Contributor – Nkem Nneka Kimberly Chiedu, MSN, RN, BA

Allow me to present a character we shall refer to as Mr. T. Picture Mr. T, a vibrant 74-year-old gentleman with a keen mind, arriving at the clinic for his routine checkup. He approaches your window to check in, and you, the nurse, welcome him warmly. He holds a plastic grocery bag, which he casually tosses onto the counter. Inside the bag lies not his lunch, nor any personal items, but rather a collection of his medication—23 in total. He places them meticulously on your counter, one after another. You gaze in astonishment as Mr. T reveals, “No one truly understands what I’m going through, and each doctor prescribes me a different medication. The doctors don’t talk to each other. ”

He wasn’t wrong.

This is bigger than just one patient

Mr. T is one of many to encounter this—in fact, he is a snapshot of a crisis hiding in plain sight. Polypharmacy, typically defined as taking five or more medications concurrently, affects an estimated 40% of older community-dwelling adults in the United States (Qiu et al., 2024). If one pushes the threshold to 10 or more medications, researchers refer to this as hyperpolypharmacy. More medications increase the chances of several issues including drug-drug interactions, falls, hospitalization, cognitive changes, and slow decline in the very quality of life that the medications were intended to protect.

So what are we doing about it?—Mostly, we continue to prescribe.

Betty Neuman saw this coming

In the year 1970, Dr. Betty Neuman crafted what she envisioned as a “teaching tool” for the graduate nursing students at UCLA. It was a visual representation that guided the nursing students to perceive the client in their entirety, rather than merely focusing on the issue at hand. The diagram was ultimately published in Nursing Research in 1972 under the title “A Total Person Approach to Patient Problems” and has since become widely recognized as the Neuman Systems Model. Reed (1993) highlights that the Neuman Systems Model has made its mark in over 50 countries, emerging as one of the three most prominent nursing models in today’s world.

The model’s central idea presents each individual as a client system, forming the essence of a fundamental structure encircled by layered defenses, continuously engaging with stressors from their surroundings. The essence of nursing lies in its commitment to help clients achieve stability. This journey begins with fortifying defenses against potential stressors, ensuring that they remain resilient in the face of challenges. When symptoms do arise, nursing steps in to provide care and treatment, guiding clients through their struggles. Finally, the focus shifts to supporting recovery and rebuilding strength, ensuring that individuals emerge stronger and more capable than before (Reed, 1993).

The process of discontinuing a medication that someone has relied on for years can evoke feelings of uncertainty and vulnerability. Nevertheless, the Neuman Systems Model provides us with the vocabulary to grasp precisely the reasons behind it.

The concept nobody talks about: The created environment

One of the most overlooked concepts in the NSM is the idea of the created environment. This is Neuman’s term for the hidden psychological refuge that individuals create when they unknowingly sense a danger to their fundamental essence. As one navigates the tumultuous waters of change, there emerges a deep-seated yearning for the comfort of the known, a refuge from the unsettling waves of uncertainty (Reed, 1993).

Mr. T. had journeyed through 17 years with a statin by his side. As the provider sought to halt the medication, he began to hoard his supply, holding onto it “just in case.” It does not reveal a failure to comply, but rather illustrates a crafted atmosphere within his system that fosters an instinctive shield against what is seen as a threat to his foundational sense of well-being.

A 2022 qualitative study conducted by Pereira and colleagues delved into the intricate journey of medication management among older adults navigating multiple prescriptions following their discharge from the hospital. The study revealed that when older adults were deliberately left out of decisions regarding their own medications, they faced challenges in sticking to their medication plans (Pereira et al., 2022). It wasn’t the difficulty of adhering to the regimens that posed a challenge, but rather the treatment plans’ inability to recognize the personal significance of the medications to each individual. The environment crafted by the individuals, encompassing the medication they were using, was never evaluated or recognized, and was not woven into their care.

This is precisely the reason why the process of reducing medications often falls short of success. Before a nurse delves into an individual’s medication list, it is essential for them to grasp the significance of that list in relation to the person’s sense of stability. This represents a nursing assessment and the Neuman Systems Model in practice.

Nurses are built for this work

The NSM not only illuminates the complexities of polypharmacy but also positions nurses as the inherent leaders in crafting the solution. Reflect on how the model portrays the client through the interplay of five interconnected elements—physiological, psychological, sociocultural, developmental, and spiritual—working together with purpose and intention. These factors intertwine in what Neuman describes as “leaky margins,” where each element seeps into the others in ways that are complex, authentic, and deeply human (Reed, 1993). An older adult’s medication regimen touches all five variables at once. Mr. T’s statin is physiological, yes — but it is also psychological (prescribed after a frightening lab result), sociocultural (his family trusts doctors without question), developmental (he is 74 and terrified of losing independence), and at times even spiritual (he believes God led him to that physician). Medicine tends to manage the first variable. Nursing is equipped to hold all five. “Nursing is seen as the use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death. Nursing encompasses the autonomous and collaborative care of individuals of all ages, families, groups, communities, and populations, sick or well” (Garrett, 2019).

In 2021, Montano shared an insightful analysis in Nursing Science Quarterly, highlighting the pivotal role of nurses as leaders within interprofessional collaborative practice teams. This model serves as a comprehensive framework, adeptly organizing intricate client information across various variables and environments all at once—an achievement beyond the reach of any single-discipline perspective. The Neuman nursing process was crafted from the ground up to involve client negotiation at each stage of the journey. This indicates that nursing goals are not simply assigned to patients, but are collaboratively developed with them (Reed, 1993). The concept of shared decision-making in the context of deprescribing has a rich history, first introduced by Betty Neuman in her influential model back in 1972.

In a compelling exploration, Montano et al. (2020) conducted a mixed-methods evaluation, featured in Geriatric Nursing, that delved into an NSM-guided and nurse-led IPCP intervention aimed at community-dwelling older adults grappling with polypharmacy and frequent emergency department visits. The study revealed a remarkable 26% decrease in emergency department visits among those involved in the research. A 2024 scoping review of NSM applications in gerontology nursing revealed that NSM-guided care across healthcare facilities effectively and flexibly addressed the multifaceted needs of older adults (Oliveira et al., 2024). Nurses who engage intimately with this demographic are already aware of this, and the research is beginning to align with their insights.

Where the gap still lives

The previously mentioned scoping review highlights the value of NSM while also revealing a notable knowledge gap: there is a lack of research that specifically investigates nurses as integral members of interdisciplinary teams dedicated to identifying stressors and implementing targeted deprescribing interventions within community settings. Initial findings show potential, yet we still lack a comprehensive, nurse-driven, theory-based strategy for reducing polypharmacy that functions on a large scale.

This is personal—and it’s a call to action

I am a registered nurse and a PhD student at Texas Woman’s University. My research focuses on the role of registered nurses in conducting medication reviews and providing deprescribing support for older adults living in the community who are facing the challenges of polypharmacy. This work is guided by clinical decision support tools and is rooted in the principles of the Neuman Systems Model.

It began with individuals like Mr. T—a grocery bag overflowing with pills and no single person accountable for understanding the complete narrative. It is my hope that this journey culminates in a solution we can implement and share across clinics, homes, and communities, where older adults are often overwhelmed by medications that may be causing more harm than benefit.

The call resonates throughout the entire nursing community. It is essential for us to recognize polypharmacy as a nursing issue, extending beyond just geriatric concerns and the challenges of polypharmacy itself. We possess a theoretical framework that has stood the test of time for 50 years, guiding our understanding of the subject. There is an increasing collection of studies that back nurse-led, interprofessional, systems-thinking methods that create a significant impact. We have forged unique connections with older adults that are unmatched by any other field.

The Neuman Systems Model is not a relic from a nursing theory class of the past. It is a dynamic and responsive framework, embraced worldwide, crafted specifically to empower nurses to perceive the entirety of a person, even when others focus solely on the individual components.

Mr. T. sought someone who could truly understand him in his entirety. In my journey, it often seems that the one person who stands out is the nurse.

We have the potential to improve, and Nursology illuminates the path forward.

References

Garrett, B. M. (2019). An empirical framework for person, family, community and population centered care. Nursology.net. https://nursology.net/nurse-theories/an-empirical-framework-for-person-family-community-and-population-centered-care/

Montano, A. R. (2021). Neuman Systems Model with nurse-led interprofessional collaborative practice. Nursing Science Quarterly, 34(1), 45–53. https://doi.org/10.1177/0894318420965219

Montano, A. R., Shellman, J., Malcolm, M., McDonald, D., Rees, C., Fortinsky, R., & Reagan, L. (2020). A mixed methods evaluation of GOT Care! Geriatric Nursing, 41(6), 822–831. https://doi.org/10.1016/j.gerinurse.2020.04.016

Oliveira, S. G., Caldas, C. P., Nicoli, E. M., Silva, F. V. C., Cardoso, R. B., & Lopes, F. M. V. M. (2024). Applicability of the Neuman Systems Model to the Gerontology Nursing practice: A scoping review. Revista Latino-Americana de Enfermagem, 32, e4224. https://doi.org/10.1590/1518-8345.6977.4224

Pereira, F., Bieri, M., Martins, M. M., Del Río Carral, M., & Verloo, H. (2022). Safe medication management for polymedicated home-dwelling older adults after hospital discharge: A qualitative study of older adults, informal caregivers and healthcare professionals’ perspectives. Nursing Reports, 12(2), 403–423. https://doi.org/10.3390/nursrep12020039

Qiu, X., Xu, Z., Sun, N., Hua, C., & Brown, J. S. (2024). Gender differences in the relationship between polypharmacy and depressive symptoms among older adults. Innovation in Aging, 8(Suppl. 1). https://doi.org/10.1093/geroni/igae098.0517

Reed, G. K. S. (1993). Betty Neuman: The Neuman Systems Model. SAGE Publications.

About Nkem Chiedu, MSN, RN, BA

Nkem Chiedu, MSN, RN, BA, is a registered nurse and doctoral student in nursing at Texas Woman’s University. Her research interests include examining RN-led medication review and deprescribing interventions of community-dwelling older adults with polypharmacy, incorporating clinical decision support and grounded in the Neuman Systems Model. She works clinically as a staff nurse and is passionate about translating nursing theory into practice that actually changes patient outcomes. She would also like to use this opportunity to thank Nursologist, Faith Tissot, RN, MSN-Ed, CCRN, for the opportunity to contribute to Nursology.net.