FACULTY OF NURSING AND ALLIED HEALTH SCIENCES

_________________________________________________________________________
NMNM5103
NURSING MODEL & DEVELOPMENT
ASSIGNMENT 2
JANUARY SEMESTER 2016
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Task:
Critically discuss how Johnsons Behavioral System Model can be applied to a 65-year-old
single lady with Uncontrolled Diabetes and Hypertension

Name: MAIZATUL AKMAR BT IBRAHIM

Matric number: CGS01304221

NRIC: 720618145398

Telephone number: 0123817871

E-mail address: akmar1972@yahoo.com

Tutors name: Associate Prof. Raijah Binti A. Rahim

Learning Centre: JOHOR BAHRU

JANUARY SEMESTER 2016

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 CONTENT PAGE

INTRODUCTION Page 2

OVERVIEW OF JOHNSONS THEORY Page 3 Page 5

HYPERTENSION IN ADULT PATIENTS Page 5 Page 7

WITH DIABETES

AN APPLICATION OF JOHNSONS Page 7 Page 11

BEHAVIORAL SYSTEM MODEL

HOW TO APPLY JOHNSON MODEL IN Page 11 Page 12

NURSING DIAGNOSIS

CONCLUSION Page 13

REFERENCE Page 14

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INTRODUCTION

To a certain degree, nursing science is a hybrid. It not only incorporates the basic
knowledge of various natural sciences, anatomy, physiology, biology, chemistry, and physics, but
it is also a very specific breed of the social sciences, those dealing with care, therapy and the so-
called helping profession. Perhaps, it is exactly this hybrid nature of the science of nursing which
makes it so susceptible to scientific fad and fancies, often at the expense of the patient in need of
care. This state of affairs is perhaps one of the single, most decisive factors which necessitated
reflection concerning the role of such conceptual frameworks, paradigms and models in
theorizing. All nursing models are articulated in theories or clusters of theories which claim to
describe actual states of affairs or provide some explanatory framework for puzzling phenomena
that nursing has to deal with. An overview of and categorization of nursing theorist reveals that
the four themes that have apparently received the most attention are need, systems, environment
and interaction (Torres 1986).
The emphasis on needs was particularly significant from the mid-1950s to the mid-1960s,
while systems gained momentum in the late 1960s and continues to be the strongest of the
themes. The interaction theme can be identified in each decade, whereas, the environmental
theme is given limited attention. An example of the latter type of theme is the approach of
Nightingale which focused on such things as air, light, noise and smell, while Rogers theory
addresses the closeness of mean-environment exchanging matter and energy. Thus Nightingaless
basic interest is the immediate environment, while Rogers more strongly addresses the totality of
the world around human ( Torres 1986). The themes which focus on systems and interaction
are two good examples of theories developed on the basis of metaphorical models.

OVERVIEW OF JOHNSONS THEORY

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 The professional practice of nursing is defined as the diagnosis and treatment of human
responses to actual or potential health problems (American Nurses Association, 1980). The
independent practice of nursing is based on the Johnson Behavioral System Model of Nursing.
This theoretical framework is utilized throughout in the healthcare facilities, forming the basis
for all major nursing decisions in respect to nursing diagnosis, care plans, discharge planning and
quality assurance. The Johnson model forms the basis of a primary nursing system. The quality
of professional nursing practice is widely recognized as excellent, an characterized by
humanistic care based on accountability, autonomi and authority. A debate which the profession
is currently undertaking concerns the applicability and usefulness of nursing models, and the
extent to which nursing theory can be said to exist. Some authors such as Luker (1988) have
suggested that nursing models may be pretentious theory.
Similar views have been expressed by Loughlin (1988) and Smoyak (1988), has argued
that there is no such thing as nursing theory, because there is no copyright or ownership of
theory. Smoyak (1988), suggests that, nursing like medicine, is an applied science that borrows
knowledge and insight generated by all disiplines, including nursing. While it is possible that
nursing models are no more than world salads or metaparadigms consisting of self evident
statements that have little direct relevance to nursing practice, the authors take the view that, it is
too early to make such a judgement, and that the ownership of the theory is a semantic debate.
What is important for the nursing profession to know is whether theory-based practice,
irrespective of whether it comes from insights generated by nursing or from other disciplines,
results in better care or improved health outcomes for patients.
The Johnson Behavioral System Model of Nursing is less well known than other models,
particularly those of Orem (1985), Roy (1981), Neuman (1989) and Peplau (1988). All this
models of nursing has its antecedents in systems theory and has a wide application in that it
identifies common patterns of behavior applicable to all persons regardless of factors such as age
and clinical setting. It was selected as the basis for nursing practice at health care facilities for
three primary reasons. Firstly, it focuses on observable behaviors of the patient with which
nursing is concerned. Second, it emphasizes the bio-psycho-socio-cultural factors which
influence behavior, thereby permitting application in all clinical settings. Lastly, the model
identifies universal patterns of behavior applicable to all individuals regardless of age, cultural

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differences or medical diagnosis. The Johnson model includes the following elements: the
individual is conceptualized as a living system in constant interaction with the environment;
specific system tasks are carried out by the individuals eight behavioral subsystems. These are
the ingestive, eliminative, affiliative, dependency, sexual, aggressive-protective, achievement
and restorative subsystems. Although each subsystem has a specific task, the individual is
viewed as a whole by virtue of the interdependence of each subsystem; balance is maintained
when there is an equal distribution of energy among the eight subsystems. Energy refers to the
subsystems ability to carry out its task adequately; environment is viewed as all regulatory
elements that influence the behavioral systems such as bio-physical, psychological and
developmental status, and socio-cultural, family an physical environmental factors. Examples
include internal regulators such as cardio-vascular functioning or external regulators such as,
family dynamics; observed patient behaviors associated with each of subsystems are the end
product of a complex interaction between bio-psycho-socio regulators specific to that individual,
as well as the influence of the immediate situational and environmental factors; the goal of
nursing is to create an environment that natures, protects and stimulates the behavioral sub
systems, so that the individuals system balance is maintained or restored. This could involve
helping individuals to rest, sleep or develop friendship relationships, depending on the subsystem
or the nature of malfunction.
Johnson has stated that, the development of theory of nursing of nursing is not as
important as the development of a conceptualization for nursing that provides direction for
practice, education and research. It is towards this end that, the theorist proposed a systems
model of the individual which serves as a basis for nursing actions. Nursing is identified by its
actions and goals and a person is described as a behavioral system. The other traditional
components of a nursing model, environment and helth, are not directly defined, but rather are
discussed in terms of their interaction with the behavioral system (Fitzpatrick & Whall, 1983).
The person is identified as a behavioral system made up of interrelated subsystems. The actions
or behavioral pattern of the total system are efforts to maintain a behavioral system balance,
while the environmental forces influence the system. Nursing is concerned with the person as a
total entity, which would indicate an involvement with all the subsystems of the behavioral
system. Health is not seen as a static process, but rather as a moving state of equilibrium which
occurs throughout the health change process. The interrelationship between person and

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environment consists of all factors which are not directly part of the individual behavioral
system. These factors act upon behavioral system, which responds is an effort to maintain
balance. Heath problems or lack of balance in the system are either structural or functional. They
arise from the system itself or from environmental factors. This matrix of terminology is now
utilized to: determine the major cause of instability within the system such as, breakdown in
internal regulatory or control mechanisms; and identify the souce of problems in the behavioral
system balance, which can lead to appropriate nursing actions.

HYPERTENSION IN ADULT PATIENTS WITH DIABETES

Hypertension is an extremely common comorbidity of diabetes, affecting 20% to 60% of

people with diabetes. Hypertension is also a major risk factor for cardiovascular events, such as
myocardial infarction and stroke, as well as for microvascular complications, such as retinopathy
and nephropathy. Cardiovascular disease is the most costly complication of diabetes and is the
cause of 80% of deaths in person with diabetes. However, until recently, not many research had
been done specifically in patients with diabetes and hypertension. Recent studies have
demonstrated the effectiveness of blood pressure treatment versus placebo in reducing
complication of diabetes, help to define the optimal of blood pressure control, and compared
treatment strategies based on different drug classes. The result of these studies support an
aggressive approach to the diagnosis and treatment of hypertension in patients with diabetes in
order to substantially reduce the incidence of both macrovascular and microvascular
complications.
Epidemiological studies and therapeutic tral have often used different criteria to define
hypertension in diabetic patients. Studies in the general population indicate an increased risk of
cardiovascular disease with an increase in the level of blood pressure. Thus, an increase in
diastolic or systolic 5 mmHg of blood pressure is associated with a concomitant increase of 20%
to 30% in cardiovascular disease. Studies in diabetic populations have shown a markedly higher
frequency of the progression of diabetic retinopathy when diastolic blood pressure is in excess of
70 mmHg. Most epidemiological studies have used a categorical definition of hypertension,
using levels of 160 mmHg for systolic and 90 mmHg for diastolic blood pressure. Based on the

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current evidence from clinical trials showing clinically significant benefits of treating diabetic
individuals to lower level of blood pressure, these values are considered too high to serve as a
threshold for the definition of hypertension in diabetic patients.
The prevalence of hypertension in the diabetic population is 1.5 to 3.0 times higher than
that of non diabetic age-matched groups. The timing and presentation of hypertension differs
between type I and type II diabetes. In type I diabetes, hypertension develops after several years
of the disease and usually reflects the development of diabetic nephropathy. It ultimately affects
about 30% of individuals with type I diabetes. In type II diabetes, hypertension may be present
at the time of diagnosis or even before the development of hyperglycemia. Several confounding
factors are present in type II diabetes that make the assessment of the prevalence of hypertension
attributable to diabetes difficult. Type II diabetic patients are older and have a greater degree of
adiposity than non diabetic patients. The prevalence of hypertension in Western populations
increases with age and degree of obesity. Thus, elevated blood pressure in these individuals may
represent the ageing or obesity in population. However, after adjusting for age and weight, the
prevalence of hypertension is still 1.5 times higher in diabetic groups. Approximately 20% to
60% of patients with type II diabetes will develop, depending on age, ethnicity, and obesity. In
some ethnic groups, diabetic nephropathy may be the primary determinant of hypertension in
type II diabetes. The clustering of hypertension, glucose intolerance or frank type II diabetes,
hyperlipidemia, central obesity, and insulin resistance has been documented in several
populations. The pathogenesis of this association is under active investigation. Extensive
epidemiological evidence indicates that diabetic individuals with hypertension have greatly
increased risks of cardiovascular disease, renal insufficiency, and diabetic retinopathy. The
relationship between diabetic neuropathy and arterial hypertension is less clear. However, some
epidemiological studies suggest that hypertension may be a contributory factors for this
condition as well. All patients with diabetes should have blood pressure measured at the time of
diagnosis or initial office evaluation and at each scheduled diabetes visit. Because of the high
cardiovascular risk associated with blood pressure 130/80 mmHg in patients with diabetes.
130/80 mmHg is considered to be cut point for defining hypertension, rather than 140/ 90
mmHg, as in the general population. Initial assessment of a hypertensive diabetic patient should
include a complete medical history with special emphasis on cardiovascular risk factors and the
presence of diabetes complications and other cardiovascular complications.

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AN APPLICATION OF JOHNSONS BEHAVIORAL SYSTEM MODEL

The Johnson Behavioral Systems Model for nursing views the human being as an open
behavioral system comprised of interactive and interdependent component (Derdiarian, 1983).
This Johnsons model can be applied to a 65 year old, single lady with Uncontrolled Diabetes
and Hypertension, and also can be use as a guide to detect any changes in behavior pattern of the
patient in relation to each of the subsystem.

Achievement
For this lady, 65 year old with uncontrolled diabetes and hypertension , are at increased
risk for cognitive impairment. Unrecognized cognitive impairment may interfere with patients
ability to implement lifestyle modifications and take medications as recommended by doctor.
Therefore, it is important that the doctor screen for cognitive impairment during the initial
evaluation period when visiting clinic and with any change in the patients clinical status,
particularly if increased difficulty with self-care and self-management is noted. A variety of
validated screening tools exist for assessing cognitive impairment. Nurse and patient caregiver
play an important roles and can be a valuable source of information as well. Involvement of
caregiver in diabetic education and management can be critical to the successful management of
the cognitively impaired the patient. Patient with uncontrolled diabetes and hypertension are at
risk for drug side effects and drug-drug and drug-disease interactions. Polypharmacy or multiple
drug therapy is a major problem for older patient with uncontrolled diabetes and hypertension,
who may require several medications to manage glycemia, hyperlipidemia, hypertension, and
other associated condition. In addition, drug therapy for uncontrolled diabetes and hypertension
and comorbid illness can be costly for this patient. Doctors should perform a careful review of
each medication currently being used by the patient during the initial visit to clinic and each
subsequent visit and document whether, the patient is taking each medication properly. All drugs
identified during the initial review and each new drug prescribed should have clear
documentation of the indication in the record, patient and her caregiver should should receive

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information describing the expected benefits, risk, and potential side effects of each medication.
The caregiver should make sure that the patient compliance to take all the medication herself.

Aggressive or protective
The patient at age 65 year old, single lady should have somebody to take care or stay with
her at home. Patient with multiple drug therapy and may be will have unrecognized cognitive
impairment may interfere and can be a risks for patient to fall especially at the toilet. Falls in
elderly patient are associated with high rates of morbidity, mortality, and functional decline.
Elderly patient with uncontrolled diabetes and hypertension are at increased risk for injurious
falls. Possible risk factors for injurious fall in elderly patient includes high rates of frailty and
functional disability, visual impairment, peripheral neuropathy,and hypoglycemia. Therefore, the
patient should be screened for their risk of falls and for opportunities to prevent their falling.
Pain also can cause patient fall at home. Patient are at risk for neuropathic pain, and those with
pain are often undertreated. Patient should be checked for persistent pain by using a targeted
history and physical examination. If there is evidence of persistent pain, further evaluation
should be performed, appropriate therapy should be offered by the doctors, and patient should be
monitored.

Dependency
Patient was a single lady and at 65 year old, patient will feel lonely and worried about her
chronic disease. Patients caregiver must stay with patient or the community or her neighbor
must always visit and see patients condition at home. If patient stay alone, patient are at risk for
depression, and presents with new-onset or recurrent depression. Medication should be evaluated
to determine whether any of them are associated with side effect of depression. If therapy is
initiated, targeted symptoms should be identified and documented in the record.

Affiliative

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 Patient with uncontrolled diabetes and hypertension, if appropriate, and family members
and caregiver should be given the following information about hypoglycemia and hyperglycemia
at diagnosis, with reassessment and reinforcement periodically as needed: precipitating factors;
prevention; symptoms and monitoring; treatment; and when to notify a member of the healthcare
team. The evidence shown that, multidisciplinary interventions that provided education on
medication compliance , monitoring, and recognizing hypoglycemia and hyperglycemia can
significantly improve glycemic control. Regular foot examinations permit identification of
diabetic neuropahy and foot lesions and may in turn prevent progression to ulcer and amputation,
but there are no data to support the optimal interval for evaluation. Most current
recommendations specify that the foot examination should be done at all nonurgent outpatients
visits. Patient should have a careful foot examination to check skin intergrity and to determine
whether there is bony deformity, loss of sensation, or decreased perfusion and more frequently if
there is evidence of any of these findings.

Eliminative
Older women are prone to have urinary incontinence due to ageing process and another
factors was side effect of multiple drug therapy for patient with uncontrolled diabetes and
hypertension. A targeted history and physical examination should be perform, focusing on
conditions associated with older age or chronic disease. Examples are polyuria (glycosuria),
neurogenic bladder, fecal impaction, prolapse, cystocele, atrophic vaginitis, vaginal candidiasis,
and urinary tract infection, which can cause or exacerbate urinary incontinence. Constipation can
cause eliminative disturbance among older patient, due to poor fluid intake, and side effects of
the drugs. Caregiver or family members must encourage patient to take a proper diet and increase
fluid intake to prevent dehydration.

Ingestive
Patient with uncontrolled diabetes and hypertension have special dietary management
that patient, caregiver and family members should compliance to reduce blood pressure and
reduce glucose level. Dietary management with moderate sodium restriction has been effective in
reducing bllod pressure in individuals with essential hypertension. Several controlled studies
have looked at the relationship between weight loss and blood pressure reduction. Weight

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reduction can reduce blood pressure independent of sodium intake and can also improve blood
glucose and lipid levels.

Restorative
Older women with uncontrolled diabetes and hypertension will experience sleep
disturbance at night, this is because of side effects of the drugs therapy and ageing process. Its
will cause lost of energy, loss of appetite and patient will feel tired, dizziness and may be will
end up with hypoglycemia. This can increase risk of fall when patient was alone. Caregiver play
the important roles and must advise patient to take proper diet and get enough sleep at night to
prevent the factors that can predisposing patient injured.

Sexual
Patient is the single lady and at this age, patient will feel lonely, sensitive and deny to
herself that she have a chronic disease and feel that patient have burden family members who
should take care of patient. Unrecognized cognitive impairment may interfere with patients
ability to implement lifestyle modifications and therefore, patient will get herself social isolation.
Patients neighbours and community must always go to visit her at home and talk to patient and
get patient to involve in certain activity that suitable for patient.

The goal of nursing actions is to maintain or restore a personss behavioral system

balance and stability or to help a person achieve a more optimal level of functioning or balance
with environmental interactions, where possible or desirable. The relationship between the two
major units of this theoretical model, the behavioral system of person and nursing, can be stated
as follows (Fitzpatrick & Whall, 1983): A state of imbalance or instability in the behavioral
system results in the need for nursing actions; and appropriate nursing actions result in the
maintenance or restoration of behavioral system balance and stability. This very brief exposition
of the basic tenets and assumptions of this theory will have to suffice. It illustrates the manner in
which a central metaphor is built into the core concept of a theory an is then articulated with
respect to the phenomena that is claims to describe and explain. However, this approach does call
for a critical comment. Models have a tendency to mislead us exactly because they are models

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and not reality in the full sense of the word. Fitzpatrick & Whalls (1983) critical comments on
this theory are therefore timely and very appropriate. They argue and I agree with them that
the moment one defines nursing is systems theory terms an important consideration is
overlooked such as, the significant role of the individual in the process of preventing and coping
with disturbances in patient life and initiating change or growth through responsible decisions.
Systems theory is a very helpful theoretical tool by means of which to understand human
behavior and action, but is a very limited theoretical tool which ought to be recognized as such.
This comment is not only applicable to systems theory but to all theoretical models.

HOW TO APPLY JOHNSON MODELS IN NURSING DIAGNOSIS

Nursing diagnosis refer to the naming of patients health problems which are of concern
to nurses, and which are responsive to nursing intervention. It refers to the phenomena to which
the skills of nurses must be applied in order to bring about favourable health outcomes to their
patient. One of the purported advantages of the Johnson model is that it makes a contribution to
the development of a nursing diagnostic system. Dee & Randell (1989) suggest that it delineates
nursing contribution to care.
Making a nursing diagnosis using the Johnson model involves several distinct phase,
each requiring an increasingly greater level of nursing knowledge, experience and clinical skills.
The route consists of the following steps. The first involves the identification of malfunction in
any of the subsystem, placing observed behaviors into the correct subsystem, for example,
sleeping during the daytime and or periodic awakening during night indicates a problem with
restorative subsystem. At this point, it is simply a restorative system problem. The second step is
to determine from the behavioral data the effectiveness of each subsystem, that is, to ask how
effective the subsystem is in achieving its purpose. The third step involves the search for
environmental regulators that are impacting upon any of the patients subsystems. At this stage,
nursing diagnoses are based on the demonstration of uneffective behavior within one or more
subsystems, and the relationship of these behaviors to the regulators. Finally, a complete nursing
diagnosis is made. This involves making a statement which describes the nature of the subsystem
problem, particularly in respect to the relationship of one subsystem behavior to another.
Currently, nurses are working with several diagnostic labels which describe the nature of the

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subsystem problem, these are insufficiency, discrepancy, dominance and incompatibility of the
subsystem. If subsystem is disturbed, it will always be possible to make a simple subsystem
diagnosis such as insufficiency or discrepancy of the ingensive subsystem. Less experienced
nurses are likely to generate frequent single subsystem diagnoses. However, nurses need to ask
themselves if the behavior in one subsystem is related in any way to inefficient behavior in
another subsystem, for example, dominance of the aggressive or protective subsystem over the
affiliative subsystem that is, a two system diagnosis. If the answer is yes, there is a need to
determine whether the observed behavior is better explained, understood and responded to it is
described in a diagnosis which pairs it with another subsystem.
An interesting feature of the nursing approach is the excistence of standardized nursing
care plans. These care plans, which were individualized when applied to specific patients, had
their origins in the literature and inductive theory resulting from clinical practice at healthcare
facilities. Phenomena addressed by existing standardized care plans included stereotypic
behavior, self-injurious behavior, bizarre speech, clinging or over-attention to adults, stealing ,
smearing faces, inappropriate international urinating , poor self-esteem, inability to make friends,
and so on. Many of the interventions appeared to stem from nbehavioral therapy methodology,
and including limit setting, time out, ignoring and positive or negative reinforcement for
maladaptive behaviors. Thus, nurses were using the Johnson model to make a nursing diagnosis.
and other theoretical statements to identify appropriate interventions. This supported Smoyaks
(1988) view that nursing is an applied rather than a pure science. Examination of the clinical
application of the Johnson model indicates that it does not enable nurses to define or prescribe
appropriate nursing interventions relating to a specific nursing diagnosis.

CONCLUSION

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 The utilization of Johnsons approach to assess patients behavioral systems demonstrated
that it is an effective way to determining the many factors that impinge on an individuals ability
to cope with and adapt to change. The Johnson model can also be used successfully in a group
situation such as a support group for Alzheimers patients, Cancers patients, where problem
solving and making choices to adapt to lifestyle changes are a definite requirement. For
professional nurses in clinical practice, the application of models for assessment of patients will
allow them to categorize the phenomena the observe and to gain insight into the clinical
situations with which they deal. A major issue facing the nursing profession relating to the
clinical applicability of nursing theories concerns the extent to which deductive theories, such as
Johnson model, are preferable to inductively developed theories of nursing which include the
developed of a diagnostic taxonomy produced from the expressed concerns of patients, and
which nurses observe during nurse-patient interactions. Thus, such a diagnostic taxonomy would
developed from expreesed and observed needs rather than cause the nurse to fit clinical data into
global theoretical frameworks which may have a limited actual clinical basis. Peplau, cited by
Reynolds & Cormack (1990), suggests that clinical data derived from observations of human
responses to health treats have explanatory powers and provide the basis for the development and
testing of nrsing theory.

4275 Words.

REFERENCE

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Arauz-Pacheco, Parrott, and Raskin, (2002). The treatment of Hypertension in Adult Patients
with Diabetes. Diabetes Care Journal, vol 25, no 1 (Online) Available:
http://care.diabetesjournals.org/content/25/suppl_1/s71.full (2016 Mac 24).

AGS (2003). Guidelines for Improving the Care of the Older Person with Diabetes Mellitus.
America Geriatricks Society (Online) Available:
https://www.rand.org/content/dam/rand/www/external/labor/aging/rsi/rsi_papers/2004_mangione
.pdf (2016 Mac 24)

Botha. M.E (1989). Theory development in perspective: the role of conceptual frameworks and
model in theory development. Journal of Advanced Nursing, vol14, 49-55. (Online) Available:
http://www.worldlibrary.org/articles/conceptual_framework (2016 Mac 24).

Reynold W& Cormack D.F.S., (1991). An evaluation of the Johnson Behavioral System Model
of Nursing. Journal of Advance Nursing, vol 16, 1122-1130. (Online) Available:
http://www.ncbi.nlm.nih.gov/pubmed/1939926 (2016 Mac 22).

Sheila E. Smith Fruehwrith (1989). An Application of Johnsons Behavioral Model: A Case

Study. Journal of Community Health Nursing, vol 6(2), 61-71. (Online) Available:
https://www.researchgate.net/publication/20431937_An_Application_of_Johnson's_Behavioral_
Model_A_Case_Study (2016 Mac 22).

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