CLINICAL

The Neumanapplication in

Systems Model:a Canadian HIV setting

Judy E Mill

N ursing and health care in Canadaand elsewhere are experiencing pro-found change. A paradigm shift

away from an emphasis on disease and illnesstowards wellness and health is evident inhealthcare research, education and practice.Nursing practice has traditionally focused onthe attainment and maintenance of health inindividuals, families and communities. Thishistorical focus provides nurses with anopportunity to assume a leadership role in thechanging healthcare forum.

This article describes the application of theNeuman Systems Model (NSM) to nursingpractice with reference to the current trendsin health care in Canada. A human immun-odeficiency virus (HIV) outpatient clinic at alarge teaching hospital in Western Canada isthe practice setting used to demonstrate theimplementation of this model. An overviewof the trends forecasted to shape health carein the 21st century is outlined in terms oftheir relevance to the continued use of nurs-ing models, specifically the NSM.

THE PARADIGM SHIFT IN HEALTH CARE

Lalonde (1974), in his report A NewPerspective on the Health of Canadians, wasone of the first to propose the need to reformhealth care in Canada. He argued that furtheradvances in the health of Canadians could notbe achieved without addressing the impact oflifestyle, human biology and environment on aperson's health. He advocated a move awayfrom the traditional emphasis on illness to afocus on the prevention of disease. Four yearslater, a seminal document, the Declaration ofAlma-Ata (World Health Organization(WHO), 1978), was produced at an interna-tional conference on primary health care, out-lining strategies with which to achieve healthfor all by the year 2000. This documentadvanced the conviction that the attainmentof the highest possible level of health for allmembers of society must become a worldwide

AbstractIn healthcare research, education and practice there Is evidence of aparadigm shift away from disease and illness towards an emphasis onweiiness and heaith. The Neuman Systems Model (NSM) is a nursingmodei that has been used in a variety of settings with individuals,famines and communities. The focus of this model on the prevention ofiiiness and the promotion of heaith is congruent with the paradigm shiftthat has occurred in all areas of health care. A review of the iiteraturereveaied limited information on tbe use of nursing modeis in the ciinicaiarea of human Immunodeficiency virus (HIV) or acquiredimmunodeficiency syndrome (AiDS). This articie describes tbeapplication of the NSM in an HIV practice setting with reference to thecurrent and future trends in health care in Canada.

societal goal. Primary health care was advo-cated as the necessary strategy to achievehealth for all (WHO, 1978).

Within the model of primary health care,health promotion is advocated as a strategyto assist individuals and communities toenhance their health status. Health promo-tion focuses on creating an environment thatenhances health and wellbeing. It 'representsa mediating strategy between people and theirenvironments...' (WHO, 1984) and includesstrategic plans to build healthy public policy,create supportive environments, strengthencommunity action, develop personal skillsand reorientate health services (WHO, 1986).The realization that the concept of healthmust include an understanding of therelationship between the mdividual/commu-nity and the environment (physical, biologi-cal, social, economic and political) hadbecome evident by this time. It had alsobecome apparent that many vulnerable popu-lations, in both developing and developedcountries, had limited access to healththrough the traditional approaches of health-care delivery.

Nurses are in a prime position to partici-pate m the implementation of these newapproaches to health care. It is remarkablethat as far back as 1978, Schlotfeldt, in

a PhDNursing Student, Universityof Alberta, Edmonton,Alberta, Canada

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In order to be aneffective partner

in the changinghealthcare arena,nursing must ensurethat its professionalpractice is guidedby theory. TheNSM [NeumanSystems Model] canprovide a theoreticalframework fornursing practice byproviding acomprehensivestrategy forassessment,intervention, andevaluationof care.

outlining her vision for the future of nursing,described a model of community health cen-tres which included nurses as the primarypatient contact. Dr Halfdan Mahler, DirectorGeneral of WHO at the time of the Alma-Ata

, stated that:

'...millions of nurses throughout theworld hold the key to an acceptance andexpansion of primary health carebecause they work closely withpeople...' {Mahler, 1985).

This statement challenges nurses and nursingto become advocates of and participants in asystem based on primary health care.

THE NEUMAN SYSTEMS MODEL AS AGUIDE FOR PRACTICE

In order to be an effective partner in the chang-ing healthcare arena, nursing must ensure thatits professional practice is guided by theory.The NSM can provide a theoretical frameworkfor nursing practice by providing a comprehen-sive strategy for assessment, intervention andevaluation of care that is compatible with thephilosophy of primary health care. The use andeffectiveness of the model in a variety of set-tings has been documented thus reflecting itsgeneralizabiiity (Smith, 1989; Knight, 1990;Pierce and Hutton, 1992). Individuals, families(Ross and Helmer, 1988; Reed, 1993) or com-munities (Beddome, 1995) may make up theclient system in this model.

An overview of the NSMThe interaction between the client and his/herenvironment is central to the NSM. Neumandescribes her model as being holistic and asone in which:

'...the client is viewed as a composite ofinteracting variables — physiological,psychological, developmental,sociocultural, and spiritual — that areideally, either functioning harmoniouslyor stable in relation to both internal andexternal environmental stressorinfluences'{Neuman, 1995).

The client is at the core of the system protect-ed by lines of resistance (factors that assist theclient in returning to his/her usual state ofwellness) and the normal and flexible lines ofdefence (Neuman, 1995). The normal line of

defence is dynamic and represents the client'susual state of healrh (Neuman, 1995).

The nurse interacts with the system byassessing the impact of environmental stressorson the client's health and assists his/her inmaintaining optimum wellness by interveningwith primary, secondary and tertiary preven-tion (Neuman, 1995). In Neuman's mode!health promotion is a component of primaryprevention. Neuman describes three types ofstressors which can influence the system:1. An intrapersonal stressor which is within

the client2. An interpersonal stressor which is outside,

but in close proximity to the boundary ofthe client

3. An extrapersonal stressor which occursoutside the client's boundaries.

The goal of intervention is 'to protect theclient system's normal line of defence or usualwellness state by strengthening the flexibleline of defence' (Neuman, 1995).

The NSM in an HIV outpatient settingDuring a recent clinical learning experience theauthor assessed the utility of the NSM in anHIV outpatient clinic of a large hospital inWestern Canada. A literature search was com-pleted to determine the use of nursing models inthe clinical area of HIV or acquired immunode-ficiency syndrome (AIDS). This inquir>' revealeda paucit\' of information in this area. Pierce andHutton (1992) used a case study to demonstratethe application of Neuman's model with anHIV-positive client. Flaskerud (1992) utilized amodel of primary, secondary and tertiary pre-vention to plan the care of HIV-positive clients,but did not use a nursing model. Clearly, furthertesting and evaluation of nursing models in thisclinical setting is necessary.

In the HIV clinic, intervention is implement-ed by an interdisciplinary team which includesphysicians, nurses, social workers, psycholo-gists and public health nurses (health visitors).The weekly client review meetings are reflec-tive of the interdisciplinary nature of the team(Field, 1988) in the HIV clinic and leadershipis dependent on the expertise required by eachclient. Although NSM has the potential to beutilized by a variety of healthcare profession-als, in this case the other members of the inter-disciplinary team did not use it.

Primary prevention in the HIV outpatientclinic occurs with individuals, families andthe community. Intervention at the primary

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THE NEUMAN SYSTEMS MODEL. ^APPLICATION IN A CANADIAN HIV SEniNG

level is aimed at reducing the likelihood of theclient confronting a stressor. Clients are mon-itored regularly on an individual level toassess the physical, social and emotionalimpact that the disease process has on them.These elements are comparable to the vari-ables Neuman identifies within each clientsystem. Through this assessment, whichincludes the careful management of a varietyof medications, the client can achieve his/herhighest level of wellness.

Primary prevention was implemented withtwo mothers who were HIV positive duringthe author's placement in the HIV clinic.Home visits were made to assess the variablesinfluencing their health and to explore possi-ble solutions to the problems they were hav-ing in coping with their illness. One singlemother was experiencing difficulty dealingwith childcare for her two young children.This mother, because of limited support fromher family, needed information regardingtemporary childcare to cover the periodswhen she required hospitalization. She alsorequired emotional support as she began thepainful task of identifying a caregiver for herchildren following her death.

Primary prevention occurred on a broaderlevel through education and outreach workin the community. Educational programmesaimed at the prevention of HIV infection inthe community were carried out by nursesand other members of the interdisciphnaryhealth team. Staff in the outpatient clinicwere also involved with other communityagencies in programme planning for the pre-vention of HIV infection.

When primary prevention failed to preventa stressor from invading the client system, sec-ondary prevention was implemented. Forexample, secondary prevention in the HIVclinic occurred with the initiation of antibi-otics to prevent opportunistic infections whena client's immune status deteriorated. Markedweight loss, accompanied by decreasedstrength, are common physical symptoms thatoccur with the progression of HIV disease.These physical changes often necessitated theprovision of home care services to clients dur-ing the later stages of their illness. Home careis another example of secondary preventionand delays the need for hospitalization.

Tertiary prevention included support andclose monitoring of the client's general healthstatus and immune system to ensure that the

client system had stabilized following an ill-ness. In the later stages of illness the healthstatus of clients was monitored in theirhomes. The process of reconstitution (tertiaryprevention) may be very protracted with anHIV client because of the impairment ofhis/her immune system. Following illness,reconstitution involves the process of theclient achieving and maintaining his/her opti-mum level of wellness. Support and coun-selling for the client and his/her family was acomponent of each level of prevention.

Cofigruence of the model with cunentpracticeThe principles outlined in the NSM are con-sistent with the current trends evident in nurs-ing practice and health care in Canada. Thefocus of this model on prevention is compati-ble with the increased emphasis on preven-tion in all areas of healthcare practice. Inaddition, Neumanns inclusion of health pro-motion in primary prevention reflects thecontemporary nature of the model. Neumanstates that this concept:

'...has unlimited potential for maior roledevelopment that could shape the futureimage of nursing'{Neuman, 1995).

Recognition of the role of the environment indetermining the health status of individuals,families, and communities is a key elementand a positive feature of the NSM.

The future role of the NSMThe NSM is a comprehensive nursing modelwhich can provide a useful framework fornursing practice in the 21st century. Severalauthors have demonstrated the utility of thismodel in the current healthcare system (Pierceand Hutton, 1992; Reed, 1993; Beddome,1995). In order to ensure the continued rele-vance of the NSM for client practice it isimportant to understand the issues surround-ing future health care.

The ageing population, poverty and ethicaldilemmas arising as a result of rapid techno-logical growth are issues which healthcareproviders will have to confront (Catley-Carlson, 1992). Sadik (1992) stresses that theimplementation of measures to control popu-lation growth are fundamental to the attain-ment of global health. In addition, thegrowing trend of delivering health care in the

The principlesoutlined in

the NSM [NeumanSystems Model] areconsistent with thecurrent trendsevident in nursingpractice and healthcare in Canada.The focus of thismodel on preventionis compatible withthe increasedemphasis onprevention in allareas ofhealthcarepractice.

BRITISH JOURNAL OF NURSING, 1997, VOL 6, No 3 165

CLINICAL

client's home and in community settings isexpected to continue (Parse, 1992).

The recognition that health is a global con-cern, in combination with the goal of achiev-ing health for all by the year 2000, necessitatethe development of nursing models which areapplicable to any culture. Nursing modelswill increasingly be required to guide theprovision of health care in vulnerable popula-tions. The future of nursing may be depen-dent on:

'...the ability of the discipline to reachout to diverse communities and to meetthe health needs of those mostvulnerable'(Hallctal, 1994).

The theoretical components of the NSM aresufficiently robust to embrace the emergingtrends in health care and thus guide futurenursing practice.

CONCLUSION

The realization that traditional approaches tohealth care were limited in their ability to effecta continued improvement in health status is evi-dent from the Lalonde report (1974) and theDeclaration of Alma-Ata (WHO, 1978). As aresult of the WHO mandate the goal of healthfor all by the year 2000 was adopted as aworldwide societal goal by many countries.Primary health care is the fundamental strategyfor attaining this goal. The nursing profession,with its historical focus on health and its closerelationship to people, is central to the imple-mentation of primary health care.

As strategies are developed to assist in theachievement of health for all, nursnig practice

KEY POINTS

Healthcare practice is shifting its emphasis away from illness anddisease towards wellness and health.

Nurses are in a key position to assume a leadership roie in thechanging healthcare forum.

The emphasis on prevention and health promotion in the NeumanSystems Model is congruent with the current philosophy evident inhealth care,

The Neuman Systems Model provides a comprehensive framework forcurrent and future nursing practice.

will change to reflect this. In the future, nurs-ing practice will focus on the elderly andother vulnerable populations. The increasingcomplexity of healthcare technology willresult in challenging ethical issues for nursing.Nurses will increasingly practice primaryhealthcare roles in the community. The NSMhas the capability of embracing the emergingconcepts in health care and has the potentialto provide a strong basis for nursing practicein the next century. USH

The author would like to acknowledge the supportshe received front the National Health andResearch Development Program to undertake hergraduate studies. This article was originally writtenfor a graduate nursing course at the University ofAlberta. The assistance of Dr Ruth Elliott andDr Peggy Atm Field, faculty of Nursing, Uuwersityof Alherta, is gratefully acknowledged.

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