Dorothy E.

Johnson
1919 1999

Behavioral System Model

All of us, scientists and practicing professionals, must turn our attention to practice and ask questions of that practice. We must be inquisitive and inquiring, seeking the fullest and truest possible understanding of the theoretical and practical problems we encounter (Johnson, 1976).

CREDENTIALS AND BACKGROUND OF THE THEORIST

Dorothy Johnson was born on August 21, 1919 in Savannah, Georgia. She was the youngest of 7 children. Her father was the superintendent of a shrimp and oyster factory and her mother was very involved and enjoyed reading. She finished her Associates of Arts degree in 1938 from Armstrong Junior college in Savannah, Georgia. Due to the Great Depression, she took a year off from school to be a governess, or teacher, for 2 children in Miami, Florida. This is when she began to realize her love for children, nursing and education. In 1942, Dorothy received her Bachelors of Science in Nursing from Vanderbilt University in Nashville, Tennessee. In 1948, she received her Masters in Public Health from Harvard University in Boston, Massachusetts. After graduation, she worked for one year in public health nursing and began to teach at Vanderbilt University. After 5 years, she moved to California where she was an instructor for pediatrics in the school of nursing at the University of California, Los Angeles. She worked at UCLA until she retired in 1978, except for one year in 1955 when Dorothy took Sabbatical from UCLA to teach in Vallore, South India at the Christian Medical College School of Nursing. Of the many honors she received, Johnson was proudest of the 1975 Faculty Award from graduate students, the 1977 Lulu Hassenplug Distinguished Achievement Award from the California Nurses Association, and the 1981 Vanderbilt University School of Nursing Award for Excellence in Nursing. She died in February 1999 at the age of 80. She was pleased that her Behavioral System Model had been found useful in furthering the development of a theoretical basis for nursing and was being used as a model for nursing practice on an institution-wide basis, but she reported that her greatest satisfaction came from following the productive careers of her students.

THEORY DEVELOPMENT AND INFLUENCES

The creation of her theory began in the 1940s when she began to teach. She was studying nursing and how it was being taught and realized that there was no evidence that supported what should be taught to nurses. Although

medicine had a biological systems model, she realized that nursing was unique. She began to use different ways to build and present knowledge and began to change her practice based on the outcomes. After more than 15 years, she began to think of man and the behavioral systems model and how it best supported nursing practice. Johnson stated that her theory is a product of philosophical ideas; sound theory and research; her clinical experiences; and many years of thinking, discussing, and writing. Johnson identified that her work was inspired by: Florence Nightingale Mother Of Nursing - Environmental Theory Hans Seyle Father Of Stress - General Adaptation Syndrome Theory (aka Stress Syndrome) Talcott Parsons Structural-Functional Approach Rapoport, Chin, von Bertalanffy, and Buckley System Theory (concepts and definitions) She adapted portions of her theory from the listed theorists in order to perfect her theory on The Behavioral System Model. Johnson's theory is also based on a systems paradigm, as perceived from a sociological perspective.

BEHAVIORAL SYSTEM MODEL

In 1968, Johnson first proposed her model of nursing care as fostering of the efficient and effective behavioral functioning in the patient to prevent illness. At this point, Johnson began to join concepts related to system models into her work. Johnsons combination of systems into her work was further demonstrated by her statement that nursing was concerned with man as an incorporated whole, and this is the specific knowledge nurses must require. In 1980, Johnson made in print her conceptualization of the Behavioral System Model for Nursing. This was the first work published by Johnson that defines her definitions of the Behavioral System Model. The evolution of this complex model is clearly demonstrated in the progression of Johnsons ideas from works published in the 1950s to her latest available work published in 1980.

MAJOR ASSUMPTIONS
NURSING

is an external force that acts to preserve the organization and integration of the patients behavior to an optimal level by means of imposing temporary regulatory or control mechanism or by providing resources while the patient is experiencing stress or behavioral system imbalance. An art and a science, nursing supplies external assistance both before and during system balance disturbance and therefore requires knowledge of order, disorder, and control. Nursing activities do not depend on medical authority, but they are complementary to medicine (Tomey and Alligood, 2010).

Nursing, defined by Johnson as:

PERSON
Person, as defined by Johnson: as a behavioral system with
patterned, repetitive, and purposeful ways of behaving that link the person with the environment.
The conception of the person is basically a motivational one. This view leans heavily on Johnsons acceptance of ethology theories (study

of animal behavioral pattern), which suggest that innate, biological factors influence the patterning and motivation of behavior. She also acknowledged that prior experience, learning, and physical and social stimuli also influence behavior. She noted that to look at a person as a behavioral system, as well as to be able to see a collection of behavioral subsystems and be knowledgeable about the physiological, psychological, and socio-cultural factors operating outside them, was a prerequisite to using this model.

HEALTH
Health as defined by Johnson: as an elusive, dynamic state
influenced by biological, psychological, and social factors. Health is reflected by the organizations, interaction, interdependence, and integration of the subsystems of the behavioral system.

 An individual attempts to achieve a balance in this system, which will lead to functional behavior. A lack of balance in the structural or functional requirements of the subsystem leads to poor health. Thus, when evaluating health, one focuses on the behavioral system and system balance and stability, effective and efficient functioning, and behavioral system imbalance and instability.

ENVIRONMENT
Environment as defined by Johnson: all the factors that are
not part of the individuals behavioral system, but that influence the system.
The nurse may manipulate some aspects of the environment so that the

goal of health or behavioral system balance can be achieved for the patient. The behavioral system attempts to maintain equilibrium in response to environmental factors by adjusting and adapting to the forces that impinge on it. Excessively strong environmental forces disturb the behavioral system balance and threaten the persons stability. An unusual amount of energy is required for the system to reestablish equilibrium in the face of continuing forces.

ASSUMPTIONS BY THE BEHAVIORAL SYSTEM MODEL

1. There

is organization, interaction, interdependency and integration of the parts and elements of behaviors that go to make up the system 2. A system tends to achieve a balance among the various forces operating within and upon it', and that man strive continually to maintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forces impinging upon him.

3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man that is to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual. 4. System balance reflects adjustments and adaptations that are successful in some way and to some degree.

JOHNSONS SEVEN BEHAVIORAL SUBSYSTEM

ATTACHMENT OR AFFILIATIVE SUBSYSTEM: social inclusion intimacy and the formation and attachment of a strong social bond. DEPENDENCY SUBSYSTEM: approval, attention or recognition and physical assistance INGESTIVE SUBSYSTEM: the emphasis is on the meaning and structures of the social events surrounding the occasion when the food is eaten ELIMINATIVE SUBSYSTEM: human cultures have defined different socially acceptable behaviors for excretion of waste but the existence of such a pattern remains different from culture to Culture. SEXUAL SUBSYSTEM: both biological and social factor affect the behavior in the sexual subsystem AGGRESSIVE SUBSYSTEM: "it relates to the behaviors concerned with protection and self preservation Johnson views aggressive subsystem as one that generates defensive response from the individual when life or territory is being threatened ACHIEVEMENT SUBSYSTEM: provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical and social skills achievement are some of the areas that Johnson recognizes".

Each of the seven subsystem can be describe and analyzed in terms of structural and functional requirements. The Four Structural Elements: 1. Drive or goal the ultimate consequence of behaviors
in it
2.

Set a tendency or predisposition to act in a certain way Set is subdivided into two types:
Preparatory what a person usually attends to o Perseverative the habits that one maintains in a situation
o

3.

Choice represents the behavior a patient sees herself as

being able to use in any given situation 4. Action the behavior of an individual

The Three Functional Requirements: 1. Protection - from noxious influences with which system
cannot cope..
2.

Nurturance - through the input of appropriate supplies

from the environment. 3. Stimulation - to enhance growth and prevent stagnation. These functional requirements must be met through the persons own efforts, or with the outside assistance of the nurse. For the subsystems to develop and maintain stability, each must have a constant supply of these functional requirements that usually are supplied by the environment. However, during illness or when the potential for illness poses a threat, the nurse may become a source of functional requirements.

Johnsons Behavioral System Model

HEALTH CHANGE PROCESS
Dynamic Environment

Nursing
Nurture

Action
Protect Stimulate

Behavioral System (Patient) Attachment/Affiliation External Stressors

(+) cue or SUBSYST EM (-)

Dependency
Stress tolerance Tension Flexibility Health or Illness

Achievement

Aggressive Ingestive/Eliminative

Sexual

Internal Stressors Structure

(+) or (-) Drive *Learning *Experience *Maturation *Other changing factors (biological, psychological, sociological) Dynamic Equilibrium Set Choice Action *Goal:

Active dynamic behavioral system (person, group, family)

Successful use of the Johnsons Behavioral System Theory in clinical practice requires the incorporation of the nursing process. The clinician must develop an assessment instrument that incorporates the components of the theory, so they are able to assess the patient as a behavioral system to determine if there is an actual or perceived threat of illness, and to determine the persons ability to adapt to illness or threat of illness without developing behavioral system imbalance. This means developing appropriate questions and observations for each of the behavioral subsystems. A state of instability in the behavioral system results in a need for nursing intervention. Identification of the source of the problem in the system leads to appropriate nursing action that results in the maintenance or restoration of behavioral system balance. Nursing Interventions can occur in such general forms as: 1. Repairing structural units 2. Temporarily imposing external regulatory or control measures 3. Supplying environmental conditions or resources 4. Providing stimulation to the extent that any problem can be anticipated, and preventive nursing action is in order. If the source of the problem has a structural stressor, the nurse will focus on either the goal, set, choice, or action of the subsystem. If the problem is one of function, the nurse will focus on the source and sufficiency of the functional requirements since functional problems originated from an environmental excess or deficiency. Nursings Goal: is to maintain and restore the persons behavioral system balance and stability or to help the person achieve a more optimum level of balance and functioning.

THE FOUR MAJOR CONCEPTS

HUMAN BEING - as having two major systems, the biological system and the behavioral system. It is role of the medicine to focus on biological system where as Nursing's focus is the behavioral system. SOCIETY - relates to the environment on which the individual exists. According to Johnson an individuals behavior is influenced by the events in the environment HEALTH is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order to maintain stability and comfort. NURSING - has a primary goal that is to foster equilibrium within the individual. Nursing is concerned with the organized and integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual.

IMPLICATIONS
Practice The Johnson Behavioral System Model was used to develop a self-report observational instrument to be carried out with the nursing process. implementation of the instrument provided a more comprehensive organized step to assessment and intervention, thereby increasing patient nurse satisfaction with care (Octaviano and Balita, 2008). and The and and

Moreover, this theory was used as a model to develop as assessment tool when caring for children. This tool allowed the nurse to objectively describe the childs behavior and to guide nursing action (Octaviano and Balita, 2008). Education A core curriculum based on a person as a behavioral system would have definite goals and clear course of planning. The study would center on the patient as a behavioral system and its dysfunction, which would necessitate the use of the nursing process. In addition to an understanding of systems theory, the student would need knowledge from the social and behavioral discipline and the physical and biological sciences. The model has been used in practice and educational institutions in Canada, the United States and Australia (Octaviano and Balita, 2008). Research Nursing research, according to Johnson, is vital to explain and identify the behavioral system disorders which arise in relation with illness, and develop good reasoning for the means of management. The theory resulting from the

Behavioral System Model influences to the researcher to choose between two options (Octaviano and Balita, 2008). One researcher might examine the functioning of the system and subsystem by focusing on the Basic Sciences and another researcher might focus on investigating methods of gathering diagnostic data or problem-solving activities as these influences the behavioral system (Octaviano and Balita, 2008).

Case Study
A 67-year-old man is admitted to the hospital for diagnostic tests after experiencing severe abdominal pain and streaks of blood in his stool. He is alert and oriented. He has a history of type II diabetes and hypertension. His blood glucose level is 187 mg/dl, and blood pressure is 188/100 mm Hg. He is 510 and weighs 145 pounds. He is currently taking anti hypertensive, anticoagulant, anti-inflammatory, and antidiabetic medications. His recent history reveals that he had an Acute Cerebral Vascular Accident (CVA) 6 weeks ago that resulted in partial paralysis and numbness of the right arm and leg, expressive aphasia (patient knows what he wishes to say but is unable to get the words out) , and slurred speech. He completed 4 weeks of inpatient rehabilitation and is able to walk short distances with a cane and moderate assistance. He is weak and becomes fatigued quickly. Although he can move his right arm, he guards it because of pain with movement. He receives acetaminophen (extra strength Tylenol) for his right arm prior to therapy and before sleep. He also continues to exhibit slight expressive aphasia. He is anxious about continuing his therapy and indicates concern about missing his appointment with the orthopedic physician who was to evaluate his right arm. He reports that food doesnt taste right anymore, and he has no appetite. With encouragement from his family, he eats small portions of each meal and drinks fluids without difficulty. The patient is a college graduate who recently retired. He has been married for 45 years and has two adult children who live in the same city. He is a leader in the church and social community. His family and friends visit him frequently in the hospital. He is cheerful and attempts to talk with them when they visit. When he doesnt have visitors, he sits quietly in a dark room or sleeps. He is tearful each time his family hugs him before leaving. He expresses appreciation for each visit and apologizes each time he gets emotional.

Behavioral Assessment
Using Johnsons Behavioral assessments are identified. System Model, the following behavioral

Achievement: The patient has achieved many developmental goals of adulthood. He is relearning how to do activities of daily living (ADLs), walk, and talk, as well as other cognitive-motor skills such as reading, writing, and speaking. Attachment-affiliative: The patient is married with two adult children who are supportive and live in the same city. He has many friends and social contacts who visit frequently. Aggressive-Proctective: The patient worries about his wife travelling to the hospital at night, and he worries that she doesnt eat well while staying with him in the hospital. Dependency: His recent stroke, resulting in decreased use of his right arm and leg, has affected his mobility and independent completion of ADLs. His potential for falling, inability to feel his arm or leg if injured, and weakness are safety concerns. His wife has taken on the financial and home maintenance responsibilities. Ingestive: Since the stroke, the patient has had a decreased appetite. He has lost 20 pounds in 6 weeks. Studies reveal no swallowing difficulties. He is able to feed himself with his left hand but needs assistance with cutting foods. Eliminative: The patient is able to urinate without difficulty in urinal but prefers to walk to the bathroom. He becomes constipated easily because of decreased fluid and food intake. Sexual: There are changes in the patients sexual relationship with his wife caused by pain, limited use of his right side and fatigue.

Environmental Assessment
The assessment of internal and external environmental factors indicates that several are creating tension and are threatening the balance and stability of the behavioral system. This hospitalization and diagnostic testing add additional stress to the already weakened biological and psychological stability of the behavioral system. The stroke produced several physical and cognitive impairments that affect independence, self-care, learning, maturation, and socialization. Hospitalization at this time can delay or decreased the prognosis

of the patients physical and speech rehabilitation. He will need assistance to move safely in the hospital environment. The patient and his wife are active in their church and participate in many social activities. The patient taught classes in Sunday school. Recent illnesses, hospitalizations, and fatigue have decreased his ability to participate in previous activities. Although he has adapted to his right sided weakness and decreased motor function by performing his ADLs with his left hand and walking with a cane, he still needs assistance. The patient and his wife live in a suburban neighborhood. Family members installed a ramp to facilitate access to the home. His wife states that neighbors watch the house when she is away and watch for her return to be sure she is safe.

Structural Components
Drive or Goal The patient seems motivated to complete the diagnostic tests and return home. He is eager to get back into his outpatient rehabilitation program. It seems equally important for him to decrease stress on his wife. His wife provides positive encouragement and support for him. He looks to her for assistance with decisions. Set - It is evident that the patient is accustomed to making his own decisions and being a leader. It is also evident that he is accustomed to conferring with his wife to ensure that she is comfortable with decisions being made. Choice Although the patient agrees to the diagnostic tests, he is no longer in pain and has had no bleeding since his hospitalization. Therefore, he is more focused on achieving his rehabilitation goals. He initiates activities and seeks assistance from his family in walking to the bathroom, walking in the hall, and competing his ADLs. Actions The patient socializes with visitors and family by actively participating in conversations. He requests assistance as needed for physical and cognitive needs. He asks for prayers from his family and friends for spiritual guidance in managing his illness.

Functional Requirements
The patient needs outside assistance for all three functional requirement, including protection, nurturance, and stimulation. His inability to feel his right side and his impaired mobility increase his potential for injury. Protective

devices such as hand bars and a shower chair can be used. The patient needs assistance with preparing meals but has adapted to using his left hand for eating and drinking. Socialization and performance expectations at the outpatient rehabilitation facility are important methods of providing stimulation for the patient. Stimulation is also provided by friends and family who visit the patient. Continued social stimulation is vital for its patient, because he has difficulty understanding other forms of stimulation such as radio, television and reading.

Nursing
Nursing actions are external regulatory forces that should protect, stimulate and nurture to preserve the organization and integration of the patients behavioral system. Nursing actions for this patient should focus on providing explanations of diagnostic tests to be performed and the results of the test. Identification of favorite foods and encouragement of small frequent meals with sufficient fluids to prevent constipation will be needed. The nurse should advocate for inpatient physical and speech therapy to stimulate functional abilities and reinforce the patients achievement behaviors to decrease dependency requirements. It will be equally important to encourage ongoing socialization with friends and family. The patient and his wife will need support and teaching to identify methods of adapting to and managing system imbalance and instability and to identify actions that will enhance behaviors to create system balance and stability.

REFERENCES: Alligood, Martha Raile and Tomey, Ann Marriner. 2010. Nursing Theory 7th edition. Mosby Elsevier. Octaviano, Eufemia and Balita, Carl. 2008. Theoretical Foundation of Nursing. Ultimate Learning Series. Parker, Marilyn E. 2001. Nursing Theories and Nursing Practice. F.A. Davis Company.
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