CREDENTIALS AND BACKGROUND OF THE THEORIST

Dorothy E. Johnson was born on August 21, 1919, in Savannah, Georgia. She received her A.A. from Armstrong Junior College in Savannah, Georgia (1938), her B.S.N. from Vanderbilt University in Nashville, Tennessee (1942), and her M.P.H. from Harvard University in Boston (1948).

Johnson’s professional experiences involved mostly teaching, although she was a staff nurse at the Chatham-Savannah Health Council from 1943 to 1944. She was an instructor and an assistant professor in pediatric nursing at Vanderbilt University School of Nursing. From 1949 until her retirement in 1978 and her subsequent move to Key Largo, Florida, Johnson was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles.

In 1955 and 1956, Johnson was a pediatric nursing advisor assigned to the Christian Medical College School of Nursing in Vellore, South India. From 1965 to 1967, she served as chairperson on the committee of the California Nurses Association that developed a position statement on specifications for the clinical specialist. Johnson’s publications include four books, more than 30 articles in periodicals, and many papers, reports, proceedings, and monographs (Johnson, 1980).

Of the many honors she received, Johnson (personal correspondence, 1984) 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 (D. Johnson, personal communication, 1996).

THEORETICAL SOURCES

Johnson’s Behavioral System Model (JBSM) was heavily influenced by Florence Nightingale’s book, Notes on Nursing (Johnson, 1992). Johnson began her work on the model with the premise that nursing was a profession that made a distinctive contribution to the welfare of society. Thus, nursing had an explicit goal of action in patient welfare. Her task was to clarify the social mission of nursing from the “perspective of a theoretically sound view of the person we serve” (Johnson, 1977). She accepted Nightingale’s belief that the first concern of nursing is with the “relationship between the person who is ill and their environment, not with the illness” (Johnson, 1977). Johnson, (1977) also noted that the “transition from this approach to the more sophisticated and theoretically sounder behavioral system orientation took only a few years and was supported by both my own, and that of many colleagues, growing knowledge about man’s action systems and by the rapidly increasing knowledge about behavioral systems.” Johnson, (1977) came to conceive of nursing’s specific contribution to patient welfare as fostering “efficient and effective behavioral functioning in the person, both to prevent illness and during and following illness.”

Johnson used the work of behavioral scientists in psychology, sociology, and ethnology to develop her theory. The interdisciplinary literature that Johnson cited focused on observable behaviors that were of adaptive significance. This body of literature influenced the identification and the content of her seven subsystems. Talcott Parsons is acknowledged specifically in early developmental writings presenting concepts of the Johnson Behavioral System Model (Johnson, 1961b). Parsons’ (1951, 1964) social action theory stressed a structural-functional approach. One of his major contributions was to reconcile functionalism (the idea that every observable social behavior has a function to perform) with structuralism (the idea that social behaviors, rather than being directly functional, are expressions of deep underlying structures in social systems). Thus, structures (social systems) and all behaviors have a function in maintaining the system. The components of the structure of a social system—goal, set, choice, and behavior—are the same in Parsons’ and Johnson’s theories.

Johnson also relied heavily on system theory and used concepts and definitions from Rapoport, Chin, von Bertalanffy, and Buckley (Johnson, 1980). In system theory, as in Johnson’s theory, one of the basic assumptions embraces the concept of order. Another is that a system is a set of interacting units that form a whole intended to perform some function. Johnson conceptualized the person as a behavioral system, in which the behavior of the individual as a whole is the focus. It is the focus on what the individual does and why. One of the strengths of the Johnson’s Behavioral System (JBS) Theory is the consistent integration of concepts defining behavioral systems drawn from general system theory. Some of these concepts include holism, goal seeking, interrelationship/interdependency, stability, instability, subsystems, regularity, structure, function, energy, feedback, and adaptation.

Johnson noted that, although the literature indicates that others support the idea that a person is a behavioral system, and that a person’s specific response patterns form an organized and integrated whole, as far as she knew, the idea was original with her. Just as the development of knowledge of the whole biological system was preceded by knowledge of its parts, the development of knowledge of behavioral systems was focused on specific behavioral responses. Empirical literature supporting the notion of the behavioral system as a whole and its usefulness as a framework for nursing decisions in research, education, and nursing practice has accumulated since it was introduced (Benson, 1997; Bhaduri & Jain, 2004; Derdiarian, 1991; Grice, 1997; Holaday, 1981, 1982; Lachicotte & Alexander, 1990; Poster, Dee, & Randell, 1997; Turner-Henson, 1992; Wilkie, 1990; Wilmoth & Ross, 1997; Wilmoth, 2007.)

Developing the Behavioral System Model from a philosophical perspective, Johnson (1980) wrote that nursing contributes by facilitating effective behavioral functioning in the patient before, during, and after illness. She used concepts from other disciplines, such as social learning, motivation, sensory stimulation, adaptation, behavioral modification, change process, tension, and stress, to expand her theory for the practice of nursing.

USE OF EMPIRICAL EVIDENCE

The empirical origins of this theory begin with Johnson’s use of systems thinking (synthesis). This process concentrates on the function and behavior of the whole and is focused on an understanding and an explanation of the behavioral system. Johnson’s work on the Behavioral System Model corresponded with the “systems age.” Buckley’s (1968) seminal text was published the same year that Johnson formally presented her theory at Vanderbilt University.

Systems theory, as a basic science, deals on an abstract level with the general properties of systems, regardless of physical form or domain of application. General Systems Theory was founded on the assumption that all kinds of systems had characteristics in common, regardless of their internal nature. Johnson used General System Theory and systems thinking to bring together a body of theoretical constructs, as well as to explain their interrelationships, to identify and describe the mission of nursing. The JBSM provides a framework that is based on her synthesis of the component parts of this system and on a description of the context of relationships with each other (subsystems) and with other systems (environment). Standing in contrast to scientific reductionism, Johnson proposed to view nursing in a holistic manner—a behavioral system. Consistent with systems theory, the JBSM provides an understanding of a system by examining the linkages and interactions between elements that compose the entirety of the system. The paragraphs that follow describe how Johnson incorporated empirical knowledge from other disciplines into the JBSM.

Concepts that Johnson identified and defined in her theory are supported in the literature. She noted that Leitch and Escolona agree that tension produces behavioral changes, and that the manifestation of tension by an individual depends on both internal and external factors (Johnson, 1980). Johnson (1959b) used the work of Selye, Grinker, Simmons, and Wolff to support the idea that specific patterns of behavior are reactions to stressors from biological, psychological, and sociological sources, respectively. Johnson (1961a) suggested a difference in her model from Selye’s conception of stress. Johnson’s concept of stress “follows rather closely Caudill’s conceptualization; that is, that stress is a process in which there is interplay between various stimuli and the defenses erected against them. Stimuli may be positive in that they are present, or negative in that something desired or required is absent” (Johnson, 1961a, pp. 7-8). Selye “conceives stress as ‘a state manifested by the specific syndrome which consists of all the nonspecifically induced changes within a biologic system’” (Johnson, 1961a, p. 8).

In Conceptual Models for Nursing Practice, Johnson (1980) described seven subsystems that make up her behavioral system. To support the attachmentaffiliative subsystem, she cited the work of Ainsworth and Robson. Heathers, Gerwitz, and Rosenthal have described and explained dependency behavior, another subsystem defined by Johnson. The response systems of ingestion and elimination, as described by Walike, Mead, and Sears, are also parts of Johnson’s Behavioral System. The works of Kagan and Resnik were used to support the sexual subsystem. The aggressive-protective subsystem, which functions to protect and preserve, is supported by Lorenz and Feshbach (Feshbach, 1970; Johnson, 1980; Lorenz, 1966). According to Atkinson, Feather, and Crandell, physical, creative, mechanical, and social skills are manifested by achievement behavior, another subsystem identified by Johnson (1980).

The restorative subsystem was developed by faculty and clinicians in order to include behaviors such as sleep, play, and relaxation (Grubbs, 1980). Although Johnson (personal communication, 1996) agreed that “there may be more or fewer subsystems” than were originally identified, she did not support restorative as a subsystem of the Behavioral System Model. She believed that sleep is primarily a biological force, not a motivational behavior. She suggested that many of the behaviors identified in infants during their first years of life, such as play, are actually achievement behaviors. Johnson (personal communication, 1996) stated that there was a need to examine the possibility of an eighth subsystem that addresses explorative behaviors; further investigation may delineate it as a subsystem separate from the achievement subsystem.

Nursing’s goal is to maintain and restore the person’s behavioral system balance and stability or to help the person achieve a more optimum level of balance and functioning. Thus, nursing, as perceived by Johnson, is an external force that acts to preserve the organization and integration of the patient’s behavior to an optimal level by means of imposing temporary regulatory or control mechanisms or by providing resources while the patient is experiencing stress or behavioral system imbalance (Brown, 2006). 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 (Herbert, 1989; Johnson, 1980). Nursing activities do not depend on medical authority, but they are complementary to medicine.

THEORETICAL ASSERTIONS

The Johnson Behavioral System Theory addresses the metaparadigm concepts of person, environment, and nursing. The person is a behavioral system with seven interrelated subsystems (Figure 18-1). Each subsystem is formed of a set of behavioral responses, or responsive tendencies, or action systems that share a common drive or goal. Organized around drives (some type of intra-organismic motivational structure), these responses are differentiated, developed, and modified over time through maturation, experience, and learning. They are determined developmentally and are governed continuously by a multitude of physical, biological, and psychological factors operating in a complex and interlocking fashion.

Each subsystem can be described and analyzed in terms of structural and functional requirements. The four structural elements that have been identified include the following: (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, or what a person usually attends to, and perseverative, the habits that one maintains in a situation; (3) choice—represents the behavior a patient sees herself as being able to use in any given situation; and (4) action—or the behavior of an individual (Grubbs, 1980; Johnson, 1980). Set plays a major role both in the choices persons consider and in their ultimate behavior. Each of the seven subsystems has the same three functional requirements: (1) protection, (2) nurturance, and (3) stimulation. These functional requirements must be met through the person’s 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.

The responses by the subsystems are developed through motivation, experience, and learning and are influenced by biological, psychological, and social factors (Johnson, 1980). The behavioral system attempts to achieve balance by adapting to internal and environmental stimuli. The behavioral system is made up of “all the patterned, repetitive, and purposeful ways of behaving that characterize each man’s life” (Johnson, 1980, p. 209). This functional unit of behavior “determines and limits the interaction of the person and his environment and establishes the relationship of the person with the objects, events, and situations in his environment” (Johnson, 1980, p. 209). “The behavioral system manages its relationship with its environment” (Johnson, 1980, p. 209). The behavioral system appears to be active and not passive. The nurse is external to and interactive with the behavioral system.

Successful use of the Johnson’s 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 person’s 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 (Brown, 2006). 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; or (4) providing stimulation to the extent that any problem can be anticipated, and preventive nursing action is in order (Johnson, 1978). “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 originate from an environmental excess or deficiency” (Grubbs, 1980, p. 242). The goal of nursing is to maintain or restore the person’s behavioral system balance and stability, or to help the person achieve a more optimum level of behavioral system functioning when this is desired and possible (Johnson, 1978).

LOGICAL FORM

Johnson approached the task of delineating nursing’s mission from historical, analytical, and empirical perspectives. Both deductive and inductive systems thinking is evident throughout the process of developing the Johnson Behavioral System Theory. A system, inasmuch as it is a whole, will lose its synergetic properties if it is decomposed. Understanding must therefore progress from the whole to its parts—a synthesis. Johnson first identified the behavioral system and then explained the properties and behavior of the system. Finally, she explained the properties and behavior of the subsystems as a part or function of the system. The analysis gave us description and knowledge, while the systems thinking (synthesis) gave us an explanation and understanding.

The utility of the Johnson Behavioral System Theory is evident from the variety of clinical settings and age groups in which the theory has been used. It has been used in inpatient, outpatient, and community settings, as well as in nursing administration. It has been used with a variety of client populations, and several practice tools have been developed (Fawcett, 2005).

Johnson does not use the term nursing process. Assessment, disorders, treatment, and evaluation are concepts referred to in a variety of Johnson’s works. “For the practitioner, conceptual models provide a diagnostic and treatment orientation, and thus are of considerable practical import” (Johnson, 1968, p. 2). The nursing process becomes applicable in the Behavioral System Model when behavioral malfunction occurs “that is in part disorganized, erratic, and dysfunctional. Illness or other sudden internal or external environmental change is most frequently responsible for such malfunctions” (Johnson, 1980, p. 212). “Assistance is appropriate at those times the individual is experiencing stress of a health-illness nature which disturbs equilibrium, producing tension” (Johnson, 1961a, p. 6). However, it is important to note that systems analysis is an important component of systems theory. One monitors outputs from a given subsystem in order to monitor performance. Signs of disequilibrium require one to identify the problem, to further define the problem by gathering data, and to design an intervention to restore equilibrium/balance (Miller, 1965; Jenkins, 1969).

Johnson (1959a) implied that the initial nursing assessment begins when the cue tension is observed and signals disequilibrium. Sources for assessment data include history taking, testing, and structural observations (Johnson, 1980). “The behavioral system is thought to determine and limit the interaction between the person and his environment” (Johnson, 1968, p. 3). This suggests that the accuracy and quantity of the data obtained during nursing assessment are not controlled by the nurse, but by the patient (system). The only observed part of the subsystems structure is behavior. Six internal and external regulators have been identified that “simultaneously influence and are influenced by behavior,” including biophysical, psychological, developmental, sociocultural, family, and physical environmental regulators (Randell, 1991, p. 157).

The nurse must be able to access information related to goals, sets, and choices that make up the structural subsystems. “One or more of [these] subsystems is likely to be involved in any episode of illness, whether in an antecedent or a consequential way or simply in association, directly or indirectly with the disorder or its treatment” (Johnson, 1968, p. 3). Accessing the data is critical to accurate statement of the disorder.

Johnson did not define specific disorders, but she did state two general categories of disorders on the basis of their relationship to the biological system (Johnson, 1968).

The “means of management” or interventions do consist in part of the provision of nurturance, protection, and stimulation (Johnson, 1968, 1980). The nurse may provide “temporary imposition of external regulatory and control mechanisms, such as inhibiting ineffective behavioral responses, and assisting the patient to acquire new responses” (Johnson, 1968, p. 6). Johnson (1980) suggested that techniques include “teaching, role modeling, and counseling” (p. 211). If a problem or a disorder is anticipated, preventive nursing action is appropriate with adequate methods (Johnson, 1980). Nurturance, protection, and stimulation are as important for preventive nursing care or health promotion as they are for managing illness (Brown, 2006).

If the problem is a structural stressor, the nurse will focus on goal, set, choice, or action of the subsystem. The nurse could work to redirect the person’s goals, change drive significance, and broaden the range of choices considered, thus altering the set, or changing the action. The nurse manipulates the structural units, or imposes temporary controls. Both types of nursing actions regulate the interaction of the subsystems.

The outcome of nursing intervention is behavioral system equilibrium. “More specifically, equilibrium can be said to have been achieved at that point at which the individual demonstrates a degree of constancy in his pattern of functioning, both internally and interpersonally” (Johnson, 1961a, p. 9). The evaluation of the nursing intervention is based on whether it made “a significant difference in the lives of the persons involved” (Johnson, 1980, p. 215).

The Behavioral System Model has been operationalized through the development of several assessment instruments. In 1974, Grubbs (1980) used the theory to develop an assessment tool and a nursing process sheet based on Johnson’s seven subsystems. Questions and observations related to each subsystem provided tools with which to collect important data that assist in discovery of other choices of behavior that will enable the patient to accomplish his or her goal of health.

That same year, Holaday (1980) used the theory as a model to develop an assessment tool when caring for hospitalized children. This tool allowed the nurse to describe objectively the child’s behavior and to guide nursing action. In expanding the concept of “set,” Holaday also identified patterns of maternal behaviors that would indicate an inadequate or poorly functioning set that was eroding to the limited choices of action in responding to the needs of chronically ill infants (1981, 1982).

Derdiarian (1990) investigated patient and nurse satisfaction using two systematic assessment instruments. The Johnson Behavioral System Model was used to develop a self-report and observational instrument to be implemented with the nursing process. The Derdiarian Behavioral System Model instrument included assessment of the restorative subsystem and the seven subsystems advocated by Johnson. The results indicated that implementation of the instruments provided a more comprehensive and systematic approach to assessment and intervention, thereby increasing patient and nurse satisfaction with care.

Lanouette and St-Jacques (1994) used Johnson’s model to compare the coping abilities and perceptions of families with premature infants with those of families with full-term infants. The results indicated that positive coping skills were relative to bonding with the infant, using resources, solving problems, and making decisions. Lanouette and St-Jacques suggested that improvement in nursing care practices in nursery, hospital, and community settings might have contributed to this outcome. This supported Johnson’s (personal correspondence, 1996) statement that “the effective use of nurturance, protection, and stimulation during maternal contact at birth could significantly reduce the behavioral system problems we see today.”

Case studies have documented the use and evaluation of the Johnson Behavioral System Model in clinical practice. In 1980, Rawls used the theory to assess systematically a patient who was facing the loss of function in one arm and hand. Herbert (1989) reported the outcomes of a nursing care plan developed for an elderly stroke patient. Rawls and Herbert concluded that Johnson’s theory provided a theoretical base that predicted the results of nursing interventions, formulated standards for care, and administered holistic care. Fruehwirth (1989) found it equally effective in assessing and intervening with a support group for the caregivers of patients with Alzheimer’s disease.

Recent studies of nursing practice using Johnson’s model have focused on decision making and evaluation of outcomes. Grice (1997) found that the nurse, the patient, and the situational characteristics influenced assessment and decision making for the administration of antianxiety and antipsychotic medication to psychiatric inpatients at certain hours. Benson (1997) conducted a review of research literature on the fear of crime among older adults. The Behavioral System Model was used to describe the “hazards of fear of crime” that could cause disturbances in the ingestive, dependency, achievement, affiliative, and aggressive-protective subsystems (Benson, 1997, p. 26). Patient- and communityfocused interventions were presented to improve quality of care and the quality of life of older adults. Brinkley, Ricker, and Toumey (2007) demonstrated the use of the Johnson Behavioral System Theory with a morbidly obese patient with complex needs.

Lachicotte and Alexander (1990) examined the use of Johnson’s Behavioral System Model as a framework for nursing administrators to use when making decisions concerning the management of impaired nurses. They suggested that, by viewing all levels of the environment, the framework encouraged nurse administrators to assess the imbalance in the nursing system when nurse impairment exists, and evaluate the “system’s state of balance in relationship to the method chosen to deal with nurse impairment” (Lachicotte & Alexander, 1990, p. 103). The results of the study indicated that nurse administrators preferred an assistive approach when dealing with nurse impairment. It was believed that “when the impaired nurse is confronted and assisted, equilibrium begins to be restored and balance brought back to the system” (Lachicotte & Alexander, 1990, p. 103).

At the University of California, Los Angeles, the Neuropsychiatric Institute and Hospital has used Johnson’s Behavioral System Model for many years as the basis for their psychiatric nursing practice (Auger & Dee, 1983; Poster et al., 1997). “Patients are assessed and behavioral data are classified by subsystem. Nursing diagnoses are formulated that reflect the nature of the ineffective behavior and its relationship to the regulators in the environment” (Randell, 1991, p. 154). The use of Johnson’s theory is also incorporated into the new graduate orientation program (Puntil, 2005). A study comparing the diagnostic labels generated from the Johnson Behavioral System Model with those on the North American Nursing Diagnosis Association list indicated that the Johnson Behavioral System Model was better at distinguishing the problems and the etiology (Randell, 1991).

It has become increasingly important to document nursing care and to demonstrate the effectiveness of the care on patient outcomes. Using Johnson’s model, Poster and colleagues (1997) found a positive relationship between nursing interventions and the achievement of patient outcomes at discharge. They concluded that “a nursing theoretical framework made it possible to prescribe nursing care as a distinction from medical care” (Poster et al., 1997, p. 73).

Dee, van Servellen, and Brecht (1998) examined the effects of managed health care on patient outcomes, using Johnson’s Behavioral System Model. Upon admission, nurses develop a behavioral profile by assessing the eight subsystems, determine the balance or imbalance of the subsystems, and rate the impact of the six regulators. This profile is used to determine the nursing diagnoses, plan of action, and evaluation of care for each patient. The results of this study indicated significant improvement in the level of functioning upon discharge for patients with shorter hospital stays.

Education

Loveland-Cherry and Wilkerson (1983) analyzed Johnson’s theory and concluded that it has utility in nursing education. A curriculum based on a person as a behavioral system would have definite goals and straightforward course planning. Study would center on the patient as a behavioral system and on its dysfunction, which would require use of the nursing process. In addition to an understanding of systems theory, the student would need knowledge from the social and behavioral disciplines and the physical and biological sciences. The model has been used in practice and in educational institutions in the United States, Canada, and Australia (Derdiarian, 1981; Fleming, 1990; Grice, 1997; Hadley, 1970; Harris, 1986; Orb & Reilly, 1991; Puntil, 2005).

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