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Developmental variable—age, degree of normalcy,
factors related to the present situation.
Spiritual variable—hope, sustaining forces.
(Neuman, 1995)
The external environment consists of all forces
or interactive influences existing outside the client-
client system. Interpersonal factors in the environ-
ment are forces between people or client systems.
These factors include the relationships and resources
of family, friends, or caregivers. Extrapersonal fac-
tors include education, finances, employment, and
other resources (Neuman, 1995).
Neuman (1995) has identified a third environ-
ment as the “created environment.” The client
unconsciously mobilizes all system variables, in-
cluding the basic structure of energy factors toward
system integration, stability, and integrity to create
a safe environment. This safe, created environment
offers a protective coping shield that helps the
client to function. A major objective of the created
environment is to stimulate the client’s health.
Neuman pointed out that what was originally cre-
ated to safeguard the health of the system may have
a negative outcome effect because of the binding of
available energy. This environment represents an
open system that exchanges energy with the inter-
nal and external environments. The created envi-
ronment supersedes or goes beyond the internal
and external environments while encompassing
both. The created environment provides an insulat-
ing effect to change the response or possible re-
sponse of the client to environmental stressors.
Neuman (1995) gave the following examples of re-
sponses: use of denial or envy (psychological),
physical rigidity or muscle constraint (physiologi-
cal), life-cycle continuation of survival patterns
(developmental), required social space range (so-
ciocultural), and sustaining hope (spiritual).
Neuman believes the caregiver, through assess-
ment, will need to determine (1) what has been cre-
ated (nature of the created environment), (2) the
outcome of the created environment (extent of its
use and client value), and (3) the ideal that has yet
to be created (the protection that is needed or pos-
sible, to a lesser or greater degree). This assessment
is necessary to best understand and support the
client’s created environment (Neuman, 1995).
Neuman suggested that nursing may wish to pur-
sue and further develop an understanding of the
client’s awareness of the created environment and

its relationship to health. Neuman believes that as

the caregiver recognizes the value of the client-

created environment and purposefully intervenes,

the interpersonal relationship can become one of

important mutual exchange (Neuman, 1995).

HEALTH

Health is the third concept in Neuman’s model.

Neuman believes that wellness and illness are on

opposite ends of the continuum and that healthis

the best possible wellness at any given time. Wellness

exists when more energy is built and stored than

expended, whereas death occurs when more energy

is needed than is available to support life. Neuman

views health as a manifestation of living energy

available to preserve and enhance system integrity.

Health is seen as varying levels within a normal

range, rising and falling throughout the life span.

These changes are in response to basic structure

factors and reflect satisfactory and unsatisfactory

adjustment by the client system to environmental

stressors (Neuman, 1995).

NURSING

Nursing is the fourth concept in Neuman’s model

and is depicted in Figure 18–4. Nursing’s major

Nursing’s major concern is to keep the

client system stable by (1) accurately

assessing the effects and possible effects

of environmental stressors, and (2) assist-

ing client adjustments required for optimal

wellness.

concern is to keep the client system stable by (1) ac-

curately assessing the effects and possible effects of

environmental stressors, and (2) assisting client ad-

justments required for optimal wellness. Neuman

defined optimalas the best possible health state

achievable at a given point in time. Nursing actions,

which she labels as prevention by intervention, are

initiated to keep the system stable. Neuman has cre-

ated a typology for her prevention by intervention

nursing actions. They include primary prevention

by intervention, secondary prevention by interven-

tion, and tertiary prevention by intervention. All of

these actions are initiated to best retain, attain, and

288 SECTION III Nursing Theory in Nursing Practice, Education, Research, and Administration