AN ADAPTATION OF THE NEUMAN SYSTEMS MODEL TO THE CARE OF THE HOSPITALIZED PRESCHOOL CHILD

Kershaw and Salvage (1986: xii) state that any model of nursing should be fluid and dynamic so that it may be adapted or modified to meet a specific need. The Neuman Systems Model was selected as a suitable framework within which to o rg an ize th e n u rs in g c a re of the hosp ita lized p reschool child as its emphasis on both system and stress th eo ry a llow ed fo r a m ean ingfu l in te rp re ta tio n of the problem s of hosp ita lization . In addition it had potential for unifying the physical care of the child with o ther aspects of his development.


INTRODUCTION
A study was u n d e rta k en w herein a nursing model was proposed to facilitate the provision of holistic care for the hospitalized preschool child.This was done in an attempt to ensure that the p h y s ic a l, e m o tio n a l, s o c ia l and intellectual needs of the young child could be all incorporated into his nursing care.Kershaw and Salvage (1986: xii) state that any model of nursing should be fluid and dynamic so that it may be adapted or modified to meet a specific need.The Neuman Systems Model was selected as a suitable framework within which to o rg a n iz e th e n u rs in g c a re o f th e h o sp ita liz ed p re sc h o o l child as its emphasis on both system and stress th e o ry a llo w e d fo r a m ea n in g fu l in te r p re ta tio n o f th e p ro b lem s of h o sp ita liz a tio n .In a d d itio n it had potential for unifying the physical care of the child with o th er aspects of his development.
The Neuman Systems Model, as appears in Neuman (1989: 26), subsequently was a d a p te d in an a tte m p t to p rovide multifaceted care for the hospitalized preschool child.Castledine maintains"... that to adapt ormodify something implies some form o f change in quality, so it fits more easily that which was intended" (Castledine 1986: 64).In this respect the Neuman Systems Model was suitable as it facilitated an understanding of the interrelationship of the various factors w hich m ak e th e e x p e rie n c e of hospitalization stressful for the young child.By beginning with the child and his fam ily a n d p r o g re s s in g to th e environm ent surrounding them , the in te rd e p e n d e n c e of all the factors r e q u ir e d fo r th e r e s to r a tio n or m a in te n a n c e o f h e a lth was m ade apparent.

Abstract
This article describes an adaptation o f the Neuman Systems Model to the care o f the hospitalized preschool child.This was done to unite the physical care o f the hospitalized preschool child with other aspects of his development and to describe the causes and prevention o f stresses o f hospitalization for this child.

DESCRIPTION OF THE NEUMAN SYSTEMS MODEL
The Neuman Systems Model emphasises "wholeness... thus avoiding the fragmented and isolated nature o f past functioning in nursing" (Neuman 1982: 1).The basic tenets of this model view man as an open system in in te r a c tio n w ith his environment and incorporate a total person approach with the view to assist a person "... to attain a maximal level o f health through the use o f purposeful interventions aimed toward strengthening adaptive mechanisms, decreasing stress factors, or decreasing adverse conditions" (Neuman 1982: 118).The health of an individual is considered in this model to be determined by his reaction to stress.Stressors in the environment may be in tr a p e r s o n a l, in te r p e r s o n a l or extrapersonal.Nursing is considered to be a cooperative activity during which the nurse assists the chent to cope with stress a or a at either a primary, secondary or tertiary level so that the client may return to a state of optimum stability and health (Hawkins 1983: 31).

Basic a ssu m p tio n s regarding the Neuman Systems Model
The following basic assumptions are considered to be inherent in this model (Neuman 1982: 12-14;Thibodeau 1983: 117-118;Whall 1983: 203;Neuman 1989: 25;Cross 1990: 261-262): • The client may be an individual, g ro u p such as a fam ily , or community; • Each client is an open system that is d y n a m ic ally a n d c o n tin u a lly in te ra c tin g w ith and reactin g to stressors in the environment; • The individual client in a state of w ellness or illness is a dynam ic composite of the interrelationship of p h y s io lo g ic a l, p s y c h o lo g ic a l, sociocultural, developm ental and spiritual variables which are always present; • Although each client is unique, each client system is a com bination of known c h a ra c te ristic s contained within a basic core structure with a normal range of response; • Stressors in the environment, which may be physiological, psychological or sociocultural, have the potential to disturb a chent's health and stabiUty; th e s e m ay b e in tr a p e r s o n a l, interpersonal or extrapersonal in origin; • The degree to which a client reacts to a s tre s so r is d e te rm in e d by his defences and his personal perception of it; • Each client develops a normal range of response to the environment which r e p r e s e n ts a d y n a m ic s ta te of Curationis, Vol. 16, No. 3,1993 adaptation.This range of response is called the normal line of defence or usual wellness/stabiUty state; » Each client has a flexible line of defence that constantly changes as a result of stressors; such flexibility cushions the client from stressors.
The interrelationship of physiological, p s y c h o lo g ic a l, s o c io c u ltu r a l, developmental and spiritual variables determine the nature and degree of reaction to a stressor; I Each "client system" has a set of internal resistan ce factors which endeavour to stabilize the client and retu rn him to his norm al line of defence and which are known as lines of resistance; ' R e c o n stitu tio n in resp o n se to a stressor results in the client achieving another (higher or lower) state of wellness than existed prior to the stress reaction; Prim ary prevention relates to the assessment and reduction of risk factors associated with environmental stressors; S eco n d ary p re v e n tio n re fe rs to in te rv en tio n a fte r a re a c tio n to stressors has occurred, so that their negative effects may be reduced; Tertiary prevention refers to that readjustm ent which is required to maintain stability.

BASIC ELEMENTS IN THE ADAPTATION OF THE NEUMAN SYSTEMS MODEL FOR THE PROVISION OF TOTAL CARE FOR THE HOSPITALIZED PRESCHOOL CHILD
T he a s su m p tio n s on w hich th e adaptation of the N eum an Systems Model are based are deduced from those which appear in the previous section.

The person receiving care
In this model the person receiving care is the preschool child viewed within the context of his family.The "preschool child" refers to the child under the age of seven years and the terms "infant" and "toddler" are not specifically used for the younger child.This age group was selected as it is the period during which the child is most likely to be anxious and d is tre s s e d by th e u n fa m ilia r environment, the threatening nature of medical procedures, separation from his parents and his inability to correctly perceive the passage of time.The child is the primary system of focus with other subsystems or suprasystems occurring in relation to him.Although the function of the nurse is to provide direct care to the child, she will, in addition, have to focus on all family members to assess the effect of the child's illness on them.According to Azarnoff & Hardgrove (1981: 18)  Each child, as well as the members of his family, are considered to be in a state of dynamic interaction with, and reaction to, the stressors in the environment.The child is seen as an open system protected by c e r ta in d e fe n c e m e c h a n ism s represented by a series of concentric rings; these protect him from stressors in the environment.Because of the age of the preschool child, his parents Eire seen to be one of the buffers or boundaries which protect him from environmental stressors and which serve to control the dynamic exchange between him and the environment.In addition to acting as a boundary, the parents and sibUngs can also be v iew ed as a s u p ra s y s te m surrounding the child.
The individual child is considered to be an interrelationship of physiological, psychological, sociocultural, cognitive and spiritual variables which comprise subsystems within him.This deviates slightly from the Neuman Systems Model in that Neuman (1989) does not include a cognitive variable but incorporates it into the psychological variable.In this model adaptation, the developmental variable has been excluded as it appears to be inherent in the other variables.The variables are thus described as follows: • th e p h y s io lo g ic a l v a r ia b le incorporates the child's physical and biological structure and functioning; • the psychological variable refers to those processes related to emotional functioning and which include the ego and self concept; • the sociocultural variable refers to those social and cultural factors which influence the life of the child and his interaction with others.The cultural background of the child and the life-style of his fam ily will often determine his reaction to unfamiliar situations such as hospitalization.
According to Walters (1983: 56) the n u rs e m u st g u a rd a g a in s t ethnocentricity and should consider the chent's cultural views of health and illness before attempting to plan or implement nursing care.She further states that "... open recognition and c o n s id e r a tio n fo r in d iv id u a l differences will help to foster interest, respect, and compliance" and avoiding cultural contradictions will eliminate confusion about differen t health practices (Walters 1983: 59).
• th e cognitive variable involves the processes of thought, understanding and learning; and • the spiritual variable refers to those factors of ethical, moral and religious origin which impinge on the preschool child through the influence of the values and beliefs of his family (Barry, 1989;Neuman, 1989).Many of the rituals p ractised at birth, such as circumcision and baptism, as well as dietary p rac tic e s, restrictions on m e d ic a l tr e a tm e n ts , or b e lie fs regarding illness causation are linked to the spiritual variable and may have an effect on health.
The reaction of the child to a stressor is determined by his defences -which in Neuman's terminology are referred to as flexible lines of resistance, normal lines of defense and flexible lines of defence.For the purposes of this adapted model, only the flexible lines of resistance and normal lines of defence are used.Within the context of this topic a function was not found for the flexible lines of defence.
• The flexible lines of resistance change c o n tin u a lly as a r e s u lt of th e interrelationship of the five previously mentioned variables making up the basic structure of the child.Factors like the age or sex of the child, his p re v io u s e x p e rie n c e of h o sp italizatio n , his sociocultural background and his developmental or cognitive stage can all help to protect him from the stress of hospitalization.
• The norm al line of defence is the child's normal range of responses to environmental factors.In terms of the hospitalized child this could be the presence of his parents in the hospital which buffer him from some of the stress experienced.

Health definition
In this adapted model, health is viewed as a state of balance between the person and his environment which permits optimal physiological, psychological, cognitive, sociocultural and spiritual functioning.The goal of nursing and a description of those activities which comprise nursing Neuman describes the major goal of nursing as "... helping stabilize both the individual and the family system, as c lie n ts, w ithin th e ir environm ent" (N eum an 1983: 253).This im plies minimizing the factors which affect optimal system functioning and reducing the degree of reaction to a stressor by strengthening the defence systems and so ensuring system stability.Neum an defines the nursing component of her model as "... keeping the client system stable through accuracy both in the assessment of effects and possible effects of e n v iro n m en ta l stre sso rs and in assisting client adjustments required for an optimal wellness level" (Neuman 1989: 34).
Nursing thus consists of intervention which occurs at the levels of primary, secondary and tertiary prevention.This is briefly described hereunder and deak with in more detail in the next section.
• Primary prevention is initiated when a stressor is suspected or before any reaction has occurred.During this stage the c h ild 's norm al line of defence or usual state of wellness is protected by preventing stress or reducing risk factors.In the model adaptation this could include health m aintenance and prom otion; the provision of altern ativ es for the h o s p ita l c a re of c h ild re n ; c o n s id e r a tio n b e in g given to environmental factors; ensuring that children are not nursed in adult wards and prehospital preparation for both the child and parent.An additional factor involved in primary prevention is to avoid separating the child from his parents and to instead encourage them to remain with him as much as possible should hospitalization be inevitable.
• Secondary prevention is instituted in o rd er to stab ilize the child and strengthen his lines of resistance after stress symptoms have appeared.
In terms of the hospitalized child this would involve providing him with opportunities to vent his stress by means of therapeutic play or other forms of crisis therapy.Free visiting by parents, siblings and peers should be encouraged.For the child who is separated from home, transitional objects, letters, audio tape-recordings and photographs could be utilized to maintain home ties and to decrease the separation anxiety.In addition, c o n sisten t care g iv e rs sh o u ld be provided to prom ote security, and attention should be given to staffing ratios and work allocation patterns to a ch iev e th is g o al.In th o se circumstances where the nurse is not able to provide play opportunities, a ch ild -life p rogram m e sh o u ld be instituted or a playleader should be employed.
• Tertiary prevention assists the child to readapt so that a recurrence of the system disorganization is prevented and stability is regained.In terms of the hospitalized preschool child this would involve aspects such as parental and staff education.If the child is severely traumatized as a result of his hospitalization experience, then he should be referred for psychological or psychiatric counselling.For the parent, tertiary prevention could take the form of self-help groups and parental support groups.

A DISCUSSION OF NURSING INTERVENTION AS IT HAS BEEN APPLIED IN THE ADAPTED NEUMAN SYSTEMS MODEL TO THE CARE OF THE HOSPITALIZED PRESCHOOL CHILD
Nursing intervention can occur at three levels.The specific application of nursing intervention to the care of the hospitalized preschool child will be discussed hereunder:

Primary prevention as intervention
The goal of primary prevention is to avoid contact with a stressor or to strengthen the child's defence so that a stress reaction does not occur.During the primary prevention stage the risk is known.Prim ary prevention for the preschool child is seen to have a number of aspects: • The provision of preventative and promotive health services in th e com m unity which could initially impact on the mother in the form of genetic counselling and antenatal services; later the baby and young child are help ed to m aintain or optimize health and to limit need for contact with the hospital environment.Such services would include, amongst oth ers, a d e q u a te p e ri-n a ta l and p o s t-n a ta l s e rv ic e s as w ell as immunization, nutritional, dental, health screening and health education services.
• Alternative forms of health care are recommended which will incorporate the extension of community facilities and home-care programmes as these are often less stressful substitutes for hospital treatment (Dimock 1960:40;Hales-Tooke 1973:30).The increased use of day clinics for minor surgical procedures or treatments could limit the child's length of exposure to a strange environm ent.Sinclair & Whyte advocate the development of co m m u n ity p a e d ia tr ic n u rsin g schemes to reduce the length of stay in hospital for most children and to p re v e n t h o s p ita l a d m issio n completely for others.These schemes c o u ld "... p ro v id e b a c k -u p fo r sh o rt-stay surgery" as well as a specialist service to children with chronic or long-term illness (Sinclair & Whyte 1987: 4).These paediatric community health nurse specialists, th ro u g h th e ir c o n tr ib u tio n s to education, practice and research, w ould have th e p o te n tia l to profoundly transform the health and development of the children of Africa (Barnes 1987: ii).The extension of day surgery clinics together with the provision of a supportive paediatric community nursing service would have benefits for all involved.The nursing scheme could serve as a link between the home and the clinic and would be able to provide the necessary pre-and post-operative preparation, information and care required.
• P re h o sp ita l p a re n ta l a n d ch ild programmes should be initiated by n u rse s, p re s c h o o l te a c h e rs , psychologists, social workers or other interested persons to help prepare the child and his family for an unexpected hospital admission.Although these would not be focused on a specific h o s p ita l or illn e ss, th ey c o u ld familiarize the child with general aspects of hospitalization and the p e rs o n s w o rk in g w ith in th a t environment.At this level the media (television, video-tapes and books), as well as hospital tours, puppet shows or fantasy play with medical equipment in the home or preschool environment could be profitably utilized (Plank, 1964;Whitson, 1972;Altshuler, 1974;Azarnoff & Regal, 1975;Galligan, 1975;Jolly, 1977;F assler, 1978;Crocker, 1979;Van Huyssteen 1980 Thompson, 1981;Vogel, 1981;Huth, 1983;Jalongo, 1983;Varni, 1983;Azarnoff, 1984;Trawick-Sm ith & Thompson, 1984;Clarke, 1986;Gross, 1986;Alexander, 1988).
• Staff education in th e fo rm of in-service program m es should be initiated to educate all those working with children about the total needs of the hospitalized child (Robertson, 1970).
• Parental presence during the child's hospitalization should be encouraged to p re v e n t th e o c c u rr e n c e of separation anxiety (Bellack 1974).An infant should be provided with a mother-substitute if the mother does not room-in (Ziegler & King, 1982;La Rossa & Brown, 1982).

Secondary prevention as intervention
In the seco n d ary p rev e n tio n stage nursing intervention occurs to treat symptoms which have occurred and internal and external resources are used to reduce the reaction and to strengthen the lines of resistance.
In terms of the preschool child, one would assume this child had already had some contact with the health care system (doctors or specialized investigations) or was alread y h o sp ita liz e d and as a consequence was showing some adverse reaction.The stages of the nursing process should be utilized to assess the situation, make a nursing diagnosis, plan for and then implement some form of nursing action and evaluate and record the outcom e (Y ura & W alsh, 1973;M auksch & David, 1974;Ashworth, 1980;Griffith-Kenney & Christensen, 1986).
• Free visiting should be allowed and encouraged in any paediatric ward to h e lp r e d u c e th e s tre s s of hospitalization for the child, as well as his family.Hospital authorities should allow visiting by parents, siblings and p e e rs (S tacey, D e a rd e n , Pill & Robinson, 1970; American Academy of Pediatrics, 1971;Jefferies, 1974;King & Ziegler, 1981).
• C on tact with home s h o u ld be encouraged for those children whose family are not able to visit due to g e o g ra p h ic a l d ista n c e or o th e r factors.(Chadwick, Pflederer & Ray, 1978;Marlow & Redding, 1988).
• The child should be allowed to bring transitional objects from home and these could include any items that are "special" to the child like blankets, toys, dummies or any other object which provides security to the child.
Parents should be discouraged from trying to wean their children from dummies or drinking bottles during this period.To help the child to deal w ith th e fe a r of a b a n d o n m e n t, parents should be advised to leave transitional objects from home, such as the mother's handbag or scarf, so that the child knows she will return.
• In order to reduce anxiety in the young child and to be able to provide the child with individualized attention, he should be exposed to as few strange people as possible.For this reason a consistent caregiver is recommended w hich w ill involve th e " p a tie n t allocation" system being used instead of th e "task a llo c atio n " system (Hales-Tooke, 1973;Weller, 1980;Pillitteri, 1981).In addition, there must be adequate staff provision so that the nurse is able to give sufficient attention to each child under her care (Cleary, 1979).
• In situations where the nurse is not able to provide play opportunities for her paediatric patients, the hospital authorities should consider instituting a child-life programme or employing a playleader w ho can p ro v id e a d e q u a te re c r e a tio n a l and therapeutic play activities (Stacey et al., 1970;Azarnoff & Flegal, 1975;Hart, 1976;Hall, 1977;Hall & Stacey, 1979).
• The child should be helped to meet his needs for control by offering him choices, for example with foods or toys, whenever possible.The older preschool child could be allowed to participate in his own personal care or nursing treatments.
Additional strategies which may be used to allow the child to regain some control over what is happening to him include continuing with those rituals and routines to which the child is accustomed at home as well as allowing him as much physical a c tiv ity a n d e x p lo ra tio n of th e environment as his condition permits.He should also be allowed to wear his own pyjamas.
• Parental participation in care should be encouraged, both in personal care activities as well as in providing comfort and support during medical and nursing procedures or treatments (Bellack, 1974).In order to promote an a tm o s p h e re co n d u c iv e to mothering, privacy and a comfortable chair should be available at each bed or cot.If parents are not able to room-in with their child then they should be advised to be available at the child's normal bedtime as this is a time w hen th e c h ild is p a rtic u la rly vulnerable.The parents should be encouraged to continue with the child's usual bedtime rituals so that the unfamiliarity of the environment is reduced.Parents should also be given the opportunity to talk openly to staff about their child's illness so that the stress that they are experiencing is acknowledged.
• Children who are confined to bed m ust re c e iv e a d e q u a te sensory stimulation (Lindsay, 1981 • Staff communication in the hospital is im p o rta n t and re g u la r m eetings should be h eld to discuss those policies and procedures which impact negatively on the child's experience of hospitalization.In addition attempts sh o u ld be m a d e , on an interdisciplinary level, to discuss the creation or institution of programmes (p read m issio n or in -hospital) to alleviate the stress of hospitalization (Schreier 1980: 52).
• Parental education is important so that the parents are made aware of the possible symptoms of regression that the child m ight exhibit after his discharge from hospital.Parents should be advised to accept regression as a healthy reaction to stress and should be reassured that the child will return to normal if he is treated with consistency and love (Hymovich, 1976;Asen-Rudbarg Vardaro, 1978;D roske, 1978;G elderblom , 1981;V estal, 1981;S ch ep p , 1991).In addition, parents should be educated regarding techniques which they can use to assist the young child to cope with stress (Honig, 1986).Any nurse who is initiating a parental education session should consider the following factors: the cultural background of the parents, their fluency in the language of tuition, their previous level of knowledge, their anxiety level and the existence of any m isconceptions regarding th eir ch ild 's illness or treatment.
• The nurse should refer the child to p sy c h o lo g ic a l o r p s y c h ia tric counselling services should he show any serious behavioural disorders as a result of his hospitalization.
• Parents should be supported during their child's hospitalization and given the opportunity to express their needs and em otions.P arents should be referred to parental support groups and self-help groups who will help them to resolve problems when help is unavailable within the traditional health structures (Skovholt, 1974;Trainor, 1983;Marlow & Redding, 1988).Likewise, help in the form of individual counselling or self-help groups should be obtained for any siblings who are experiencing stress so th a t th e ir c o p in g a b ilitie s a re strengthened.

CONCLUSION
The manner in which a child copes with illness and hospitalization is significantly influenced by stressors which affect him in varying degrees, dependant upon the treatment of sick children"... should take into account their physical and emotional environment ... [which includes their] ... relationships with their families".
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