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The Effect of a Care Program Based on Betty Neuman’s Nursing Model on Death Anxiety, Fear of Disease Progression, and Psychosocial Adjustment to Illness in Patients with Multiple Sclerosis: A Randomized Clinical Trial

This randomized clinical trial demonstrates that a nursing care program based on Betty Neuman's Systems Model significantly reduced death anxiety and fear of disease progression in patients with multiple sclerosis, although it did not produce a statistically significant improvement in their psychosocial adjustment to illness within the study timeframe.

Original authors: Zahra Haji Rahimi, Raheleh Javanbakhtian, Farshad Heidari¹

Published 2026-09-09

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CC BY 4.0

Original authors: Zahra Haji Rahimi, Raheleh Javanbakhtian, Farshad Heidari¹

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Living with a chronic illness often means carrying a heavy, invisible burden alongside physical symptoms. For people with multiple sclerosis, a condition that gradually weakens the nervous system, this burden includes not just fatigue or pain, but deep-seated worries about the future. Among the most pressing of these worries are the fear that the disease will get worse and the anxiety that comes from thinking about death. These feelings are not just emotional side effects; they can shape how a person copes with their daily life, their relationships, and their ability to function. Nurses, who spend more time with patients than almost any other healthcare provider, are uniquely positioned to help manage these fears. However, they need a structured way to do so, one that moves beyond simple comfort and addresses the root causes of stress. This is where a specific framework known as Betty Neuman's Systems Model comes in. Developed decades ago, this approach views a person as an open system constantly interacting with stressors from their environment, their relationships, and their own thoughts. The goal of nursing within this model is to strengthen the person's natural defenses against these stressors to maintain a state of balance and well-being.

In a recent study conducted in Shahrekord, Iran, researchers put this theory to the test to see if a care program based on Neuman's model could actually help people with multiple sclerosis. The team, led by Zahra Haji Rahimi and her colleagues, recruited 70 patients who were living with the disease. These participants were divided into two groups: one that received the standard medical care they were already getting, and another that received an additional, specialized nursing intervention. This intervention was not a single conversation but a series of four group sessions, each lasting 40 minutes. During these meetings, nurses worked with the patients to identify what specifically was causing them stress, whether it was the fear of losing mobility, the worry about death, or the difficulty of adjusting to a changing life. The nurses then guided the patients through exercises designed to strengthen their mental and emotional defenses. This included learning relaxation techniques, practicing positive thinking, engaging in enjoyable activities to distract from negative thoughts, and discussing how to accept their limitations without feeling defeated. The researchers measured the patients' levels of death anxiety, fear of disease progression, and their overall psychosocial adjustment at the start of the study, immediately after the four sessions ended, and again two months later.

The results of the study were clear and encouraging for two of the three areas measured. The group that received the special nursing care showed a significant drop in their fear of death and their fear that the disease would progress. These improvements were not just temporary; the lower levels of anxiety held steady even two months after the sessions concluded. In contrast, the group that received only standard care did not see these same reductions. The data suggested that by actively addressing the stressors and helping patients build stronger internal defenses, the nurses were able to calm the specific, intense fears that often plague those with chronic conditions. The researchers noted that the effect was substantial, indicating that the intervention worked well to change how these patients felt about their mortality and their disease's future.

However, the story was different when it came to the third measure: psychosocial adjustment. This term refers to how well a person adapts to their illness in terms of their work, family life, social relationships, and overall emotional state. Despite the success in reducing fear and anxiety, the study found that the nursing program did not lead to a statistically significant improvement in how well the patients adjusted to their illness compared to the control group. While the patients felt less afraid, they did not necessarily feel more adjusted to the daily realities of living with multiple sclerosis within the short timeframe of the study. The researchers suggested that changing deep-seated habits of how one lives with a chronic disease takes more time than the four sessions provided. It is possible that the benefits of the program on this specific aspect would only become visible if the intervention were extended over a longer period.

Ultimately, this research highlights the power of a structured, theory-based approach to nursing care. It demonstrates that when nurses use a comprehensive model to tackle the psychological stressors of multiple sclerosis, they can effectively lower the terrifying fear of death and the dread of the disease getting worse. While the program did not immediately solve the complex challenge of full psychosocial adjustment, it proved that targeted support can make a profound difference in the emotional landscape of patients. The findings suggest that such programs are a valuable tool for healthcare teams, offering a way to provide relief from the most acute psychological burdens while acknowledging that helping patients fully adapt to a new life with illness is a journey that may require a longer road.

Technical Summary: The Effect of a Care Program Based on Betty Neuman's Nursing Model on Death Anxiety, Fear of Disease Progression, and Psychosocial Adjustment in Patients with Multiple Sclerosis

Problem Statement
Patients with Multiple Sclerosis (MS) face a complex array of psychological stressors, including death anxiety, fear of disease progression, and impaired psychosocial adjustment. The chronic, progressive, and incurable nature of MS, coupled with physical limitations and uncertain life trajectories, exacerbates these psychological burdens. While nursing interventions grounded in theoretical frameworks are recognized as critical for patient rehabilitation, there is a scarcity of comprehensive quantitative investigations applying Betty Neuman's Systems Model to address these specific psychological variables in the MS population. Existing literature largely relies on qualitative or case-based approaches within this theoretical framework. This study addresses the gap by evaluating the efficacy of a structured care program based on Neuman's model in mitigating death anxiety, fear of disease progression, and maladjustment among MS patients.

Methodology

Study Design: A two-group randomized clinical trial (RCT) conducted in 2025–2026 at teaching hospitals in Shahrekord, Iran.
Participants: 70 patients with confirmed MS diagnoses (Expanded Disability Status Scale < 4), aged 20 and older, recruited via convenience sampling. Participants were randomly assigned to an intervention group or a control group (35 per group initially; 70 completed the study after two withdrawals).
Intervention:
- Control Group: Received routine care.
- Intervention Group: Received a nursing care program based on Betty Neuman's Systems Model, delivered over four in-person group sessions (40 minutes each). The program followed the nursing process: assessment of patient perceptions, identification of stressors (death anxiety, fear of progression), and implementation of secondary and tertiary prevention strategies. Interventions included education on disease management, relaxation techniques, cognitive reframing, spiritual/artistic engagement, and strengthening lines of defense against stressors.
Instruments: Data were collected using:
- Demographic Information Questionnaire.
- Templer's Death Anxiety Scale (TDAS).
- Herschbach's Fear of Disease Progression Questionnaire.
- Derogatis's Psychosocial Adjustment to Illness Scale (PAIS).
Data Collection Points: Baseline (pre-intervention), immediately post-intervention, and at a two-month follow-up.
Analysis: Data were analyzed using SPSS version 23. Repeated-measures ANOVA and Analysis of Covariance (ANCOVA) were used to compare mean scores between groups and over time.

Key Results

Demographics: The intervention and control groups were homogeneous regarding age, sex, marital status, education, income, disease duration, and other demographic variables at baseline.
Death Anxiety: There was no significant difference between groups at baseline. Post-intervention, the intervention group demonstrated a statistically significant reduction in death anxiety scores compared to the control group ( $P < 0.001$ ). This reduction was sustained at the two-month follow-up, with a large effect size observed ($0.194$).
Fear of Disease Progression: Similarly, the intervention group showed a significant decrease in fear of disease progression scores over time compared to the control group ( $P < 0.001$ ). The effect size was substantial ($0.814$) at the follow-up stage.
Psychosocial Adjustment to Illness:
- Total Score: The trajectory of change in the total mean score for psychosocial adjustment did not differ significantly between the two groups over time ( $P = 0.265$ ).
- Dimensions: While most dimensions (attitude toward illness, vocational/family/social environments, sexual relationships) showed no significant group differences, the psychological distress dimension did show a significant group $\times$ time interaction ( $P = 0.002$ ), with the intervention group experiencing a significant reduction in distress compared to the control group.

Significance and Claims
The study concludes that a nursing intervention grounded in Betty Neuman's Systems Model is an effective strategy for reducing death anxiety and fear of disease progression in patients with MS. The authors posit that by systematically identifying stressors and reinforcing the patient's lines of defense, nurses can successfully mitigate these specific psychological burdens.

However, the paper maintains a modest stance regarding psychosocial adjustment. It claims that while the intervention improved psychological distress, it did not yield a statistically significant improvement in overall psychosocial adjustment within the study's timeframe. The authors attribute this to the complexity of maladaptive behaviors and the potential need for longer intervention periods and follow-up to effect broader psychosocial changes. They suggest that while the model is effective for anxiety and fear reduction, enhancing full psychosocial adjustment may require extended durations and further investigation into influencing factors.

The study positions this model-based approach as a valuable complementary therapeutic modality for nursing specialists, emphasizing the role of structured, theory-driven education in patient advocacy and stressor management.

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