journal nps3c47

INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Stressors in five client populations: Neuman systems model-based

literature review

Carole Ann Skalski BS RN

Staff Nurse, Christ Hospital, Emergency Room, Jersey City, New Jersey, USA

Louisa DiGerolamo AAS RNC

Senior Staff Nurse, Maimonides Medical Center, Brooklyn, New York, USA

Eileen Gigliotti PhD RN

Professor, College of Staten Island, City University of New York, New York, USA

Accepted for publication 22 April 2006

Correspondence:

Eileen Gigliotti,

College of Staten Island,

City University of New York,

2800 Victory Boulevard,

Marcus Hall,

Staten Island,

New York 10314,

USA.

E-mail: [email protected]

doi: 10.1111/j.1365-2648.2006.03981.x

SKALSKI C.A. , DIGEROLAMO L. & GIGLIOTTI E. (2006)SKALSKI C.A. , DIGEROLAMO L. & GIGLIOTTI E. (2006) Journal of Advanced

Nursing 56(1), 69–78

Stressors in five client populations: Neuman systems model-based literature review

Aim. This paper reports a literature review identifying and categorizing client sys-

tem stressors in Neuman systems model-based studies.

Background. To date, literature reviews related to the Neuman systems model have

focused broadly on all concepts of the model. The concept of stressors has been

selected by the Neuman Systems Model Research Institute as the focus for an initial

collaborative research project.

Method. Cooper’s five-stage integrative review method was used: problem formu-

lation, data collection, data evaluation, analysis and interpretation, and dissemin-

ation. The Neuman systems model research literature from 1983 to February 2005

was searched using Fawcett’s Neuman systems model bibliography and a follow-up

review of the CINAHL database using the keywords ‘Neuman systems model’ and

‘stressors’. A total of 87 studies published as journal articles or book chapters

between 1983 and 2005 were reviewed; 13 of the 87 studies met the definition of

‘stressor studies’.

Findings. Stressors were identified in five client populations: caregivers, cancer

survivors, ICU patients in intensive care units, care receivers, and parents whose

children were undergoing day surgery. The most common data collection method

was the interview, and investigator-developed interview guides were most often

used. Evidence of categorization of intra-, inter- and extra-personal stressors was

present. The following overall stressors were identified: burden of responsibility

(caregivers); awareness of vulnerability (cancer survivors); being overwhelmed

(patients in intensive care units); loss of control (parents); and frustration with role

changes (care receivers).

Conclusions. These data could form the basis for nursing practice as well as future

research within a collaborative environment. Given the existing body of knowledge

concerning Neuman system model-derived middle range theory concepts in the

caregiver population, the middle-range theory of caregiver role strain could be tested

empirically.

� 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd 69

Keywords: caregiver role strain, caregivers, literature review, Neuman Systems

Model Stressors, nursing, nursing theory, patients

Introduction

Based on systems theory, the Neuman systems model (NSM)

was developed in 1970 as an educational model or holistic

framework to organize nursing knowledge (Neuman 2002).

The NSM (see Figure 1) proposes that the client is a system in

constant interaction with intra-, inter-, and/or extra-personal

phenomena. These phenomena are collectively known as

environmental stressors. Such stressors may invade the

normal line of defence, or the client’s usual health state,

unless warded off by a concept referred to as the flexible line

of defence. This flexible line of defence consists of five client

system variables denoted as physiological, psychological,

sociocultural, developmental and spiritual. If the flexible line

of defence is weak and the normal line of defence is invaded,

a stress response occurs. This in turn activates the lines of

resistance to prevent a severe health consequence within the

basic core structure of the client. The lines of resistance are

also composed of the five previously identified client system

variables but represent variables that are more stable (e.g.

coping styles, support systems, etc.) than flexible line of

defence variables. The goal of nursing is to assist the client to

strengthen the lines of defence and resistance to promote

health and reduce the likelihood of a severe health conse-

quence.

Although developed for use an educational model, its focus

on client response to environmental stressors quickly led to

its utilization as a research model as well. However, client

response to environmental stressors is a highly abstract

proposition that precludes direct testing and thus, like all

conceptual models, the credibility of the NSM propositions

demands the testing of middle-range theories. That is, the

abstract NSM concepts (e.g. stressors, lines of resistance, core

response, etc.) are linked to more concrete middle-range

theory concepts (e.g. role conflict, social support, role strain,

etc.) and then these are linked to empirical indicators such as

instruments designed to measure these concepts. After

empirical testing, findings are discussed in terms of direct

support or refutation of the middle-range theory propositions

as well as indirect support or refutation of the conceptual

model’s (NSM) propositions (Fawcett 2005). Though this

work has begun, efforts have been hampered somewhat by

the diversity of middle-range theory concepts of interest to

nursing. Thus, as Gigliotti (2003) noted, a sustained program

of research by a team of researchers interested in formulating

and testing an NSM-derived middle range theory does not

presently exist.

To facilitate such work, the Neuman Systems Model

Research Institute (NSMRI) was created in 2003 specifically

to provide an organizing structure for the formulation and

Stressors Stressor Stressor

BASICSTRUCTURE

ENERGYRESOURCES

Stressors

Normal defense line varieswith age and development

Same stressors could varyas to impact or reaction

More than one stressorcould occursimultaneously

Basic structureBasic factors common toall organisms, e.g.,

Normal temperaturerangeGenetic structureResponse patternOrgan strength orweaknessEgo structureKnowns or commonalities

• Identitied

• LossPain

IntraInterExtra

Personalfactors

Sensory deprivationCultural change

Classified as to known orpossibilities, i.e.,

Normal Line of Defense

Flexible Line of Defense

Lines of Resistance

•

•••

•

•

•

••

•

•

•

••

Figure 1 From The Neuman Systems Model by B. Neuman (2002) The Neuman Systems Model, 4th edn. p. 20 (eds B. Neuman & J. Fawcett),

Prentice Hall, Upper Saddle River, NJ. Reprinted with permission of publisher.

C.A. Skalski et al.

70 � 2006 The Authors. Journal compilation � 2006 Blackwell Publishing Ltd

testing of NSM-derived middle range theories through

collaborative efforts. Gigliotti (2003) described the creation

of the NSMRI and documented its preliminary work inclu-

ding resource assemblage, formulation of NSM principles

and presuppositions, identification of concepts and concept

interrelations, and synthesis of existing research based on the

NSM concepts. Gigliotti also proposed that the time had

come to begin the research conduction phase and suggested

strategies toward that goal. To provide NSM researchers

with a common organizational context, one suggested strat-

egy was to build on existing work by focusing middle range

theory development initially on middle-range theory concepts

already derived from particular NSM concepts in specific

client populations.

Perhaps, due to the above mentioned NSM focus of client

response to environmental stressors, the stressor is the most

frequently studied NSM concept (Fawcett & Giangrande

2001, 2002, Gigliotti 2001). Thus, there is an existing body

of knowledge concerning middle-range theory concepts

derived from stressors, and so it is practical to begin the

research conduction phase with the study of the impact of

particular stressors in a particular client population. How-

ever, before such ambition can be fulfilled, greater detail

regarding the existing knowledge of stressors in the NSM

research literature is needed. That is, the above mentioned

literature syntheses focus broadly on all NSM concepts and

client populations studied. Thus, the purpose of this paper is

to report the results of an integrative literature review to

identify and categorize client systems stressors in NSM-based

studies. Analysis of the literature encompassed identification

of particular stressors in particular client populations,

instruments used to identify stressors, and procedures used

to collect data. Findings are synthesized and suggestions

made for nursing practice and further research.

Review method

Cooper’s (1989) five-stage integrative review method was

used: problem formulation, data collection, data evaluation,

analysis and interpretation, and dissemination.

Problem formulation

Stressors were conceptually defined as environmental factors,

intra-, inter- and extra-personal in nature, that have the

potential for disrupting system stability. A stressor is any

phenomenon that might penetrate either or both the flexible

and normal lines of defence, resulting in system disturbance.

Intra-personal stressors occur within the client system’s

boundary while inter- (proximal range) and extra-personal

(distal range) stressors occur outside this boundary (Neuman

2002). Stressor studies were defined as NSM-based studies

whose major purpose was to assess relevant stressors in a

population. To qualify for inclusion, either stressor identifi-

cation was evident in the purpose statement or the conceptual

framework provided evidence that stressor identification was

a focus of the study.

Six research questions were posed:

• What methods and assessment instruments were used to

identify stressors?

• In which client populations are stressors identified?

• What terminology is used to identify stressors?

• Are intra-, inter- and extra-personal stressors specifically

categorized?

• Which stressors are identified in each population?

• What stressor commonalities exist within and across pop-

ulations?

Data collection

The NSM research literature from 1983 to February 2005

was searched using Fawcett’s (2005) NSM bibliography and

a follow-up review of the CINAHL database using the

keywords ‘Neuman systems model’ and ‘stressors’. A total of

87 studies published as journal articles or book chapters

between 1983 and 2005 were reviewed; 13 of the 87 studies

met the definition of ‘stressor studies’. No relevant studies

were published after 1996. Three studies were conducted in

Canada, and 10 were conducted in the United States of

America (USA).

Investigators independently reviewed each study using a

coding sheet which elicited the following information:

purpose statement, client population, sample size, data

collection method (interviews, self-administered question-

naires, etc.), assessment instrument, stressor terminology

(stressors, needs, concerns, etc.), and evidence of categoriza-

tion of intra-, inter- and extra-personal stressors.

After independent review, investigators met to synthesize

findings.

Data evaluation

Methods/assessment instruments used

Stressors were identified by interview in 10 studies and in three

studies self-administered surveys were used (see Table 1). Of

the 10 interview studies, one investigator employed the 1982

version of the NSM Interview Guide (Neuman 1982) as the

assessment tool and four investigators developed their own

interview guides based on the NSM framework. That is, they

structured interviews to elicit information concerning intra-,

Integrative literature reviews and meta-analyses Stressors in the Neuman systems model literature


Table

1Sel

ecte

dst

udie

s,m

ethods,

ass

essm

ent

tools

,popula

tions,

term

inolo

gy,

and

cate

gori

zati

on

of

stre

ssors

Auth

or/

sT

itle

and

publica

tion

det

ails

Met

hod

Ass

essm

ent

Popula

tion

Ter

min

olo

gy

Cate

gori

es

Wil

son

(1987)

‘Iden

tifica

tion

of

stre

ssors

rela

ted

topati

ents

’psy

cholo

gic

al

resp

onse

sto

the

surg

ical

inte

nsi

ve

care

unit

’,H

eart

and

Lung,

16,

267–2

73

Inte

rvie

wIn

ves

tigato

r

dev

eloped

(NSM

base

d)

38

SIC

Upat

ients

Str

esso

rsN

one

Gri

esand

Fer

nsl

er

(1988)

‘Pati

ent

per

cepti

ons

of

the

mec

hanic

al

ven

tila

tion

exper

ience

’,Focu

son

Cri

tica

l

Car

e,15,

52–59

Inte

rvie

wIn

ves

tigato

r

dev

eloped

(post

hoc

codin

g)

Nin

eC

CU

pat

ients

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

Bla

nk

etal

.

(1989)

‘Per

ceiv

edhom

eca

renee

ds

of

cance

rpati

ents

and

thei

r

care

giv

ers’

,C

ance

rN

urs

ing,

12,

78–84

Inte

rvie

wN

SM

Inte

rvie

w

Guid

e

Eig

ht

Car

ere

ceiv

ers

under

goin

gca

nce

r

trea

tmen

t

Eig

ht

care

giv

ers,

Pati

ent

wit

hca

nce

r

Nee

ds

from

stre

ssors

Inte

r-,

intr

a-,

extr

a-p

erso

nal

Loes

cher

etal

.(1

990)

‘The

impact

of

the

cance

r

exper

ience

on

longte

rm

surv

ivors

’,O

nco

logy

Nurs

ing

Foru

m,

17,

223–229.

Sem

i-

stru

cture

d

inte

rvie

w

Inves

tigato

r

dev

eloped

(NSM

base

d)

17

Can

cer

surv

ivors

Pro

ble

ms/

conce

rns

Physi

olo

gic

al,

psy

cholo

gic

al,

soci

oec

onom

ic

Montg

om

ery

and

Cra

ig

(1990)

‘Lev

els

of

stre

ssand

hea

lth

pra

ctic

esof

wiv

esof

alc

oholi

cs’,

Can

adia

nJo

urn

alof

Nurs

ing

Res

earc

h,

22,

60–70

Inte

rvie

wIn

ves

tigato

r

dev

eloped

(post

hoc

codin

g)

30

Car

egiv

ers

alc

oholi

chusb

ands

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

Dec

ker

and

Young

(1991)

‘Sel

f-per

ceiv

ednee

ds

of

pri

mary

care

giv

ers

of

hom

e-hosp

ice

clie

nts

’,Jo

urn

alof

Com

munit

y

Hea

lth

Nurs

ing,

8,

147–154

Inte

rvie

wIn

ves

tigato

r

dev

eloped

(NSM

base

d)

19

Car

egiv

ers

term

inally

ill

hom

e

hosp

ice

pati

ent

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

Cava

(1992)

‘An

exam

inati

on

of

copin

g

stra

tegie

suse

dby

long-

term

cance

rsu

rviv

ors

’,C

anad

ian

Onco

logy

Nurs

ing

Journ

al,

2,

99–102

Sem

i-

stru

cture

d

inte

rvie

w

Inves

tigato

r

dev

eloped

(NSM

base

d)

Fiv

eca

nce

rsu

rviv

ors

Pro

ble

ms/

stre

ssare

a/

expec

tati

ons

None

Gra

nt

and

Bea

n(1

992)

‘Sel

f-id

enti

fied

nee

ds

of

info

rmal

care

giv

ers

of

hea

d-i

nju

red

adult

s’,

Fam

ily

and

Com

munit

y

Hea

lth,

15(2

),49–58

Mailed

Surv

ey

Inves

tigato

r

dev

eloped

(NSM

base

d)

84

Car

egiv

ers

traum

ati

chea

d

inju

red

pati

ents

Nee

ds

Inte

r-,

intr

a-,

extr

a-p

erso

nal

C.A. Skalski et al.


Table

1(C

onti

nued

)

Auth

or/

sT

itle

and

publica

tion

det

ails

Met

hod

Ass

essm

ent

Popula

tion

Ter

min

olo

gy

Cate

gori

es

Mali

galig

(1994)

‘Pare

nts

’per

cepti

ons

of

the

stre

ssors

of

ped

iatr

icam

bula

tory

surg

ery’,

Journ

alof

Post

Anes

thes

iaN

urs

ing,

9,

278–2

82.

Inte

rvie

wIn

ves

tigato

r

dev

eloped

(post

hoc

codin

g)

Six

par

ents

wit

h

childre

nin

day

surg

ery

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

Skip

wit

h

(1994)

‘Tel

ephone

counse

ling

inte

rven

tions

wit

hca

regiv

ers

of

elder

s’,

Journ

alof

Psy

choso

cial

Nurs

ing

and

Men

tal

Hea

lth

Serv

ices

,32(3

),7–12,

34–35

Tel

ephone

Inte

rvie

w

None

(tel

ephone

inte

rven

tion)

Car

egiv

ers

of

elder

s

(unknow

nn)

Pro

ble

ms

None

Hea

man

(1995)

‘Per

ceiv

edst

ress

ors

and

copin

g

stra

tegie

sof

pare

nts

who

have

chil

dre

nw

ith

dev

elopm

enta

l

dis

abil

itie

s:a

com

pari

son

of

moth

ers

wit

hfa

ther

s’,

Journ

alof

Ped

iatr

icN

urs

ing,

10(5

),311–

320

Surv

eyPare

nt

per

cepti

on

inven

tory

(no

codin

g)

203

Car

egiv

ers

dev

elopm

enta

lly

dis

able

dch

ildre

n

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

Sem

ple

(1995)

‘The

exper

ience

sof

fam

ily

mem

ber

sof

per

sons

wit

h

Hunti

ngto

n’s

dis

ease

’,

Per

spec

tive

s,19(4

),4–10

Inte

rvie

wN

one

(phen

om

enolo

gy)

Fiv

eC

areg

iver

sof

pati

ents

wit

h

Hunti

ngto

n’s

Chore

a

Str

esso

rsN

one

Jones

(1996)

‘Str

esso

rsin

the

pri

mary

care

giv

ers

of

traum

ati

chea

din

jure

d

per

sons’

,A

XO

N,

18,

9–11

Surv

eyA

ppra

isal

Care

giv

er

Sca

le(N

SM

adap

ted)

23

Car

egiv

ers

Tra

um

atic

Hea

d

Inju

red

Pati

ents

Str

esso

rsIn

ter-

,in

tra-,

extr

a-p

erso

nal

NSM

,N

eum

an

Syst

ems

Model

.



inter- and extra-personal stressors. In an additional three

interview studies, investigators coded data post hoc as intra-,

inter- and extra-personal stressors though no mention is made

of the interview being guided by the NSM. In the remaining two

interview studies, one was phenomenological in nature and no

mention is made of NSM guidance or stressor categorization,

and one study was actually designed to evaluate a telephone

intervention in which stressor information is elicited during the

course of the telephone session (see details Table 1).

Of the three studies in which self-administered surveys

were used, two investigators designed or adapted the survey

instrument to elicit information concerning intra-, inter- and

extra-personal stressors. In the remaining study (Heaman

1995), a standardized instrument: The Parent Perception

Inventory is used to elicit information concerning stressors

but they were not categorized as such.

Client populations studied

As shown in Table 1, the focus of eight of the 13 studies was

the stressors of caregivers and the focus of one of these eight

stressor studies was both caregiver and care receiver. Thus,

the focus of the majority of stressor studies was caregivers

who were overwhelming women who were, with one

exception, caring for relatives including elders, patients with

Huntington’s chorea, head-injured children and children with

developmental disabilities, alcoholic husbands, terminally ill

people, and those undergoing cancer treatment. In the

remaining five studies, stressors of ICU patients (2), cancer

survivors (2), and parents whose children were undergoing

surgery (1) were identified.

Terminology and categories used

For the most part, the term ‘stressors’ was used. However, in

several studies the stated purpose was to identify stressors but

these stressors were referred to as needs from stressors, needs,

problems, problems/concerns, stress area, or expectations (see

Table 1). Concerning categories of stressors, most stressors

were identified as intra-, inter- and extra-personal while in

four studies no categorization was provided and in one study

stressors were categorized as physiological, psychological,

and socioeconomic. It should be noted here that, while the

purpose of the majority of studies was categorization and

identification of stressors, in two studies investigators also

sought to relate these stressors to outcome variables. Jones

(1996) investigated the relation between stressors and the

changing stress level of caregivers and Wilson (1987) inves-

tigated the relation between stressors and psychological

response in ICU patients. In addition, as previously noted, in

one study a telephone intervention was described in which the

stressors were first identified and the intervention discussed.

Identified stressors

Because each investigator gave unique terms to identified

intra-, inter- and extra-personal stressors it was first necessary

to list stressors in each study and then bestow a common

term. For example, while problems with coordinating care

through various social service agencies were cited in each

study in the caregiver population, Grant and Bean (1992)

cited alternative housing arrangements and transportation

services amongst the extra-personal stressors of informal

caregivers of head injured adults while Semple (1995) cited

agency rules concerning hours of care and need for home care

help amongst extra-personal stressors of family members

caring for patients with Huntington’s chorea. Therefore, after

listing stressors, this study’s investigators met to code stres-

sors within populations. In the above example, all stressors

that dealt with social services were listed as ‘social service

issues’. Table 2 shows all coded stressors of each population

with the corresponding study.

Within-populations commonalities

Caregivers. Intra-personal stressors cited in the majority (‡5)

of caregiver studies were role conflict/role fatigue/role stress,

caregiving responsibility, and caregiver’s physical and emo-

tional health; inter-personal stressors were social service

issues, lack of information from health care professionals,

and lack of family/friends support; and extra-personal stres-

sors were lack of respite support as well as financial concerns.

Their overall stressor could be described as caregiver’s

responsibility.

Cancer survivors. The most frequently cited stressors by

cancer survivors were intra-personal in nature: anxiety/

uncertainty and treatment related side effects/health vulner-

ability. The overall stressor identified was awareness of

vulnerability.

ICU patients. Physical discomforts (pain, restricted move-

ment, thirst, suctioning, etc.) and psychological problems

(losing track of time, vivid dreams, etc.) were commonly

described by ICU patients as intra-personal stressors; lack of

explanation from health care professionals as an inter-personal

stressor; and environmental problems such as sleep interrup-

tion, noise, and lack of privacy as common extra-personal

stressors. Their overall stressor was being overwhelmed.

Other. The remaining two populations were the focus of

only one study each. The overall stressor identified by parents

of children undergoing day surgery was loss of control.

Finally, care receivers’ overall stressor could be described as

frustration with role changes.

C.A. Skalski et al.


Across-population commonalities

The stressor common to all populations was an inter-personal

one: lack of informational support from health care profes-

sionals. This lack came in many forms including lack of

information about illness trajectory and resources (caregiv-

ers), lack of continuity of health care (care receivers), unmet

expectations regarding currency of knowledge (cancer survi-

vors), lack of explanations and being talked about and not to

(ICU patients), and lack of information regarding care post

discharge (parents).

Table 2 Population stressors

Caregivers Role conflict, role fatigue, role stress (Blank et al. 1989, Decker & Young 1991, Grant &

Bean 1992, Skipwith 1994, Heaman 1995, Semple 1995, Jones 1996)

Caregiving responsibility (Blank et al. 1989, Decker & Young 1991, Grant & Bean 1992,

Skipwith 1994, Heaman 1995, Semple 1995, Jones 1996)

Social service issues (Blank et al. 1989, Decker & Young 1991, Grant & Bean 1992,

Skipwith 1994, Heaman 1995, Semple 1995, Jones 1996)

Lack of information from healthcare professionals (Blank et al. 1989, Decker & Young

1991, Grant & Bean 1992, Semple 1995)

Lack of support from family/friends (Blank et al. 1989, Grant & Bean 1992, Skipwith

1994, Semple 1995, Jones 1996)

Lack of support-respite care (Decker & Young 1991, Grant & Bean 1992, Skipwith 1994,

Semple 1995)

Caregiver health: physical and emotional (Montgomery & Craig 1990, Decker & Young

1991, Skipwith 1994, Semple 1995, Jones 1996)

Finances/insurance (Blank et al. 1989, Montgomery & Craig 1990, Decker & Young 1991,

Grant & Bean 1992, Heaman 1995, Semple 1995)

Relationship with care receiver (Blank et al. 1989, Montgomery & Craig 1990, Jones 1996)

Relationship with partner (Blank et al. 1989, Heaman 1995)

Treatment uncertainty/uncertainty (Blank et al. 1989, Decker & Young 1991, Heaman

1995, Semple 1995)

Legal concerns (Decker & Young 1991)

Care receiver’s health (Skipwith 1994, Heaman 1995)

Occupational concerns (Montgomery & Craig 1990)

Hereditary Concerns (Heaman 1995, Semple 1995)

Guilt (Blank et al. 1989)

Care receivers Anxiety/uncertainty, lack of support from family/friends, unmet expectations of care from

healthcare professionals, employment concerns, transportation (Blank et al. 1989)

Cancer survivors Anxiety/uncertainty (Loescher et al. 1990, Cava 1992)

Lack of support from family/friends (Cava 1992)

Unmet expectations of care from healthcare professionals (Cava 1992)

Treatment related side effects/health vulnerability (Loescher et al. 1990, Cava 1992)

Body image concerns/unexpected physical changes (Loescher et al. 1990)

Overprotective family (Loescher et al. 1990)

Sensing discomfort from others when discussing cancer (Loescher et al. 1990)

Employment concerns (Loescher et al. 1990)

Insurance concerns (Loescher et al. 1990)

Decreased socializing Loescher et al. 1990)

Going for checkups (Cava 1992)

Guilt over calling oncologist with minor concerns (Loescher et al. 1990)

ICU Patients Lack of explanation (healthcare professionals) (Wilson 1987, Gries & Fernsler 1988)

Doctors/nurses talk about you not to you (Wilson 1987)

Physical discomforts (Wilson 1987, Gries & Fernsler 1988)

Environmental problems (Wilson 1987, Gries & Fernsler 1988)

Lack of patience – nursing care (Gries & Fernsler 1988)

Psychological problems (Wilson 1987, Gries & Fernsler 1988)

Unable to visit with family/friends (Wilson 1987)

Parents children undergoing day surgery Loss of control, separation anxiety, anxiety, fear of surgical risk/fear of unknown,

Laboratory tests and procedures, lack of confidence to care for child at home, lack of

information about resources w/problems post discharge, time off from work: impact on

job security (Maligalig 1994)



The most common intra-personal stressor was anxiety for

care receivers, cancer survivors, ICU patients, and parents,

while caregivers experienced role conflict, role fatigue and

role stress most often. Finally, extra-personal stressor com-

monalities can be notably categorized as short or long-term

stressors. That is, in populations whose conditions are of a

long term nature (cancer survivors, caregivers and care-

receivers) financial, insurance, and other social service issues

are noted while in populations whose conditions are shorter in

term (ICU patients, parents of day surgery patients) immedi-

ate stressors such as noise, and lab tests/procedures are noted.

Data analysis and interpretation

This NSM-based knowledge serves as the foundation for both

future research as well as guiding nursing practice. One

conceptual problem, however, is that though stressors are

mentioned as the focus of these studies, it is evident that

identified stressors, problems, concerns, and needs from

stressors represent not only stressors but the flexible and

normal lines of defence, lines of resistance, and core response

as well. Thus use of alternate terms (needs, etc.) raises an

interesting point. That is, depending on the context, stressors

could be considered other NSM system variables: flexible and

normal lines of defence, lines of resistance, or risk for a core

response. In fact, the first question of the Neuman Interview

Guide, under the heading of stressors, asks, ‘What do you

consider your major stress area, or area of health concern?

(Neuman 2002). It is likely, then, that investigators who used

alternate terminology recognized that the designation ‘stres-

sor’ was dependent on context.

For example, in the caregiver example, the most often

mentioned ‘stressors’ were role conflict/role fatigue/role

stress; caregiving responsibility; caregiver’s physical and

emotional health; social service issues; lack of information

from health care professionals; lack of family/friends support;

lack of respite support; and financial concerns. Thus, while

their overall stressor was caregiving responsibility, the

remainder of these identified ‘stressors’ could more fittingly

be described as variables in the normal line of defence, lines

of resistance, and core. Role conflict/role fatigue/role stress

are representative of normal line of defence invasion; the

initial stress response to caregiving responsibility. Social

service issues, lack of information from health care profes-

sionals, lack of support from family and friends, financial

concerns, and lack of respite care are conceptually congruent

with the socio-cultural line of resistance and caregiver’s

physical health and emotional health concerns are manifes-

tations of the potential for a core response. Therefore, after

problems, needs, or concerns are identified investigators

should accurately place these variables within the context of

the NSM.

The results of this literature review can be summarized as a

middle-range theory of caregiver role strain (Figure 2). As

illustrated in Figure 2, caregiver responsibility leads to role

conflict/role fatigue/role stress which then leads to caregiver

role strain as manifested by profound depression unless

mediated by emotional and tangible support from family and

friends, tangible and informational support from social

services, and informational support from health care profes-

sionals. In addition, other middle-range theories concerning

cancer survivors and ICU patients could also be developed

based on the findings of this literature review.

Dissemination

These findings were presented at the 10th International

Neuman Systems Model Symposium in April 2005. A

synopsis of the findings will be placed on the NSM website

http://www.neumansystemsmodel.com simultaneous with

the publication of this paper.

Conclusions and recommendations

Practice

Gigliotti (2002) proposed a schema to use NSM-derived

assessment data as the basis for formulating a nursing

Normal Line of Defense Invasion: Role Conflict/Role Fatigue/Role Stress

Socio-cultural Line of Resistance:Support

Stressor:Caregiving Responsibility

Core Response:Caregiver Role Strain(Depression)

Figure 2 Proposed model of middle-range

theory of Caregiver Role Strain.

C.A. Skalski et al.


diagnosis, and linking it with a nursing sensitive outcome,

and nursing interventions using the standardized nursing

languages: NANDA, NIC and NOC. To form the diagnosis,

one must sift through the data to identify the client’s overall

health problem/life process of concern (stressor), identify the

response to the stressor which is the diagnostic label (either

normal line of defence invasion or core response), identify the

aetiology of the health problem/life process (stressor, flexible

line of defence and/or lines of resistance), and present the

manifestations (objective indicators of normal line of defence

invasion or core response).

Again using the caregiver example, the overall life process

of concern (stressor) was the caregiver’s responsibility. One

then determines if the normal line of defence has been

invaded: has the initial stress response occurred? In this case,

role conflict/role fatigue/role stress represent invasion of the

normal line of defence. Therefore, evaluation of potential for

a core response is necessary. Caregivers identified concerns

for their own physical and emotional health and so there is

potential for a core response; therefore, the NANDA diag-

nostic label or response to this life process (stressor) is: Risk

for Caregiver Role Strain defined as ‘caregiver is vulnerable

for felt difficulty in performing the family caregiver role’

[North American Nursing Diagnosis Association (NANDA)

2003, p. 31]. The aetiology of this response is the stressor

(caregiver’s responsibility), the stress response denoting

invasion of the normal line of defence (role conflict/role

fatigue/role stress) and the weak socio-cultural line of

resistance (lack of support). There are no manifestations at

present due to the risk status. Thus, depending on assessment

data, the following diagnosis may be written: Risk for

Caregiver Role Strain related to caregiver’s responsibility,

role conflict/role fatigue/role stress, and lack of support. Note

that rapidly changeable flexible line of defence variables may

also be relevant but the current data does not provide such

evidence.

The next step is to choose the relevant nursing sensitive

outcome from the NOC. The nurse and client mutually assess

the client’s current level of functioning (not adequate to

totally adequate) on the outcome: Caregiving Endurance

Potential (2210): factors that promote family care provider

continuance over an extended period of time. The chosen

outcome indicators are: health care system support, social

(family/friend) support, resources to provide care, and respite

for caregiver (Moorhead et al. 2004). Then the nurse and

client mutually set a desired level of attainment (e.g. moving

from not adequate to moderately adequate) and the nurse

identifies appropriate nursing interventions from the NIC, to

strengthen the weak socio-cultural line of resistance and

prevent a core response. One appropriate intervention is

Caregiver Support (7040): explore coping behaviours, teach

health maintenance strategies, foster caregiver social net-

working, identify sources of respite care, inform about health

care and community resources, teach strategies to access and

maximize health care and community resources, support for

setting limits and taking care of self (McCloskey Dochterman

& Bulechek 2004).

Research

As noted, two investigators (Wilson 1987, Jones 1996)

explored the relation between stressors and an outcome

variable and both found evidence to support Neuman’s

proposal that stressor strength is associated with normal line

of defence invasion. Building on this body of knowledge,

future research could concentrate on correlational studies to

determine the extent of normal line of defence invasion after

taking into account the strength of the stressor and the

flexible line of defence variables. Also, models that investigate

the ability of the lines of resistance to mediate the response

between normal line of defence invasion and core response

(Gigliotti 1997) should be developed.

Given the existing NSM-derived research concerning str-

essors and caregivers, the middle range theory of caregiver

role strain (see Figure 2) could be tested empirically. The

Neuman systems model has active groups in Holland,

Canada, and the USA, and researchers interested in furthering

What is already known about this topic

• The stressor is the most frequently studied Neuman

systems model concept.

• Although much is known about client stressors, the

available literature has not yet been integrated.

• Two previous literature reviews focused broadly on

Neuman systems model concepts but did not focus

specifically on stressors.

What this paper adds

• Identification of common stressors and assessment

instruments in five client populations.

• Stressor commonalities within populations and across

populations are burden of responsibility (caregivers);

awareness of vulnerability (cancer survivors); being

overwhelmed (patients in intensive care units); loss of

control (parents); and frustration with role changes

(care receivers).

• A middle-range theory of caregiver role strain is pro-

posed.



this work within a collaborative environment are invited to

contact the NSMRI at http://www.neumansystemsmodel.

com.

Author contributions

CS, LD and EG were responsible for the study conception

and design and drafting of the manuscript. CS, LD and EG

performed the data collection and data analysis. EG provided

administrative support. CS, LD and EG made critical

revisions to the paper. EG supervised the study.

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