1 │ Introduction

Hospitalization and illness often lead to heightened levels of anxiety and stress among individuals, as evidenced by various stressors such as the fear of illness, unfamiliar environments, separation from the community and family, occupational concerns, and the financial burden associated with the illness [1-3]. These stressors significantly impact an individual's mental state, potentially leading to chronic anxiety and increased vulnerability [4]. Anxiety, characterized by an unpleasant sense of worry or pressure, has been identified as a hindrance to the treatment process, impeding the patient's resilience [5, 6].

The inhibitory and detrimental nature of anxiety contributes to various consequences and complications associated with illness and hospitalization, including heightened heart excitability, increased blood pressure, delayed healing processes, and an elevated risk of infection [7, 8]. During such challenging circumstances, individuals often seek assistance from healthcare professionals, who play a crucial role in providing necessary support [9].

The experience of illness and hospitalization induces role loss and changes, disrupting an individual's sense of control and coordination over their own well-being [10, 11]. Successful adaptation to the condition of the disease is pivotal for effective treatment and a timely recovery [12]. Contemporary healthcare services aspire to deliver quality care, with nursing care models grounded in different theories utilized by nurses to enhance health, expedite treatment processes, and foster patient recovery [13, 14].

Betty Neuman's systemic model emerges as one such theoretical framework employed by nurses to assess, integrate information about individuals, and holistically enhance health status [15, 16]. The model's fundamental structures provide nurses with a framework to consider each client's uniqueness, assess the client's environment, and subsequently plan meaningful care interventions [16]. Central to Neuman's model is the examination of stressful factors affecting individuals and the corresponding nursing interventions aimed at facilitating patient recovery [17]. The open system perspective inherent in Betty Neuman's model positions it as a suitable framework for implementing patient care programs [18].

Against this backdrop, this study aims to apply Betty Neuman's systemic model in the execution of the nursing process for a patient undergoing Whipple surgery, recognizing the model's potential to guide and enhance patient care interventions in a holistic manner.

1.1 │ Betty Neuman's systemic model

Betty Neuman's systemic model intricately incorporates the fundamental concepts of holism, client health, stress, the client's response to stressors, and the notion of client adaptation through defense lines [19]. Within Neuman's model, the client is conceptualized as an open system, wherein iterative cycles of input, process, output, and feedback establish a dynamic organizational pattern [20]. A client, in this context, may refer to an individual, group, family, or community engaged in reciprocal exchanges with the environment [21]. The optimal environment is achieved when the client attains the desired stability [22]. Each concentric circle in Neuman's model comprises five personal variables: physiological, psychological, socio-cultural, spiritual, and evolutionary [23].

Neuman's systemic model features a core structure and associated energy sources essential for the client's survival [18, 19]. The individual is viewed as an open, dynamic system continually undergoing change. Stability, or homeostasis, is achieved when the available energy surpasses the energy expended by the system [21]. Protective circles encompass the core structure, comprising resistance lines, the natural defense line, and the flexible resistance line [22]. The outermost circle is identified as the natural line of defense, signifying system stability under normal circumstances. Beyond this lies the flexible defense line [12]. If the flexible defense line proves insufficient in protecting against the natural defense line, resistance lines are activated [13]. These resistance lines, encircling the core structure, are triggered when a stressful factor breaches the natural defense line [14]. In cases where the resistance lines are ineffective, the system faces energy depletion, potentially leading to adverse outcomes, including death [23].

Neuman's model addresses the impact of stressful factors on health and delineates strategies for stress relief and reduction [15]. Stress factors encompass any environmental force whether internal (emotions and feelings), interpersonal (role expectations), or external (job or financial pressures)—that has the potential to disrupt system stability [16]. The model posits that individuals are in constant, dynamic interaction with the environment, which comprises internal and external forces, including stressful factors, intrapersonal, interpersonal, and extra personal forces, all capable of influencing system stability [24].

Intervention in Neuman's model is categorized into three levels: primary, secondary, and tertiary prevention [25]. Primary prevention precedes the system's response to a stressor and involves health promotion and maintenance [26]. Secondary prevention focuses on preventing damage to the central core after the system reacts to a stressor, strengthening internal lines of resistance [27]. Tertiary prevention comes into play after treating the system through secondary prevention, aiming to add energy to the system or reduce the required energy for facilitative regeneration [28].

Additionally, Neuman's model incorporates the concepts of reaction and reconstruction [15]. The degree of reaction signifies the level of system instability resulting from the onslaught of stressors countered by the body's natural defense line [23]. Restoration refers to the return and maintenance of system stability post a stressful reaction [28]. Neuman posits that client health equates to the optimal stability of the system, representing the pinnacle of health [29]. She introduces a health continuum, wherein an excess of required energy over available energy propels the client's system towards disease and death, while an abundance of available energy over necessity propels it towards health [30, 31]. Nursing, according to Neuman, is a distinctive profession that comprehensively addresses all variables influencing an individual's response to a stressor [32]. A person is viewed holistically, and it is the nurse's responsibility to approach the individual in their entirety [33]. Neuman defines nursing as actions geared towards assisting clients in maintaining the highest possible level of health [4, 19]. She underscores the significance of evaluating not only the client's perceptions but also those of the caregiver (nurse) as the nurse's perception significantly impacts the care provided [34].

2 │ Case presentation

This research constituted a clinical case study that explored the implementation of the nursing process utilizing the Betty Neuman nursing model in the provision of care for a patient admitted to the surgery department of a hospital located in Northern Iran. The focus of the study was on a patient who underwent Whipple surgery. Following the project's approval by the research council and the acquisition of ethical clearance under the reference number IR.GOUMS.REC.1402.422 from the Biomedical Ethics Committee of Golestan University of Medical Sciences, the researcher proceeded to the research setting and purposefully selected an available patient. Adhering to the ethical principles outlined in the Declaration of Helsinki, and subsequent coordination with the patient, the nursing process for patient care was systematically designed based on the Betty Neuman model, encompassing nursing diagnoses, nursing goals, and nursing outcomes (Table 1). The initial phase involved conducting an interview with the patient and their family to acquaint them with the process, assess their condition, and identify potential stressors. The preliminary assessment entailed scrutinizing the interaction among the five patient variables, stressors, and resources within the intrapersonal, interpersonal, and extra personal domains. Following comprehensive data collection and evaluation, three nursing diagnoses were ascertained according to the classification outlined by the North American Nursing Diagnosis Association International (NANDAI). Subsequently, nursing care interventions were implemented based on the three levels of prevention deemed significant within the framework of Neuman's model.

The research findings encompass the assessment and compilation of information, as detailed in Table 2. The application of the nursing process within the Betty Neuman model, prioritized according to identified needs, is delineated in Table 3. This includes the presentation of three nursing diagnoses formulated as a result of the evaluation and collection of pertinent patient data.

Table 1. Stages of the nursing process based on Neuman's systemic model.

3 │ Discussion

The nurse's role in the control model is characterized by the management of five primary variables within the foundational structure of the client's system, encompassing flexible, natural, and resistant defense lines. Stress is categorized into three types based on its environmental origin: internal, external, and created. The intrapersonal dimension involves interactions within an individual, while interpersonal factors pertain to interactions between two or more individuals. Extra personal factors encompass all interactions occurring in the extra personal environment. Nursing care, within the framework of the Betty Neuman model, is delineated as preventive interventions across primary, secondary, and tertiary levels, addressing the impact of stress on each line of defense. The first dimension of interventions seeks to prevent the adverse effects of stress on the client's system. The second dimension involves secondary interventions following the system's response to stressors and the inadequacy of the natural defense line. Interventions in the third dimension aim to forestall the progression of signs and symptoms, mitigate the severity of the disorder, and prevent damage to the lines of resistance. According to the Betty Neuman model, prevention occurs at the third level post-nursing and treatment. Level two interventions focus on reinforcing lines of resistance, preventing the manifestation of signs and symptoms, and improving the prognosis of the disease to restore and enhance health conditions within the client's system. In this model, the nurse plays a crucial role in supporting the client by fortifying defense lines and implementing appropriate nursing actions to facilitate the restoration of health conditions.

4│ Conclusions

The utilization of Neuman's system model in nursing practice facilitated the identification of diverse facets of interpersonal, intrapersonal, and extra personal stressors experienced by Mr. A-M. This proved beneficial in delivering comprehensive care. The application of this theoretical framework elucidated the manner in which primary, secondary, and tertiary prevention interventions can be employed to address issues within the client population.

Table 2. Evaluation and collection of information.

Table 3. The nursing process of Betty Neuman's model based on the priority of nursing diagnoses.

Acknowledgements

Not applicable.

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: MK, KY; Drafting the work or revising it critically for important intellectual content: MK, KY; Final approval of the version to be published: MK, KY; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: MK, KY.

Funding

Self-funded.

Ethics approval and consent to participate

The study obtained ethical approval from the Ethics Committee of Golestan University of Medical Sciences, identified by the code IR.GOUMS.REC.1402.422. Before participation, individual provided informed consent after receiving detailed information about the study's aims. Participant was explicitly informed of their right to withdraw from the study at any time if they chose to do so.

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

Using artificial intelligent chatbots

None.