress and coping
• Social system concepts includes: organization, authority, power, status, and
• In order to identify problems and establish goals, the nurse and patient has
to perceive one another, act and react, interact, and transact.
THEORY OF GOAL ATTAINMENT
• Describes the importance of the participation of all individuals in decision
making as well as choices, alternatives, and outcomes of nursing care.
• It pertains to the importance of interaction, perception, communication,
transaction, self, role, stress, growth and development, time, and personal
• Reflects King’s belief that the practice of nursing is differentiated from other
healthcare professions by what nurses do with and what they do for
• The nurse and patient/client communicates information in order to set goals
mutually and then acts to attain those goals.
SEVEN HYPOTHESIS IN
1. Perceptual congruence in nurse-patient interactions increases mutual goal
2. Communication increases mutual goal setting between nurses and
patients which leads to satisfaction
3. Satisfaction in nurses as well as patients increases goal attainment
4. Goal attainment decreases stress and anxiety in nursing situations
5. Goal attainment increases patient learning and coping in nursing situations
6. Role conflict experienced by nurses, patients, or both decreases
transactions in nurse-patient interactions
7. Congruence in role expectations and role performance increases
transactions in nurse-patient interactions.⁵
PUTTING THE THEORY TO USE
• King believed that if nursing students are taught the theory of goal
attainment and it is used in nursing practice, then goal attainment can be
measured and the effectiveness of nursing care can be demonstrated.
• This theory focuses on all aspects of nursing process: assessment, planning,
implementation, and evaluation.
• King believed that a nurse must assess in order to set mutual goals, plan to
provide alternative means to achieve goals, and evaluate to determine if
the goal was reached. ³
PUTTING THE THEORY TO USE
• It is useful in nursing practice to create individualized plans of care while
encouraging active participation from clients in decision making
• One current way in practice of doing this is Bedside report-this allows for the
patient to interact and know their plan of care during the stay at the hospital.
• This theory has also been used fro curriculum design in nursing programs and
used as frameworks for books. ³
• It provides a systematic means of viewing nursing as a profession, organizing
a body of knowledge for nursing, and clarifying nursing as a discipline.
• Not a perfect theory but easily understood
• Clear and conceptual defined from research literature at the time of
• Some has critiqued the theory to have limited application to nursing
especially in patients who are unable to competently interact with the nurse.
KING’S RESPONSE TO CRITIQUE
• 70% of communication is non-verbal
• It is impossible for a theory to address every person, event, and situation⁴
• King presented an open systems framework from which she derived a theory
of goal attainment. The framework consists of 3 systems including personal,
interpersonal, and social.
• The major concepts of the theory are interaction, communication,
transaction, role, stress, growth and development, space and time.
• This theory is useful, testable, and applicable to nursing practice, although it
is not a perfect theory.
KING’S THEORY APPLIED IN
• In current practice the use of this theory relies on participation of both the
nurse and the patient for effectiveness
• It can be used in most any practice
• Reviewing the patient’s plan of care and providing the patient with
information as well as education each day
• Providing the patient with options for their plan of care
• Keeping the patient “in the loop” during their process of care
• Making decisions with the patient rather than for the patient
• Bedside report is a good start to this theory.
Texas Woman’s University (2014). Nursing Theorist. Retrieved from
George, J.B. (Ed.) (2008). Nursing theories: the base for professional nursing
practice. Upper Saddle River, N.J.:Prentice Hall.
Nursing theories. (2008). Retrieved October 2, 2014 from
Blais, K. & Hayes, J. (2011). Professional nursing practice: concepts and
perspectives. Boston: Pearson.
Person is the recipient of
nursing care and may include
individuals, patients, groups,
families, and communities.
and actions of the
care on behalf of
or in conjunction
with the client.
Health is defined
as the degree of
situation) is defined as
the internal and external
surrounds that affect