Betty Neuman

Betty Neuman
Betty Neuman

Health Care System Model




Open system consisting of a basic structure or central core of survival factors surrounded by concentric rings that are bounded by lines of resistance , a normal line of defense, and a flexible line of defense. The total person is a composite of physiologic, psychologic, sociocultural, and developmental variables.


Both internal and external environments exists and a person maintains varying degrees of harmony and balance between them. It is all factors affecting and affected by the system.


Wellness is the condition in which all parts and sub-parts of an individual are in harmony with the whole system. Wholeness is based on interrelationships of variables that determine the resistance of an individual to any stressor. Illness indicates lack of harmony among the parts and sub-parts of the system of the individual. Health is viewed as a point along a continuum from wellness to illness; health is dynamic. Optimal wellness or stability indicates that all a person’s needs are being met. A reduced state of wellness is the result of unmet systemic needs. The individual is in a dynamic state of wellness-illness, in varying degrees, at any given time.


Neuman’s Health Care Systems Model

Betty Neuman’s systems model, first published in 1972, is based on the individuals relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. Reconstitution is the state of adaptation to stressors.

Neuman views the client as an open system consisting of a basic structure or central core of energy sources surrounded by two concentric boundaries or rings referred to as lines of resistance. The two lines of resistance represent internal factors that help the client defend against a stressor. The inner or normal line of defense represents the person’s state of equilibrium of the state of adaptation developed and maintained over time  and considered normal for that person. The flexible line of defense is dynamic and can be rapidly altered over a short period of time. It is a protective buffer that prevents stressors from penetrating  the normal line of defense.

The nurse’s focus is all the variables affecting an individual’s response to stressors. Nursing interventions are carried out on three preventive levels:

1. Primary prevention identifies risk factors, attempts to eliminate the stressor, and focuses on protecting the normal line of defense and strengthening the flexible line of defense. A reaction has not yet occurred, but the degree of risk is known.

2. Secondary prevention relates to interventions or active treatment initiated after symptoms have occurred. The focus is to strengthen internal lines of resistance, reduce the reaction, and increase resistance factors.

3. Tertiary prevention refers to intervention following that in the secondary stage. It focuses on readaptation and stability and protects reconstitution or return to wellness follwing treatment. The nurse emphasizes educating the client in strengthening resistance to stressors and ways to help prevent recurrence of reaction or regression.

Betty Neuman’s model of nursing has been widely accepted by the nursing community, nationally and internationally. it is applicable to a variety of nursing practice settings involving individuals, families, groups, and communities.


Kozier, Barbara Fundamentals of Nursing 5th edition

Addison-Wesley Publishing Company, Inc.1998 p.49


Imogene King

Imogene King
Imogene King

Goal Attainment Theory (1971,1981,1986,1987,1989)


Three interacting systems; individuals (personal system), groups (interpersonal system), and society (social system); the personal system is a unified, complex, whole self who perceives, thinks, desires, imagines, decides, identifies goals, and selects means to achieve them.


Adjustments to life and health are influenced by an individual;s interactions with environment. The environment is constantly changing.


A dynamic state in the life cycle; illness is an interference in the life cycle. Health implies continuous adaptation to stress in the internal and external environment through the use of one’s resources to achieve a maximum potential for daily living.


A helping profession that assists individuals and groups in society to attain, maintain, and restore health. If this is not possible, nurses help individuals die with dignity. Nursing is perceiving, thinking, relating, judging and acting a vis-avis the behavior of individuals who come to a nursing situation.  A nursing situation is the immediate environment, spatial and temporal reality, in which nurse and client establish a relationship to cope with health state and adjust to changes in activities of daily living if the situation demands adjustment. It is an interpersonal process of action, reaction, interaction, and transaction whereby nurse and client share information about their perceptions in the nursing situation.

King’s Goal Attainment Theory

Imogene King’s theory of goal attainment, first published in 1971, was derived from conceptual framework of three dynamic interacting systems; (a) personal systems (individuals), (b) interpersonal systems (groups), and social systems (society). Key concepts are identified for each system as follows:

1. Personal system concepts: perception, self, body image, growth and development, space and time

2. Interpersonal system concepts: interaction, communication, transaction, role and stress

3. Social system concepts: organization, authority, power, status, and decision making.

The client ans nurse are personal systems subsystems within interpersonal and social systems. To identify problems and to establish goals, the nurse and client perceive one another, act and react, interact, and transact. Transactions are defined as purposeful interactions that lead to goal attainment. Transactions have the following characteristics:

1. They are basic to goal attainment and include social exchange, bargaining and negotiating, and sharing a frame of reference toward mutual goal setting.

2. They require perceptual accuracy in nurse-client interactions and congruence between role performance and role expectation for nurse and client.

3. They lead to goal attainment, satisfaction, effective care, and enhanced growth and development.

King postulates seven hypothesis in goal attainment theory:

1. Perceptual congruence in nurse-client interactions increases mutual goal setting.

2. Communication increases mutual goal setting between nurses and clients and leads to satisfactions.

3. Satisfaction in nurses and clients increase goal attainment.

4. goal attainment decreases stress and anxiety in nursing situations.

5. Goal attainment increases client learning and coping ability in nursing situations.

6. Role conflict experienced by clients, nurses, or both decreases transactions in nurse-client interactions.

7. Congruence in role expectations and role performance in creases transactions in nurse-client interactions.

King’s theory highlights the importance of the participation of all individuals in decision making and deals with the choices, alternatives, and outcomes of nursing care. The theory offers insight into nurses’ interactions with individuals and groups within the environment t.



Kozier, Barbara Fundamentals of Nursing  5th edition

Addison-Wesley Publishing Company, Inc pp.48-49

Fundamentals Theorists

Florence Nightingale (1860)

Nightingale’s Environmental Theory

Florence Nightingale, the “mother of modern nursing,” considered nursing to be a religious calling to be fulfilled only by women. Her theory focused on the environment, although this term never appeared in her writings. She linked health with five environmental factors: (1) pure or fresh air (2) pure water (3) efficient drainage (4) cleanliness, and (5)light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness.

The above factors attain significance when one considers that sanitation conditions in hospitals of the mid 1800s were extremely poor, and the women working in the hospital were unreliable, uneducated, and incompetent to care for the ill.

In addition to the factors above, Nightingale also stressed the importance of keeping the patient warm, maintaining a noise-free environment, and attending to the patient’s diet in term,s of assessing intake, timeliness of the food, and its effect to the person.

Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warm, and diet remain integral parts of nursing and health care today.

Kozier, Barbara Fundamentals of Nursing 5th edition

Addison-Wesley Publishing  Company, Inc.  pp. 46 & 50