Middle Range Theory:Dorothy Johnson’s Behavior System Model on the Population of Substance UsersLeana Snyder, Emma Cuccurullo, Jenna Rosenfeld, and Charlyn Humes Adelphi University College of NursingNur 602-01 Frameworks for Advanced Nursing PracticeOctober 25, 20231AbstractNursing theories and models play a pivotal role in terms when it comes to a better understanding of nursing care. Dorothy Johnson developed a behavioral system model which details how the human body and mind are the two central systems which comprise who we are. The patient’s behavior is profoundly affected by the social context in which they find themselves and as well as the events which occur. Maintaining fitness requires actively adapting to internal and external stresses in order to keep things under control and in balance. Mental, emotional, and social reactions also play a role and are factored in. Substance users attempt to reestablish behavioral stability while adjusting to the substantial changes their habit brings. Substance use can cause the behavioral subsystems of an individual to be negatively affected. What is affected and at risk are mental health, healing, and overall well-being. Scholarly articles are used to evaluate how Johnson’s theory can be applied and tested when it comes to understanding and addressing substance abuse issues.Keywords: Dorothy Johnson, behavioral system model, substance user, subsystems, internal stressors, external stressors, drug addiction2Dorothy Johnson BackgroundDorothy Johnson was one of the first “grand theorists” to present her views on a conceptual model related to nursing. Johnson was born August 21, 1919, in Savannah, Georgia. Johnson received her Bachelor of Science degree in nursing from Vanderbilt University in 1942. She then received her Master of Public Health in 1948 from Harvard University. After completing her education, Johnson began her academic teaching career at the Vanderbilt University School of Nursing. Her career flourished, serving as an assistant, associate, and professor. She even wrote a series of clinical articles for the Nursing Journal of India. Johnson took an early retirement due to health conditions, but at the time of her retirement her work was just beginning to be widely recognized (Smith, 2015).Database SearchAdelphi ONESearch was used based on our collective research. Databases include ProQuest, PubMed, and Google Scholar. As well as textbooks and dissertations.Keywords used were “Dorothy Johnson Behavioral System Model,” “substance users,” “drug addiction,” “interventions,” and “nursing.” Collectively, the number of initial search outputs obtained varied between 203 to 41,176, which was later narrowed down by relevance to three to four articles individually chosen by each group member. Additional searches with delimiters were used to refine the search. Using search limiters, scholarly articles were located that fit the parameters of the assignment. To pare down output, all sources found were from the past decade and were peer reviewed. Utilizing these parameters ensures obtaining the most relevant and accurate articles. Discussion of Behavioral System ModelDorothy Johnson’s behavioral system model, first proposed in 1968, implied a set of rules to which nurses should adhere. This model cited several sources including work by3theorists, including Florence Nightingale, Buckley, Chin, Parsons & Shils, Rapoport, and Von Bertalanffy. Similar to Florence Nightingale, Johnson believed that nursing’s concern is a focus on the person as opposed to just the disease (Smith, 2015). Johnson served briefly as a staff nurse at the Chatham-Savannah Health Council before completing her master’s (Smith, 2015). As Johnson’s nursing career began to take shape, so did her theoretical model. Johnson’s background in pediatric nursing is evident throughout the model. Johnson’s model consisted of two components, nursing, and the individual. Johnson viewed the individual as a behavioral system with patterned, repetitive, and purposeful ways of behaving which link the person with the environment (Alligood & Holaday, 2022). The goal of this model is to maintain equilibrium. In order to have balance and order, it is important to keep in mind that the entirety of the organism (system) is greater than the sum of its parts (subsystem). There are five core principles of system thinking within Johnson’s model: wholeness and order, stabilization, reorganization, hierarchic interaction, and dialectical contradiction. The patient’s behavior is considered a mix of seven subsystems: affiliation, dependency, ingestive, eliminative, sexual, aggressive, and achievement. Each subsystem performs a different function. The function of the affiliation subsystem is security through intimacy and social inclusion. The ingestive subsystem serves to cover biological requirements of an individual. The eliminative subsystem functions to aid in the excretion of wastes for an individual. Procreation and gratification are the functions of the sexual subsystem. Self-protection and preservation are the function of the aggressive subsystem. The achievement subsystem focuses on mastery or control. Lastly, the dependency subsystem is an evolving subsystem which begins with dependency on others and evolves to independence (Fawcett, 2006). This entire theory is based on the balance between the seven subsystems, and a lack of balance leads to poor health in a person. Johnson’s philosophy describes nursing as an4external force which acts to preserve the organization and integration of the patient’s behavior to an optimal level by imposing temporary regulatory or control mechanisms or in addition by providing resources while a patient is experiencing stress or behavioral system imbalance (Alligood & Holaday, 2022).Diagram5 This diagram illustrates Dorothy Johnson’s Behavioral System Model as to the causes, subsystems, and effects. As seen in the results, either the system will lead to effective functioning and adaptation or ineffective functioning in which then it goes back into the same feedback loop again.Theory’s Relevance to NursingThe usefulness of Dorothy Johnson’s model helps to guide nursing practice. The strength of the behavioral system model provides the possibility for its application in a variety of cases, including behavioral disorders. Moreover, Johnson’s theory allows nurses to assess the psycho- emotional state of each patient thoroughly and draw the right conclusions based upon the information obtained (McEwen, 2014). A limitation to this theory is the complexity of the subsystems since no individual is the same. The value of extending nursing science is to help nurses to grow professionally, improve patient care and provide them with a basis for their practice. The nursing process ends with the evaluation phase, which is where the behavioral system model is best applied. This is where the nurse can determine if the subsystems of apatient are properly balanced. Johnson’s goal was to link nursing with this behavioral model and have it form the framework for future generations of nurses. (McEwen, 2014) The use of this theory in advanced personal practice can help to assess the patient’s condition from a professional point of view and draw the appropriate conclusions regarding the optimal course of treatment. Following this concept nurses can achieve efficient results of treatment.Some examples of the theory already used in practice can be seen in the work of Derdiarian (1990, 1991) and Tamilarasi and Kanimozhi (2009). Derdiarian examined the role of nurses as an action within the practice. She focused on the importance of quality of care in relation to the nurse’s assessment of the patient utilizing Johnson’s model. The results yielded an increase in patient and nurse satisfaction when using Johnson’s model (Smith, 2015). Tamilarasi and Kanimozhi used Johnson’s model in order to develop interventions to help improve the quality of life in breast cancer survivors (Smith, 2015). These are just two examples of Johnson’s theoretical model being put to use.Research Using Dorothy Johnson’s ModelAnukam (2021) used Dorothy Johnson’s behavioral systems model as the theoretical model for the project within this study. The project used the Pfizer patient health questionnaire (PHQ-9) tool to screen for depression amongst adults in the primary care setting. Depression is a prevalent psychiatric illness in America. As of 2016, 7.4 % of adults have been affected by depression (Anukam, 2021). Between 2009 and 2017, there was an increase in depression and suicide risk by nearly 63% (Anukam, 2021). Johnson’s behavioral subsystems were used to guide the treatment process for individuals who were positively screened for depression by utilizing the PHQ-9 tool (Anukam, 2021). As a result of the study, people with depressive6symptoms as identified by using the PHQ-9 tool were able to be adequately treated based upon Johnson’s model, focusing on the subsystems.Evgin & Bayat (2020) conducted an experimental study to determine the effect of the behavioral system model. Utilization of the creative drama method on adolescents who were at risk for bullying was examined using pre and post tests and a control group. Eighty-three students in total were recruited, 43 were in the study group and 40 in the control group. Data was collected using the Individual Information Form, Traditional Peer Bullying Scale, Problem- Solving Inventory for Children, and the Empathy Index for Children. Pre-study data was collected according to the model’s subsystems. According to this model, when a student has a behavioral system under stress, the present stress in their lives can lead to bullying (Evin & Bayat, 2020). This study aimed to increase both empathy and problem-solving skills in students as well as decrease bullying incidents amongst students after the education provided in accordance with the creative drama method. It has been found that the combination of the education given by the creative drama method in accordance with the behavioral system model was effective for decreasing exposure to threats, and physical and verbal bullying in the study group of students.Obaseki (2022) created a dissertation which utilized the Dorothy Johnson behavioral system model and the health belief model. The aim included a nurse practitioner directing behavioral modification initiative for patients with Type 2 diabetes mellitus in a community Health Center. This study was based on key areas such as counseling, dieting, exercise, motivation with group support, and reminders. A questionnaire for the data collection and measurements via Patient Activation Measure-13 (PAM-13) scale was administered to the participants for baseline engagement data. There was a mean value increase of 12.33, which7translated to an improved engagement level in patient care management (Obaseki, 2022). Creating a structured behavioral modification regimen for combating poor engagement levels, with reminders and encouragement calls, proved to be essential in achieving enhanced involvement in managing a patient’s health condition.Oymaağaçlio & Karabacak (2021) explored the application of Dorothy Johnson’s behavioral system model in caring for a patient with multiple sclerosis. The paper underscores the importance of nursing theories and models in providing evidence-based and holistic nursing care (Oymaağaçlio & Karabacak, 2021). These theoretical frameworks are significant in chronic disease management, care planning, nursing practice, and research. The study delves into Dorothy Johnson’s behavioral system model. The model posits that individuals possess two systems: biological and behavioral. The latter comprises seven subsystems as described in Johnson’s model. Nurses need to consider the individual as a whole, focusing on behavior change, and being responsible for maintaining balance within these subsystems. The research also highlights the limited literature on Dorothy Johnson’s model and the use of theories and models in treating multiple sclerosis patients. It offers a case study which demonstrates the application of the behavioral system model in the care process of a patient with multiple sclerosis.Hidayati & Ismail (2023) created a theoretical analysis to provide guidelines which were used to analyze Dorothy Johnson’s theory of model behavioral systems. The Chinn and Kramer theory analysis guidelines were utilized. Six main concepts and sub-concepts were identified. As recommended by Chinn and Kramer, the definition of Dorothy Johnson’s theory will contribute to a better evaluation of the description component (Hidayati & Ismail, 2023). The behavioral system model is a model of nursing care which advocates efficient and effective development of8behavioral functions in patients to prevent disease (Hidayati & Ismail, 2023). Patients were identified based on the behavioral system which consists of seven behavioral subsystems as described in Johnson’s model. The three functional requirements for each subsystem include protection from harmful influences, provisions for maintaining the environment, and stimulation for growth.Dorothy Johnson’s Theory Applied to Substance UsersThe selected middle range theory of Dorothy Johnson’s behavior system model is applied to the hypothetical scenario of the minority group of substance users. Theory-based interventions are used to help this population. Application of this model can help to improve the substance user’s approach to healthier living and promote healthier behaviors.In the model, the seven subsystems are not isolated. Each subsystem’s three functional requirements include protection from toxic influences, creating a nurturing environment, and stimulating growth. The journal Society for the Study of Addiction provides the use of internet interventions for illicit substance users. Through their meta-analysis, 17 studies inclusive of 2,836 adult illicit substance users were utilized to demonstrate the significant effects in decreasing substance use among various target populations at post-treatment and at follow-up assessments. Three target populations were addressed in these trials; opioid users, stimulant users, and users of any illicit substances (Boumparis et al., 2017). Internet interventions allowed for a wide variety of advantages to become possible, such as the widespread dissemination of information to individuals. This focuses on the ingestive and restorative subsystems by taking in needed resources from the internet and relieving negative feelings in order to heal.The Evaluation &amp: The Health Professions Journal conducted research identifying behavioral therapies for treatment seeking cannabis users. This helps confirm Johnson’s theory9by identifying that the average patient receiving behavioral therapy fared better than 66% of those in the control conditions (Davis et al., 2014). Behavioral therapy was compared to a waitlist, psychological placebo, and treatment as usual. In this study, it was found that individuals who have a difficult time quitting substances have a higher vulnerability and reactivity to stress. In the control conditions, the treatment focused on the act of quitting the substance, however as stated in Johnson’s theory, all subsystems need to be addressed.ConclusionIn its totality, these databases help to piece together the meaning of Dorothy Johnson’s behavioral systems model. Provided is literature on behavioral interventions with the goal of helping substance users as well as examples as to how Johnson’s theory was implemented and tested. In conclusion, this model can help to improve substance users’ approach to healthier living and promote healthier behaviors. Utilization of this model will also enhance nursing practice by focusing on and treating the patient as a whole. Finding and putting into practice a theory which potentially provides better patient outcomes for this population is essential.10ReferencesAlligood, M. R., & Holaday, B. (2022). Dorothy Johnson: Behavioral System Model. In Nursing theorists and their work (pp. 270–287). essay, ElsevierAnukam, A. (2021). Implementing Patient Health Questionnaire Tool to Improve Depression Screening in a Primary Care Practice. ProQuest Dissertations Publishing.Boumparis, N., Karyotaki, E., Schaub, M. P., Cuijpers, P., & Riper, H. (2017b). Internet interventions for adult illicit substance users: A meta-analysis. Addiction, 112(9), 1521–1532.  M. L., Powers, M. B., Handelsman, P., Medina, J. L., Zvolensky, M., & Smits, J. A. (2014). Behavioral therapies for treatment-seeking cannabis users.Evaluation & the Health Professions, 38(1), 94–114.  D., & Bayat, M. (2020). The effect of Behavioral System Model based nursingintervention on adolescent bullying. Florence Nightingale Journal of Nursing, 28(1), 71–82.  J. (2006). (Dorothy) Johnson’s Behavioral System Model. In S. Wilkerson (Ed.), Encyclopedia of Nursing Research (pp. 310–311). essay, Springer Publishing Company.Hidayati, E., & Ismail, S. (2023). Theory analysis: Dorothy E. Johnson (behavioral theory) according to the Chinn and Kramer model. 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