Johnson’s Behavioral System Model in Nursing Practice

Achievement

Affiliative

Aggressive/Protective

Dependency

Ingestive

Sexual

Restorative

Diagnosis and Intervention

Diagnosis and Intervention

In examining Debbie’s perseveratory set, one would note that Debbie’s perception of herself as an independent agent generally capable of accomplishing her tasks and goals has been substantially altered. In terms of the preparatory set, her situational context is also substantially altered. She is most likely uncertain about herchoices. The diagnosis is insufficiency in the achievement subsystem. In terms of intervention, the nurse may protect Debbie from noxious stimuli because she is not presently able to cope with all situations. The nurse can provide nurturance in terms of providing counseling and help with goal setting. Stimulation in terms of teaching new self-care behaviors can also help. The biological disease process is unique for each person, and the psychosocial response to mastering the situation will be equally unique. Thus frequent reassessment and revision of the care plan will be needed.

Most patients faced with a diagnosis of cancer experience a life crisis. Although death is often the first fear, the potential for other stressors exists. Surgery, adjuvant therapy (radiation), the possible spread of malignancy, and an uncertain prognosis are all stressors. Surgery may lead to an altered body image with accompanying feelings of lost femininity. It is reasonable to assume that Debbie is experiencing some sexual concerns, and the sexual subsystem should be thoroughly examined because objective data indicate the potential for behavioral system imbalance.

The objective data identify that Debbie had a radical hysterectomy, which means the vaginal canal has been shortened. Because the trigone of the bladder and the sigmoid colon may be closely associated with the new vaginal apex, sexual intercourse may be uncomfortable. Debbie will receive radiation therapy. Side effects from this therapy may include fatigue, nausea and vomiting, and infection. The subjective data indicate that Debbie’s husband is emotionally distant and sometimes abusive and that Debbie is tearful and worried about the future. The perseveratory set reveals that the current physiological functioning of the sex organs has been disrupted. Past socialization and experience in sex role behaviors may no longer seem applicable to Debbie. Within the context of the present situation (preparatory set), Debbie is most likely unsure where to direct her attention. The selection of a sexual behavior (choice) to meet goals is unclear.

Because the subsystem is not functioning to its fullest capacity, the nurse could diagnose insufficiency. If Debbie takes actions that do not meet the intended goal of the subsystem, a diagnosis of discrepancy could also be made.

Achievement

Mark looked at the nurse with a great little smile when he described his school and how it is different. He describes it as a “handicap school.” He likes it because there are only “16 kids and 2 teachers and I get lots of help.” He is also proud of what he can do on the computer. Mark attributes his success to the presence or absence of ability and attributes little to motivational factors. He enjoyed the Piagetian testing, which placed him in the concrete operations period. Both the nursing staff and his mother note that he requires verbal prompts to perform self-care activities. His mother notes that he has missed a lot of school during the past 2 years, which is why she and her husband removed Mark from regular public school and placed him in a special education school. The classes are ungraded, but his mother says he has made great progress at this school and now reads at a sixth-grade level and has math skills at a fifth-grade level. Mark is worried about “getting behind” while he is in the hospital. Mark has no idea what he wants to be when he grows up. He has not been to camp, nor has he ever spent the night at another child’s home. Mark has never been home alone; a parent or sibling is always present.

Aggressive/Protective

His mother and the nursing staff describe him as passive and more likely to sulk than get angry. When the nurse asked what he would do if someone took something of his or hit him, Mark said he “wouldn’t like it.”

Dependency

Mark refused to answer questions about self-care. The nursing staff states that they saw little evidence of self-care activity during previous admissions. He lets the nursing staff or his mother maintain his blood glucose level, inject his insulin, select his menu, and perform his bowel and bladder care. Mark’s mother states that he has become more dependent on her during the past year. He asks for help to dress in addition to his other requests. The staff has noted more independent behavior when the mother and grandmother are absent. Nurses noticed a tremendous difference between the way he acted with them when his mother and grandmother were not present (adult/child to adult/parent with the nurse; and child/parent with mother and grandmother).

Ingestive

Mark states, “I like to eat.” His mother also describes Mark as “loving food” and “eating too much.” The switch to the “diabetic diet has been difficult for him.” The family eats meals together. Postoperatively, he usually has nausea and vomiting and fluid and food intake is poor. Mark is very observant of what goes on around him. He likes to “have tests and things explained” to him when he is in the hospital.

Eliminative

Mark has minimal bowel and bladder control. He has frequent problems with dribbling of urine. Mark himself admits this bothers him. His mother suspects he does not perform intermittent self-catheterization regularly at school because he is embarrassed about sexual changes and about the fact that he must wear sanitary protection pads. As for his communication pattern, Mark tucks his head to his chest and mumbles when he is talking about his feelings or his parents. Sometimes he simply refuses to answer or looks away. The nurse suspects the mumbling and shyness are a means of coping with his overtalkative and overprotective mother and grandmother.

Restorative

Mark sleeps 8 hours a night but sleeps less in the hospital “because they wake you up all the time.” He usually gets up around 7 AM on school days and 8:30 AM on the weekends. He has a somewhat restricted repertoire of interests and activities. He spends much time watching TV and rental videos and plays computer games. He participates in no groups, clubs, or regular physical activity. He enjoys family weekend trips to the lake and dune buggy and boat rides.

Familial

Social/Cultural

Mark is part of a Protestant, middle-class family who does not attend church regularly. Both parents place a high value on home and family. The father has assumed the patriarchal provider role in the family. The family has lived in the same house for 17 years and has several close friends in the neighborhood who will help whenever needed. The parents have also maintained social relationships with several of the father’s business associates. They belong to no outside social clubs or groups. Insurance covers 90% of Mark’s expenses, and they sometimes face financial troubles. Currently, however, there are no major financial problems.

Developmental

Mark laughed when the nurse said he was about to become a “terrible teen.” He said he has heard adults talk about it, but he would not elaborate. Mark enjoys heavy metal rock, computer games, and watching TV. When asked about girls, he shrugged and looked away. Mark attends a special education school and is behind his grade level. His social skills are not age-appropriate. Medical treatments, parental overprotectiveness, and physical disability all seem to be reinforcing dependence while diminishing any sense of self-control over health. Self-care responsibility is less than what we would expect of a 12-year-old.

Pathological and Biological

Mark stated that he hates “everything about hospitals.” He acknowledged that the increase in restrictions of activity bothered him. The “tests” and “surgery” worry him. He knows the surgery is to try to stop the “leaking” of urine, but Mark is uncertain about where they will operate and exactly what will be done. Mark doesnot like diabetes because he can no longer “eat whatever I want.” Mark has a poor understanding of diabetes. He could not explain the role of insulin and diet in the management of the illness. Mark better understands myelomeningocele and how that affects his walking and bowel and bladder control. On admission, Mark’s vital signs are normal. He is in the 25th percentile for height for his age and 90th percentile for weight. His blood urea nitrogen (BUN), creatinine, and blood glucose levels are slightly elevated. His glycohemoglobin level is elevated, indicating poor long-term glucose control.

Ecological

The family owns a home in the suburbs. A park is located about 1 mile from their home, and a school and playground are located about ½ mile from home. The parents describe the neighborhood as safe. No public transportation is available in the area.

Psychological

As a preadolescent, Mark is concerned about body image and is anxious about any bodily disruption or change. He seems self-conscious about his early sexual maturation. His mother has noted Mark’s childlike behaviors and increasing dependency during the past year (e.g., wants help dressing). He is socially isolated from peers, and interaction with his brothers has decreased during the past 2 years. He also needs more emotional support from his mother. His mother calls Mark shy, and the nursing staff’s observations support this assessment. His scores on the self-esteem interview were low. He copes by withdrawing from situations that make him uncomfortable. He does not like to discuss his feelings about sensitive issues (e.g., parents, sexuality, illness). However, he wants information about specific events that are stressful for him (e.g., surgery).

This case study is presented because it reflects both acute and long-term problems associated with managing a chronic illness. It also demonstrates that children’s developmental domains (behavioral subsystems) are often significantly influenced by their illness. One of the strengths of JBSM is that it identifies not only current acute problems but also chronic subsystem disturbances. These alterations involve a disturbance in normal developmental sequences. Without intervention, these alterations may lead to more serious problems as the child matures. This analysis applies the nursing process to an acute problem related to this admission and to a long-term problem.

Acute Problem

Mark has been admitted to the hospital for a bladder augmentation and placement of an artificial sphincter. He is behind his grade level at school. Piagetian testing places him at the concrete operations level of cognitive development. The subjective data inform the nurse that Mark is worried about tests and surgery and is unsure about specific aspects of the surgery. He has some understanding of myelomeningocele and little understanding of diabetes. However, he does like to have “tests and things” explained to him. Also contributing to this problem is the mother’s overprotection of Mark and the apparent failure of the family to openly discuss aspects of the illness.

Planning and Intervention

Given the complexity of this case, the intervention needs to be planned carefully. The intervention could also affect the dependency subsystem (self-care), achievement subsystem (sense of mastery), affiliative subsystem (socialization), and eliminative subsystem (expression of feelings). It was mutually agreed that the preoperative teaching would be done with both Mark and his parents together and then alone with Mark. Diagrams and pictures will be used to explain the surgery, and postoperativetreatments and procedures would also be explained and demonstrated. Thus the nurse will provide the functional requirements of protection and nurturance.

The immediate goal of the intervention is to inform Mark about his surgery and postoperative care. The intermediate goal is for Mark to maintain his healthy physiological system through the intake of food, fluids, and medicine during the postoperative period. This will occur as a result of his understanding the surgical procedure and the postoperative care needed for recovery (e.g., internalizing the external environment). The long-term objective is that the intervention will restore Mark’s sense of mastery and of autonomy.

Chronic Problem

It is helpful to think of parenting in terms of the JBSM as a set of environmental actions performed by the parents or a set of environmental conditions arranged by parents that assists or impedes the child in carrying out his or her functions. It is important to make clear that in this examination of parenting actions and conditions as elements external to the child, the independence of the child and environment is not implied. Rather, the examination occurs only for the purposes of assessment and the convenience of organization.

From a JBSM perspective, the idea of an external regulator of growth and development is also useful. The idea of nursing care as a set of regulatory acts, aimed at successful adaptation and goal attainment for the child (behavioral system), is consistent with most ecological developmental models and with the general precepts of control systems’ theory. However, as potentially useful as the concept of an external regulator might be in classifying the actions and conditions of nursing care (i.e., in terms of adjusting parenting actions or environmental conditions arranged by the parent), it carries with it a practical paradox—external regulation is unlikelyto be a simple matter for a complex organism. The JBSM provides a means to approach this issue, but much work remains in building theory in this area. The next care problem clearly addresses the complexity involved.

The family-centered intervention would be best if carried out by a nurse who has sustained contact with Mark and his parents.