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The Johnson Behavioral Systems Model as a framework for patient outcome evaluation
J o u r n a l o f the American P s y c h i a t r i c N u r s e s Association
The Johnson Behavioral Systems Model as a Framework for Patient Outcome Evaluation Elizabeth C. Poster, RN, PhD, Vivien Dee, RN, DNSc, FAAN,and Brooke P. Randell, RN, DNSc BACKGROUNI~Although there is a g r e a t deal o f interest in the outcome o f the nursing care o f p s y c h i a t r i c patients, there is little empirical research a b o u t the effectiveness o f nursing care. METHODX"This s t u d y e v a l u a t e d the m e d i c a l r e c o r d d o c u m e n t a t i o n by n u r s e s a s a n i m p o r t a m d a t a b a s e (N=380 p a t i e n t s ) . The p r e d i c t e d p a t i e n t o u t c o m e i n s t r u m e n t d e v e l o p e d by the a u t h o r s w a s u s e d to collect the d a t a related to p a t i e n t d e m o g r a p h i c s , acuity, n u r s i n g diagnosis, short- a n d long-term goals, a n d n u r s i n g interventions. The J o h n s o n B e h a v i o r a l S y s t e m M o d e l w a s the n u r s i n g c o n c e p t u a l f r a m e w o r k usecL FINDINGX" Overall 80% o f the p r e d i c t e d p a t i e n t o u t c o m e s w e r e a c h i e v e d by the t i m e o f discharge, w i t h i n c r e a s e d length o f s t a y being a f a c t o r in i n c r e a s i n g the l i k e l i h o o d o f a c h i e v e m e n t o f goals. A p o s i t i v e link w a s f o u n d b e t w e e n a c h i e v e m e n t o f o u t c o m e s a t t i m e o f d i s c h a r g e a n d n u r s i n g interventions. A n u r s i n g theoretical f r a m e w o r k m a d e it p o s s i b l e to p r e s c r i b e n u r s i n g care a s a distinction f r o m m e d i c a l care. CONCLUSION."This s t u d y s h o w e d the i m p o r t a n c e o f the n u r s i n g d a t a b a s e in the m e d i c a l r e c o r d s a n d the effectiveness o f n u r s i n g interventions on p r e d i c t e d p a t i e n t o u t c o m e s a c h i e v e d by the t i m e o f discharge. ( J A m P s y c h i a t r N u r s e s A s s o c [199 7]. 3, 73-80.)
Elizabeth C. Poster is a Dean and Professor in the School of Nursing at the University of Texas in Arlington and wasformerly the Director of Nursing Research and Education at the UCLANeuropsychiatric Institute and Hospital. Vivien Dee is Director of Nursing and Associate Hospital Director at the UCLANeuropsychiatric Institute and Hospital. Brooke P. Randell is a Senior Post-Doctoral Fellow in the School of Nursing at the University of Washington and was formerly Director of Nursing Practice at the UCLA Neuropsychiatric Institute and Hospital. Supported by the UCLANeuropsychiatric Hospital. The Predicted Patient Outcome Instrument is availablefrom the authors upon request. Reprint requests.. Elizabeth C. Poster, RN, PhD, School of Nursing, University of Texas, Arlington, P.O. Box 29407, Arlington, TX 76019. Copyright © 199 7by the American Psychiatric Nurses Association. 10 78-3903/9 7/$5.00 + 066/1/82494 June i 9 9 7
approximately 58,000 psychiatric nurses in the United States are a major force in the psychiatric health care delivery system. These nurses must b e able to demonstrate what it is they do and w h e t h e r what they do makes a difference in patient outcomes. Nurses systematically collect and record critical patient information. The vast majority of these data are u s e d for d o c u m e n t a t i o n of the process of care and are not fully u s e d as a rich source of nursing knowledge and a measure of the impact of the care on patient outcomes. Although there is a growing interest in measuring patient outcomes directly influenced by nursing interventions (Bond & Thomas, 1991; Higgins, McCaughan, Griffins, & Cart-Hill, 1992, EIinshaw, 1992; Marek, 1989; Poster, 1991), very little outcome research is available in the psychiatric nursing literature. In a review of the major psychiatric nursing journals published between T h e
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1989 and 1994, Merwin (1994) found only a small by patterned, repetitive, and purposeful ways of benumber of articles that focused on the outcomes of having and reflect the behavior system's relationship psychiatric nursing practice. with b o t h the internal and external environment. Previously, Flaskerud (1987) conducted a compreThe ingestive subsystem refers to the m a n n e r in hensive review of the nursing literature to describe which the behavioral system meets the need for food the influence of psychiand fluid and generally atric nursing intervenis used to describe the tions o n p a t i e n t outw a y in which ingestion The nursing care provided to comes. Only four studies is managed (e.g., when, patients is directed at fostering ( B e a r d & Scott, 1975; w h e r e , and h o w the inBird, Marks, & Lindsey, dividual eats and takes efficient and effective behavior 1979; Lieb, Underwood, fluid). The eliminative within the context of the combined & Glick, 1976; Slavinsky s u b s y s t e m r e f e r s tO environments. & Krauss, 1982) actually the behavioral system's linked nursing intervenmanagement of biologic tions to patient outcomes. None of these studies used waste. The d e p e n d e n c y subsystem is descriptive of a nursing model or a theoretic framework, nor was the manner in which individuals manage their relanursing documentation in the medical record used as tionships with the environment in an effort to meet a clinical database. the needs for attention, recognition, and approval. The Johnson Behavioral Systems Model (Johnson The a c h i e v e m e n t subsystem reflects the d e g r e e to Model) was used to structure the assessment, planwhich the individual achieves mastery of the self ning, and implementation of nursing care at the Uniwithin the e n v i r o n m e n t and refers to those behavversity of California Los Angeles Neuropsychiatric iors e n g a g e d in for p u r p o s e s of self-care, p r o b l e m Hospital for 14 years. With a conceptual structure in solving, d e c i s i o n m a k i n g , a n d a s s e r t i o n . T h e place, it was possible to generate a clinical database affiliative subsystem is the part of the behavioral for a patient outcome evaluation study with nursing system that mediates the individual's connection to documentation in the medical record. other individuals within the environment. The aggresThe degree to which behavior is seen as more efsive-protective subsystem represents those behaviors fective or efficient must be evaluated to support that engaged in for the purpose of keeping the individual the nursing care of the hospitalized psychiatric patient safe and may or may not include overtly aggressive does indeed make a difference in terms of outcomes. behaviors. The sexual subsystem refers to those beThe purpose of this study was to evaluate the effechaviors that relate to procreation and reflect gender tiveness of nursing care within a theoretic context as identification. And finally, the restorative subsystem is measured by patient outcomes. responsible for mediating the balance between rest and activity (Auger, 1976).
BACKGROUND According to Johnson (1980), the person w h o is i11, not the illness, should remain the focus of nursing care. The Johnson Model operationalizes the individual as a behavioral system, which is c o m p o s e d of eight subsystems of behavior within the context of an internal and external environment. The internal environment includes the biophysical and psychologic aspects of the person, whereas the external environment refers to the sociocultural and physical worlds within which the person resides (Auger & Dee, 1983; Dee & Auger 1983). The nursing care provided to patients is directed at fostering efficient and effective behavior within the context of the combined environments. The eight behavioral subsystems are characterized 74
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Model-based Assessment The nursing assessment of the psychiatric patient from the Johnson Model perspective involves observations of behaviors in all eight subsystems and a determination of the d e g r e e to which each subsystem is functioning effectively and efficiently. Individuals are usually admitted to an inpatient unit b e c a u s e their behaviors are inefficient or ineffective. Frequently, these patients are unable to k e e p themselves safe. T h e y are e x p e r i e n c i n g severe interpersonal p r o b l e m s , seek a t t e n t i o n i n a p p r o p r i a t e l y , cannot provide for their o w n self-care, are not eating or sleeping properly, a n d / o r cannot control their activity level. Vol. 3, No. 3
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Table 1. Criteria for Rating Overall Behavior Category and Level of Nursing Intervention Required Categories o f Patient Behaviors Category 1 Patient demonstrates behaviors/actions that are effective and compatible in all eight subsystems, therefore achieving system balance. Energy may be unequally distributed among the eight subsystems but not to the detriment of any one subsystem or to the system as a whole. System balance denotes health.
Levels o f Nursing Interventions Level 1 Category 1 patients demonstrate system baIance; therefore they are able to protect, nurture, and simulate all behavioral subsystems. The patient requ!res a minimum amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category I patient is the provision of a nurturing and stimulating environment within a group context.
Category 2 Patient demonstrates behavior/actions that are inconsistently effective in one or more subsystems resulting in short-term incompatibility among the subsystems and the potential for system imbalance. Energy may be temporarily distributed unequally among the subsystems creating ineffective subsystem functioning but not to the detriment of the system as a whole. Potential for system imbalance results in the potential for health deviation.
Level 2 Category 2 patients demonstrate a potential for system imbalance; therefore they are not able to consistently protect, nurture, and stimulate all behavioral subsystems. The patient requires a moderate amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category 2 patient is the provision of a nurturing, stimulating, and protective environment within a group context.
Category 3 Patient demonstrates behaviors/actions that are incompatible within one or more subsystems resulting in system imbalance and incompatibility among subsystems. Energy is unequally distributed among the eight subsystems and frequently results in the detriment of the system as a whole. System imbalance results in illness.
Level 3 Category 3 patients demonstrate system imbalance; therefore they are not able to protect, nurture, and stimulate all behavioral subsystems. The patient requires an intensive amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category 3 patient is the provision of a nurturing, stimulating, and protective environment within a small group.
Category 4 Patient demonstrates behaviors/actions that are incompatible within one or more subsystems, resulting in serious system imbalance. Energy is unequally distributed among the subsystems. This unequal distribution of energy is of acute intensity, long duration, and/or high frequency and results in serious detriment to the system as a whole. Severe system imbalance results in critical illness.
Level 4 Category 4 patients demonstrate serious system imbalance; therefore they are not able to protect, nurture, and stimulate all behavioral subsystems. The patient requires continuous one-to-one supervision and nursing care. The primary goal of nursing care for the Category 4 patient is the provision of a nurturing and protective environment on an individual level.
Ineffective and inefficient behaviors must be analyzed if they are to have meaning. Because o b s e r v e d b e h a v i o r s can h a v e m a n y m e a n i n g s , the a c c u r a c y of a b e h a v i o r a l a s s e s s m e n t m u s t b e b a s e d on the ability of the o b s e r v e r to identify the goal of the b e h a v i o r o b s e r v e d . For e x a m p l e , eating b e h a v i o r has an obvious ingestive function; however, in m a n y situations eating b e h a v i o r is affiliative. The goal of the b e h a v i o r in a given situation g o v e r n s h o w a b e h a v i o r is c a t e g o r i z e d a n d h o w the relationship b e t w e e n the person and the environment is ultimately understood. For the nursing assessment to be comprehensive, it must include information on the biophysical, psychologic, social-cultural, and ecologic factors influencing a patient's behavior.
Behavior and its efficacy have different meanings and must be responded to differently based on its context. For example, patient A w h o demonstrates unsafe behavior in response to internal stimuli telling him to harm himself is very different from patient B w h o demonstrates unsafe behavior in response to a recent social change such as a job loss or the b r e a k u p of a relationship. Patient A is responding to the internal environment by cutting himself (aggressive-protective subsystem) in an attempt to pacify the voices. Patient B is responding to the external environment b y cutting himself as a suicidal attempt (aggressive-protective subsystem). Although both behaviors are similar, the nursing interventions will differ in these two situations.
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Table 2. Interrater Reliability Among Subscales of the Predicted Patient Outcome Instrument (n = 51 records) Subscales
Interrater reliability
Demographics Nursing diagnoses, subsystems, regulators Long term goals/discharge outcomes met/not met Consistencybetween nursing diagnoses and predicted outcomes Additional subsystems targeted Frequency of short term goals/predicted patient outcomesmet/notmet by discharge Expected improvementrelated to nursing interventions Subsystems targeted by nursing interventions Regulators targeted by interventions Behavioral categoryscores
.94 .99 .84 .74 .92 .76 .90 .89 .87 .99
Acuity Ratings of Behaviors A patient classification system based on the Johnson Model has been used effectively in the neuropsychiatric hospital for more than a decade (Auger & Dee, 1983; Dee, 1986, 1990). Behavioral data are gathered to determine the effectiveness of each subsystem. Each subsystem is assigned a category score ranging from 1 to 4 (1 = effective; 2 = inconsistently effective; 3 = ineffective; 4 = critically ineffective) (Table 1). An overall behavioral category score is determined for the entire system ranging from 1 to 4 (1 = health; 2 = potential for health deviation; 3 = illness; and 4 = critical illness) based on the degree of effectiveness or ineffectiveness of each behavioral subsystem. These scores are computed on admission, discharge, and interim points during hospitalization. (Nurses are trained in the model and scoring system; each subsystem score stands alone as does the overall score.) Priorities for nursing interventions are established based on the nursing diagnoses that are formulated for those subsystems and pose the greatest threat to the overall behavioral system. In addition, nursing interventions are designed to achieve specific behavioral outcomes for selectively targeted subsystems. These nursing interventions focus not only on increasing behavioral effectiveness and efficiency of the subsystems but also the effectiveness and efficiency of the internal and external environment as they affect the subsystems. With a patient classification system in place, it is possible to review the nursing documentation in an effort to answer specific questions regarding nursing's contribution to patient outcomes (i.e., "What is the 76
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impact of nursing care on the patient's behavior?"). A decrease in behavioral score in a particular subsystem from admission to discharge in a subsystem specifically targeted by nursing intervention would suggest that nursing care was responsible in part for increasing behavioral effectiveness and efficiency (Table 1).
METHODS Setting This study was conducted at the University of California Los Angeles Neuropsychiatric Hospital in Los Angeles, California. The Neuropsychiatric Hospital provides c o m p r e h e n s i v e multidisciplinary inpatient services to child, adolescent, adult, and geriatric patients. The primary psychiatric diagnoses of the patient population across all units are: major depression, psychosis, borderline personality disorder, attention deficit disorder, bipolar disorder, and anorexia nervosa. At the time of data collection, the average length of stay varied by the type of service: adult, 12.4 days; geriatric, 11.2 days; child, 26 days; and adolescent, 17.6 days.
Measures The Predicted Patient Outcome Instrument was developed to collect data documented in the medical record on patient demographics, acuity ratings of patient behaviors, nursing diagnoses, predicted outcomes/shortand long-term goals, and nursing interventions (Poster & Randell, 1992). The instrument is unique in the following ways: (a) The items that are included are theorydriven, and the language is reflective of the Johnson Model; (b) The terminology provides consistency and links the problem statement to nursing interventions and patient outcomes, making comparisons across patient populations possible; (c) It focuses on the appropriateness of theory-based nursing diagnoses, information, and specific patient outcomes; and (d) It measures changes in behavior.
Procedure Data on 190 adult/geriatric and 190 child/adolescent patients discharged over the same 6-month period were included in the study. A retrospective review of the 380 medical records was conducted by six members of the Nursing Quality Assurance Committee, the Director of Nursing Practice, the Director of Nursing Research and Education, and the Director of Nursing. The group met for five 8-hour sessions to gather and Vol. 3, No. 3
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Table 3. Percentage Improvement by Subsystem: Admission to Discharge Ingestive Eliminative Dependency Achievement AfflHative Patients
Aggressiveprotective
Sexual Restorative Overall
227
184
324
306
306
300
193
241
253
57.3
54.9
34.6
41.8
38.2
56.7
52.3
58.3
53.0
(no.) Improved
(%)
score the data. The medical records were randomly selected by date of admission to comprise an equal number of patients in the child and adult services. Data were collected from the five sections of the patients' medical records: Nursing Assessment, Nursing Care Plan, Nursing Progress Notes, Nursing Shift Report, and Nursing Discharge Summary. Training sessions for the data collectors were held before the study. Interrater reliability was established in a review of 36 patient demographic forms and 53 nursing care plans. The Cronbach alpha for the total scale was .88 and for the subscales ranged from .99 to .74 (Table 2). Predicted patient outcomes (PPOs) were defined as positive short-term goals, which are observable patient behaviors described in measurable terms. Examples of PPOs that were expected by discharge included: • Aggressive-protective subsystem (e.g., Adam will earn 75% of contract points for safe behavior; Patient will be able to come to staff and talk about suicidal thought by 1/5/94) • Ingestive subsystem (e.g., Patient will continue to gain 2 pounds per week from 12/27/93 through 1/ 9/94) • Achievement Subsystem (e.g., Lisa will be able to attend two meetings every day for at least 15 minutes; Patient will be able to verbally state techniques for managing side effects of medications 100% of the time by 1/10/94)
FINDINGS Documentation Of the 2427 PPOs in the 380 medical records, 732 nursing care plans (some patients had several care plans in their medical records) identified major areas of ineffective patient behaviors in the aggressive-protective (n = 348) and dependency subsystems (n = 241). In contrast, the ingestive (n = 42) and sexual subsystems (n = 4) were infrequently the patient's primary problematic behavior. There were an average of 6.4 PPOs per patient. Eighty percent (n = 1619) were
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Table 4. Percentage Improvement from Admission to Discharge of Patients with Behavioral Category Rating of 4 at Admission Subsystem
n
Aggressive-protective Dependency Affiliative Achievement
73 38 24 24
Percentage Lowered Same 85 79 75 75
15 21 25 25
achieved by discharge. Sixty-three percent of the patients (n = 238) had a length of stay less than 30 days. Although overall 80% of the PPOs were achieved, the percent of goals met increased from 33% for patients with a length of stay of 1 or 2 weeks to 44% for a length of stay of 3 weeks to 50% to 55% for lengths of stay over 3 weeks.
Acuity On admission, most (82%, n = 311) of the patients were rated at least an overall behavioral score of 3 on a 4-point scale. The subsystems having the greatest impact on the patient's overall acuity scores were the dependency (64°/6, n = 243), affiliative (59%, n = 224), achievement (57%, n = 216), and aggressive-protective (55%, n = 209). Although patients displayed inefficient behaviors in numerous subsystems, nursing care plans specifically "targeted" an average of two to three behaviors requiring immediate individual intervention beyond that provided for all patients as part of the milieu program. Problem behaviors in nontargeted subsystems were addressed by standard milieu intervention and were not specifically mentioned in the nursing care plans. There was greater improvement in subsystem scores for the achievement and the aggressive-protective subsystems when the nursing care plan specifically targeted those subsystems. The dependency subsystem improved approximately at the same rate whether or not the subsystem was targeted. The affiliative subsystem, howPoster, Dee, & Randell
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Table 5. Subsystem Improvement of 60% or Better By Psychiatric Diagnosis Psychiatric diagnosis
Subsystem improved
Depression
Ingestive Eliminative Aggressive-Protective Ingestive Eliminative Restorative Ingestive Eliminative Sexual Restorative
Anxiety disorder
Bipolar manic
ever, showed greater improvement when the subsystem was not addressed by the nursing care plan. The geriatric population also reflected a similar pattern with substantial improvement w h e n the achievement subsystem was targeted but no difference w h e n the aggressive-protective subsystem was targeted. Eighty-six percent of the PPOs identified in the nursing care plans were achieved by patients who were admitted with a rating of 4 in any of the eight subsystems. In addition, 79% of the PPOs were achieved by those patients admitted with behavioral subsystem scores of 2 or 3. Also, 53% of the patients with an overall behavioral category score of 2 or 3 at admission showed improvement at discharge. All patients admitted with an overall behavioral category score of 4 at admission (n = 16) improved. The greatest i m p r o v e m e n t w a s n o t e d in the restorative (58%, n = 241), ingestive (57%, n = 227), a g g r e s s i v e - p r o t e c t i v e (57%, n = 300), and eliminative (55%, n = 184) subsystems (Table 3). At discharge 43% of all patients had an overall b e h a v ioral score of 3, and an additional 45% had an overall behavior score of 2. Behaviors that improved most during hospitalization w e r e ingestive, eliminative, aggressive-protective, restorative, and sexual. The only s u b s y s t e m that did not i m p r o v e significantly by discharge was the achievement subsystem for the geriatric and child patients. The most acutely ill patients on admission had varied psychiatric diagnoses (Table 4). Forty-one percent of the sample (n = 159) had a lower overall behavioral category rating at discharge. Forty-one percent of the sample (n = 159) had a rating of 4 on admission in at least one subsystem (Table 5). The behavioral category score showed improvements in 75% to 85% of these subsystems at the time 78
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of discharge, with the most improvement in the aggressive-protective subsystem. PPOs were not significantly related to level of psychosocial stressors as measured by GAF scores on axis 5 (American Psychiatric Association, 1994). Even for those patients with extreme and catastrophic stressors (n = 38), 84% of the PPOs were met at discharge.
DISCUSSION Documentation The mission of the hospital's department of nursing is to provide exemplary patient care based on a conceptual framework, which guides the professional practice of nursing. One of the current problems in demonstrating nursing effectiveness is lack of "nursing sensitive" patient outcome measures (Hinshaw, 1992, p. 10). The PPOs in this study were directly linked to nursing interventions as separate from the interventions of other members of the multidisciplinary team as discussed in the nursing care plan. Having a nursing theoretic framework in place made it possible for nurses to prescribe nursing care, which focused on their distinct contribution to the patient's overall care. This study demonstrated that nursing interventions are effective in achieving positive outcomes of hospitalized psychiatric patients. This finding supports the belief that psychiatric patients benefit from a therapeutic environment that is structured to meet their needs and support achievement of behavioral goals. This is especially so for most acutely ill patients admitted to inpatient settings because they are exhibiting aggressive-protective behavior and are a danger to themselves or others. The influence of length of stay on PPOs in the achievement subsystem may attest to the nature of
Nursing care during relatively short hospitalizations increases patients' abilities to keep themselves safe and meet their basic needs. these behaviors. Achievement behaviors such as mastery of self-help/independent living, problem solving, and decision making include cognitive tasks, which are complex in nature and not amenable to rapid change. Vol. 3, No. 3
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Acuity The frequency of the patient problems related to the aggressive-protective subsystem and identified in the nursing care plan clearly demonstrated the nature of the patient's behaviors requiring immediate and close attention to safety. These behaviors are consistent with
This study has illustrated the importance of the nursing database in the medical record. a major criterion for hospital admission, that is, patients' inabilities to maintain their own safety in the community. The patients demonstrating the most ineffective behaviors (category 4), either overall or in specific subsystems, indicated the most improvement. Standard nursing interventions on each unit, which reflect the milieu program, are provided to all patients. The therapeutic milieu, which offers containment, support, involvement, validation, and structure, may account for the striking improvement in all age groups (Gunderson, 1978). Improvement in nontargeted subsystems cannot be attributed to an absence of intervention but to a milieu program on all units that ensures that patients attend meals, receive adequate nutrition, and experience assistance in modifying inappropriate mealtime behaviors. For example, only in situations where ingestive behavior is extremely ineffective (e.g., refusal to eat resulting in severe weight loss) is this subsystem targeted for immediate individual attention. It is clear that nursing care has the greatest impact on patients' safety, sleep, eliminative, and eating behaviors. Nursing care during relatively short hospitalizations increases patients' abilities to keep themselves safe and meet their basic needs. The behaviors that require more long-term intervention such as socialization (affiliative) skills, dependency issues, and achievement behaviors may not show significant improvement over the course of a short inpatient hospitalization. Although these more complex behaviors were most frequently targeted in nursing care plans, the 4-point scale did not have sufficient variability to capture the subtle changes in these behaviors, which were reflected in narrative charting. Patients on the child and geriatric units did not have significant positive changes in the achievement,
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affiliative, and dependency subsystems. For example, on the child unit (n = 56) evaluation of dependency behaviors showed that 3 patients became worse, 40 showed no change, and 13 improved. However, more than four times as many patients improved as became worse, thus suggesting that this finding is not likely due to chance (p = .01). Although improvement is a desired outcome, the fact that severely disturbed patients maintained their level of functioning during hospitalization might suggest that nursing intervention prevented further deterioration. Ineffective behaviors in the dependency subsystem require not only nursing intervention during hospitalization but also longterm approaches such as parent effectiveness training. This finding is consistent with a previous study demonstrating the need for intervention after discharge in adolescent patients' achievement and dependency behaviors (Poster & Beliz, 1992). The achievement of behavioral goals documented as a consequence of the nursing interventions reflect realistic expectations of gains that are possible during an inpatient length of stay. Although psychosocial stressors are a factor in the patient's need for inpatient hospitalization, these stressors may have a less direct influence on patient behavior when the patient is no longer in the stressful environment. For example, the adolescent who was sexually abused and suicidal at the time of admission can reach the goal of talking with staff about suicidal thoughts within 3 days of admission.
CONCLUSION This study was conducted with the medical record documentation of nurses. There may be incongruities between patient outcomes as defined by caregivers and the patients themselves. To further strengthen the measurement of patient outcomes, it is important to include the patient's perspective. This study has illustrated the importance of the nursing database in the medical record. The qualitative and quantitative documentation provided a rich source, which could be analyzed and used to demonstrate the effectiveness of nursing care. The authors stressed the importance of maintaining the nursing care plan or similar documents to permit a vehicle by which nurses prescribe and document their distinct contributions to the care of the patient. Without a specific part of the medical record that includes the nurses' prescription for interventions and a method for evaluation, the blurring of the professional roles will increase in the multidisciplinary-focused psychiPoster, Dee, & Randell
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atric setting. P r o g r e s s i v e limitations o f t h e p r a c t i c e o f nursing by hospital administrators and nonnursing h e a l t h c a r e p r o f e s s i o n a l s a r e a l r e a d y in e v i d e n c e . T h e u s e o f a t h e o r e t i c f r a m e w o r k , in this c a s e t h e Johnson Model, provided a nursing department with t h e ability to g e n e r a t e a c o n c e p t u a l l y s o u n d p a t i e n t o u t c o m e e v a l u a t i o n study. T h e a u t h o r s s t r o n g l y a d v o c a t e t h e u s e o f a n u r s i n g t h e o r e t i c f r a m e w o r k to d e scribe, p r e d i c t , a n d structure clinical p h e n o m e n a to achieve and measure positive patient outcomes.
The authors thank thefollowing nursesf o r their involvement as data collectors: Joann Rigali, Joyce Reinholdt, Joanne Clendenning, Karen Kay, Pam Koller, Jan Halliday, a n d Thelma Saddul.
REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (p. 32). Washington, DC: Author. Auger, J. (1976). Behavioral systems in nursing. Inglewood Cliffs, NJ: Prentice Hall. Auger, J., & Dee, V. (1983). A patient classification system based on the behavioral systems model of nursing, Part 1. Journal of Nursing Administration, 14(4), 38-43. Beard, M., & Scott, P. (1975). The efficacy of group therapy by nurses for hospitalized patients, Nursing Research, 24, 120-125. Bird, J., Marks, I., & Lindley, P. (1979). Nurse therapists in psychiatry: Developments, controversies and implications. BritishJourhal of Psychiatry, 135, 321-326. Bond, S., & Thomas, L. S. (1991). Issues in measuring outcomes of nursing. Journal of Advanced Nursing, 16, 1492-1502. Dee, V. (1986). Validation of a patient classification instrument for psycbiamc patients based on the Johnson Model for Nursing. Unpublished doctoral dissertation, University of California, San Francisco, CA. Dee, V. (1990). Implementation of the Johnson Model: One hospital's experience. In M. Parker (Ed.), Nursing theory in practice. New York: National League for Nursing.
Dee, V., & Auger, J. (1983). A patient classification system based on the behavioral systems model of nursing, Part II.Journal of Nursing Administration, 13(5), 18-23. Flaskerud, J. (1987). Evaluation of the impact of psychiatric/mental health nursing through research. In L. Birckhead (Ed.), Psychiatric~mental health nursing (pp. 717-731). New York: Lippincott. Gunderson, J. G. (1978). Defining the therapeutic processes in psychiatric milieus. Psychiatry, 41, 327-335. Higgins, M., McCaughan, D., Griffins, M., & Cart-Hill, R., (1992). Assessing the outcomes of nursing care. Journal of Advanced Nursing, 17, 561-568. Hinshaw, A. S. (1992). Patient outcomes research: Examining the effectiveness of nursing practice. Proceeding of the State of the Science Conference (p. 10). Washington, DC: US Department of Health and Human Services. Johnson, D. (1980). The behavioral system model of nursing. In J. Riehl & C. Roy (Eds.), Conceptual models of nursing practice (2nd ed.). New York: Appleton-Century Crofts. Lieb, A., Underwood, P., & Glick, I. (1976) The staff nurse as a primary therapist: A pilot study. Journal of Psychiatric Mental Health Services, 14(11), 16-21. Marek, K. D. (1989). Outcomes measurement in nursing. Journal of Nursing Quality Assurance, 4(1), 1-9. Merwin, E. (1994, November). Current trends in psychiatric outcome research. Paper presented at the meeting of Society of Research and Education in Psychiatric Mental Health Nursing. Rockville, MD. Poster, E. C. (1991). A nursing quality assurance perspective. In S. Mirin, M. Grob, & J. Gossett (Eds.), Psychiatric treatment: Advances in outcome research (pp. 279-292). Washington, DC: APA Press. Poster, E. C., & Beliz, L. (1992). The use of the Johnson Behavioral System Model to measure changes during adolescent hospitalization. International Journal of Adolescence and Youth, 4, 7384. Poster, E. C., & RandeU, B. A. (1992). The Predicted Patient Outcome Instrument. Los Angeles: University of California Los Angeles, Neuropsychiatric Hospital, Nursing Department. Slavinsky, A., & Krauss, J. (1982). Two approaches to the management of long-term psychiatric outpatients in the community. Nursing Research, 31, 294-303.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the Journal of the American Psychiatric Nurses Association are available to subscribers (only) from the publisher, at a cost of $28.00 for domestic, $35.31 for Canadian, and $33.00 for international subscribers, for Volume 3 (February-December); shipping charges are included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA; phone 314-453-4351 or 800-453-4351. Subscriptions m u s t b e i n force to qualify. Bound v o l u m e s are n o t available i n p l a c e o f a r e g u l a r subscription.
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Vol. 3, No. 3
The Johnson Behavioral Systems Model as a Framework for Patient Outcome Evaluation Elizabeth C. Poster, RN, PhD, Vivien Dee, RN, DNSc, FAAN,and Brooke P. Randell, RN, DNSc BACKGROUNI~Although there is a g r e a t deal o f interest in the outcome o f the nursing care o f p s y c h i a t r i c patients, there is little empirical research a b o u t the effectiveness o f nursing care. METHODX"This s t u d y e v a l u a t e d the m e d i c a l r e c o r d d o c u m e n t a t i o n by n u r s e s a s a n i m p o r t a m d a t a b a s e (N=380 p a t i e n t s ) . The p r e d i c t e d p a t i e n t o u t c o m e i n s t r u m e n t d e v e l o p e d by the a u t h o r s w a s u s e d to collect the d a t a related to p a t i e n t d e m o g r a p h i c s , acuity, n u r s i n g diagnosis, short- a n d long-term goals, a n d n u r s i n g interventions. The J o h n s o n B e h a v i o r a l S y s t e m M o d e l w a s the n u r s i n g c o n c e p t u a l f r a m e w o r k usecL FINDINGX" Overall 80% o f the p r e d i c t e d p a t i e n t o u t c o m e s w e r e a c h i e v e d by the t i m e o f discharge, w i t h i n c r e a s e d length o f s t a y being a f a c t o r in i n c r e a s i n g the l i k e l i h o o d o f a c h i e v e m e n t o f goals. A p o s i t i v e link w a s f o u n d b e t w e e n a c h i e v e m e n t o f o u t c o m e s a t t i m e o f d i s c h a r g e a n d n u r s i n g interventions. A n u r s i n g theoretical f r a m e w o r k m a d e it p o s s i b l e to p r e s c r i b e n u r s i n g care a s a distinction f r o m m e d i c a l care. CONCLUSION."This s t u d y s h o w e d the i m p o r t a n c e o f the n u r s i n g d a t a b a s e in the m e d i c a l r e c o r d s a n d the effectiveness o f n u r s i n g interventions on p r e d i c t e d p a t i e n t o u t c o m e s a c h i e v e d by the t i m e o f discharge. ( J A m P s y c h i a t r N u r s e s A s s o c [199 7]. 3, 73-80.)
Elizabeth C. Poster is a Dean and Professor in the School of Nursing at the University of Texas in Arlington and wasformerly the Director of Nursing Research and Education at the UCLANeuropsychiatric Institute and Hospital. Vivien Dee is Director of Nursing and Associate Hospital Director at the UCLANeuropsychiatric Institute and Hospital. Brooke P. Randell is a Senior Post-Doctoral Fellow in the School of Nursing at the University of Washington and was formerly Director of Nursing Practice at the UCLA Neuropsychiatric Institute and Hospital. Supported by the UCLANeuropsychiatric Hospital. The Predicted Patient Outcome Instrument is availablefrom the authors upon request. Reprint requests.. Elizabeth C. Poster, RN, PhD, School of Nursing, University of Texas, Arlington, P.O. Box 29407, Arlington, TX 76019. Copyright © 199 7by the American Psychiatric Nurses Association. 10 78-3903/9 7/$5.00 + 066/1/82494 June i 9 9 7
approximately 58,000 psychiatric nurses in the United States are a major force in the psychiatric health care delivery system. These nurses must b e able to demonstrate what it is they do and w h e t h e r what they do makes a difference in patient outcomes. Nurses systematically collect and record critical patient information. The vast majority of these data are u s e d for d o c u m e n t a t i o n of the process of care and are not fully u s e d as a rich source of nursing knowledge and a measure of the impact of the care on patient outcomes. Although there is a growing interest in measuring patient outcomes directly influenced by nursing interventions (Bond & Thomas, 1991; Higgins, McCaughan, Griffins, & Cart-Hill, 1992, EIinshaw, 1992; Marek, 1989; Poster, 1991), very little outcome research is available in the psychiatric nursing literature. In a review of the major psychiatric nursing journals published between T h e
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1989 and 1994, Merwin (1994) found only a small by patterned, repetitive, and purposeful ways of benumber of articles that focused on the outcomes of having and reflect the behavior system's relationship psychiatric nursing practice. with b o t h the internal and external environment. Previously, Flaskerud (1987) conducted a compreThe ingestive subsystem refers to the m a n n e r in hensive review of the nursing literature to describe which the behavioral system meets the need for food the influence of psychiand fluid and generally atric nursing intervenis used to describe the tions o n p a t i e n t outw a y in which ingestion The nursing care provided to comes. Only four studies is managed (e.g., when, patients is directed at fostering ( B e a r d & Scott, 1975; w h e r e , and h o w the inBird, Marks, & Lindsey, dividual eats and takes efficient and effective behavior 1979; Lieb, Underwood, fluid). The eliminative within the context of the combined & Glick, 1976; Slavinsky s u b s y s t e m r e f e r s tO environments. & Krauss, 1982) actually the behavioral system's linked nursing intervenmanagement of biologic tions to patient outcomes. None of these studies used waste. The d e p e n d e n c y subsystem is descriptive of a nursing model or a theoretic framework, nor was the manner in which individuals manage their relanursing documentation in the medical record used as tionships with the environment in an effort to meet a clinical database. the needs for attention, recognition, and approval. The Johnson Behavioral Systems Model (Johnson The a c h i e v e m e n t subsystem reflects the d e g r e e to Model) was used to structure the assessment, planwhich the individual achieves mastery of the self ning, and implementation of nursing care at the Uniwithin the e n v i r o n m e n t and refers to those behavversity of California Los Angeles Neuropsychiatric iors e n g a g e d in for p u r p o s e s of self-care, p r o b l e m Hospital for 14 years. With a conceptual structure in solving, d e c i s i o n m a k i n g , a n d a s s e r t i o n . T h e place, it was possible to generate a clinical database affiliative subsystem is the part of the behavioral for a patient outcome evaluation study with nursing system that mediates the individual's connection to documentation in the medical record. other individuals within the environment. The aggresThe degree to which behavior is seen as more efsive-protective subsystem represents those behaviors fective or efficient must be evaluated to support that engaged in for the purpose of keeping the individual the nursing care of the hospitalized psychiatric patient safe and may or may not include overtly aggressive does indeed make a difference in terms of outcomes. behaviors. The sexual subsystem refers to those beThe purpose of this study was to evaluate the effechaviors that relate to procreation and reflect gender tiveness of nursing care within a theoretic context as identification. And finally, the restorative subsystem is measured by patient outcomes. responsible for mediating the balance between rest and activity (Auger, 1976).
BACKGROUND According to Johnson (1980), the person w h o is i11, not the illness, should remain the focus of nursing care. The Johnson Model operationalizes the individual as a behavioral system, which is c o m p o s e d of eight subsystems of behavior within the context of an internal and external environment. The internal environment includes the biophysical and psychologic aspects of the person, whereas the external environment refers to the sociocultural and physical worlds within which the person resides (Auger & Dee, 1983; Dee & Auger 1983). The nursing care provided to patients is directed at fostering efficient and effective behavior within the context of the combined environments. The eight behavioral subsystems are characterized 74
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Model-based Assessment The nursing assessment of the psychiatric patient from the Johnson Model perspective involves observations of behaviors in all eight subsystems and a determination of the d e g r e e to which each subsystem is functioning effectively and efficiently. Individuals are usually admitted to an inpatient unit b e c a u s e their behaviors are inefficient or ineffective. Frequently, these patients are unable to k e e p themselves safe. T h e y are e x p e r i e n c i n g severe interpersonal p r o b l e m s , seek a t t e n t i o n i n a p p r o p r i a t e l y , cannot provide for their o w n self-care, are not eating or sleeping properly, a n d / o r cannot control their activity level. Vol. 3, No. 3
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Table 1. Criteria for Rating Overall Behavior Category and Level of Nursing Intervention Required Categories o f Patient Behaviors Category 1 Patient demonstrates behaviors/actions that are effective and compatible in all eight subsystems, therefore achieving system balance. Energy may be unequally distributed among the eight subsystems but not to the detriment of any one subsystem or to the system as a whole. System balance denotes health.
Levels o f Nursing Interventions Level 1 Category 1 patients demonstrate system baIance; therefore they are able to protect, nurture, and simulate all behavioral subsystems. The patient requ!res a minimum amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category I patient is the provision of a nurturing and stimulating environment within a group context.
Category 2 Patient demonstrates behavior/actions that are inconsistently effective in one or more subsystems resulting in short-term incompatibility among the subsystems and the potential for system imbalance. Energy may be temporarily distributed unequally among the subsystems creating ineffective subsystem functioning but not to the detriment of the system as a whole. Potential for system imbalance results in the potential for health deviation.
Level 2 Category 2 patients demonstrate a potential for system imbalance; therefore they are not able to consistently protect, nurture, and stimulate all behavioral subsystems. The patient requires a moderate amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category 2 patient is the provision of a nurturing, stimulating, and protective environment within a group context.
Category 3 Patient demonstrates behaviors/actions that are incompatible within one or more subsystems resulting in system imbalance and incompatibility among subsystems. Energy is unequally distributed among the eight subsystems and frequently results in the detriment of the system as a whole. System imbalance results in illness.
Level 3 Category 3 patients demonstrate system imbalance; therefore they are not able to protect, nurture, and stimulate all behavioral subsystems. The patient requires an intensive amount of nursing time in supervision and nursing care. The primary goal of nursing care for the Category 3 patient is the provision of a nurturing, stimulating, and protective environment within a small group.
Category 4 Patient demonstrates behaviors/actions that are incompatible within one or more subsystems, resulting in serious system imbalance. Energy is unequally distributed among the subsystems. This unequal distribution of energy is of acute intensity, long duration, and/or high frequency and results in serious detriment to the system as a whole. Severe system imbalance results in critical illness.
Level 4 Category 4 patients demonstrate serious system imbalance; therefore they are not able to protect, nurture, and stimulate all behavioral subsystems. The patient requires continuous one-to-one supervision and nursing care. The primary goal of nursing care for the Category 4 patient is the provision of a nurturing and protective environment on an individual level.
Ineffective and inefficient behaviors must be analyzed if they are to have meaning. Because o b s e r v e d b e h a v i o r s can h a v e m a n y m e a n i n g s , the a c c u r a c y of a b e h a v i o r a l a s s e s s m e n t m u s t b e b a s e d on the ability of the o b s e r v e r to identify the goal of the b e h a v i o r o b s e r v e d . For e x a m p l e , eating b e h a v i o r has an obvious ingestive function; however, in m a n y situations eating b e h a v i o r is affiliative. The goal of the b e h a v i o r in a given situation g o v e r n s h o w a b e h a v i o r is c a t e g o r i z e d a n d h o w the relationship b e t w e e n the person and the environment is ultimately understood. For the nursing assessment to be comprehensive, it must include information on the biophysical, psychologic, social-cultural, and ecologic factors influencing a patient's behavior.
Behavior and its efficacy have different meanings and must be responded to differently based on its context. For example, patient A w h o demonstrates unsafe behavior in response to internal stimuli telling him to harm himself is very different from patient B w h o demonstrates unsafe behavior in response to a recent social change such as a job loss or the b r e a k u p of a relationship. Patient A is responding to the internal environment by cutting himself (aggressive-protective subsystem) in an attempt to pacify the voices. Patient B is responding to the external environment b y cutting himself as a suicidal attempt (aggressive-protective subsystem). Although both behaviors are similar, the nursing interventions will differ in these two situations.
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Table 2. Interrater Reliability Among Subscales of the Predicted Patient Outcome Instrument (n = 51 records) Subscales
Interrater reliability
Demographics Nursing diagnoses, subsystems, regulators Long term goals/discharge outcomes met/not met Consistencybetween nursing diagnoses and predicted outcomes Additional subsystems targeted Frequency of short term goals/predicted patient outcomesmet/notmet by discharge Expected improvementrelated to nursing interventions Subsystems targeted by nursing interventions Regulators targeted by interventions Behavioral categoryscores
.94 .99 .84 .74 .92 .76 .90 .89 .87 .99
Acuity Ratings of Behaviors A patient classification system based on the Johnson Model has been used effectively in the neuropsychiatric hospital for more than a decade (Auger & Dee, 1983; Dee, 1986, 1990). Behavioral data are gathered to determine the effectiveness of each subsystem. Each subsystem is assigned a category score ranging from 1 to 4 (1 = effective; 2 = inconsistently effective; 3 = ineffective; 4 = critically ineffective) (Table 1). An overall behavioral category score is determined for the entire system ranging from 1 to 4 (1 = health; 2 = potential for health deviation; 3 = illness; and 4 = critical illness) based on the degree of effectiveness or ineffectiveness of each behavioral subsystem. These scores are computed on admission, discharge, and interim points during hospitalization. (Nurses are trained in the model and scoring system; each subsystem score stands alone as does the overall score.) Priorities for nursing interventions are established based on the nursing diagnoses that are formulated for those subsystems and pose the greatest threat to the overall behavioral system. In addition, nursing interventions are designed to achieve specific behavioral outcomes for selectively targeted subsystems. These nursing interventions focus not only on increasing behavioral effectiveness and efficiency of the subsystems but also the effectiveness and efficiency of the internal and external environment as they affect the subsystems. With a patient classification system in place, it is possible to review the nursing documentation in an effort to answer specific questions regarding nursing's contribution to patient outcomes (i.e., "What is the 76
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impact of nursing care on the patient's behavior?"). A decrease in behavioral score in a particular subsystem from admission to discharge in a subsystem specifically targeted by nursing intervention would suggest that nursing care was responsible in part for increasing behavioral effectiveness and efficiency (Table 1).
METHODS Setting This study was conducted at the University of California Los Angeles Neuropsychiatric Hospital in Los Angeles, California. The Neuropsychiatric Hospital provides c o m p r e h e n s i v e multidisciplinary inpatient services to child, adolescent, adult, and geriatric patients. The primary psychiatric diagnoses of the patient population across all units are: major depression, psychosis, borderline personality disorder, attention deficit disorder, bipolar disorder, and anorexia nervosa. At the time of data collection, the average length of stay varied by the type of service: adult, 12.4 days; geriatric, 11.2 days; child, 26 days; and adolescent, 17.6 days.
Measures The Predicted Patient Outcome Instrument was developed to collect data documented in the medical record on patient demographics, acuity ratings of patient behaviors, nursing diagnoses, predicted outcomes/shortand long-term goals, and nursing interventions (Poster & Randell, 1992). The instrument is unique in the following ways: (a) The items that are included are theorydriven, and the language is reflective of the Johnson Model; (b) The terminology provides consistency and links the problem statement to nursing interventions and patient outcomes, making comparisons across patient populations possible; (c) It focuses on the appropriateness of theory-based nursing diagnoses, information, and specific patient outcomes; and (d) It measures changes in behavior.
Procedure Data on 190 adult/geriatric and 190 child/adolescent patients discharged over the same 6-month period were included in the study. A retrospective review of the 380 medical records was conducted by six members of the Nursing Quality Assurance Committee, the Director of Nursing Practice, the Director of Nursing Research and Education, and the Director of Nursing. The group met for five 8-hour sessions to gather and Vol. 3, No. 3
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Table 3. Percentage Improvement by Subsystem: Admission to Discharge Ingestive Eliminative Dependency Achievement AfflHative Patients
Aggressiveprotective
Sexual Restorative Overall
227
184
324
306
306
300
193
241
253
57.3
54.9
34.6
41.8
38.2
56.7
52.3
58.3
53.0
(no.) Improved
(%)
score the data. The medical records were randomly selected by date of admission to comprise an equal number of patients in the child and adult services. Data were collected from the five sections of the patients' medical records: Nursing Assessment, Nursing Care Plan, Nursing Progress Notes, Nursing Shift Report, and Nursing Discharge Summary. Training sessions for the data collectors were held before the study. Interrater reliability was established in a review of 36 patient demographic forms and 53 nursing care plans. The Cronbach alpha for the total scale was .88 and for the subscales ranged from .99 to .74 (Table 2). Predicted patient outcomes (PPOs) were defined as positive short-term goals, which are observable patient behaviors described in measurable terms. Examples of PPOs that were expected by discharge included: • Aggressive-protective subsystem (e.g., Adam will earn 75% of contract points for safe behavior; Patient will be able to come to staff and talk about suicidal thought by 1/5/94) • Ingestive subsystem (e.g., Patient will continue to gain 2 pounds per week from 12/27/93 through 1/ 9/94) • Achievement Subsystem (e.g., Lisa will be able to attend two meetings every day for at least 15 minutes; Patient will be able to verbally state techniques for managing side effects of medications 100% of the time by 1/10/94)
FINDINGS Documentation Of the 2427 PPOs in the 380 medical records, 732 nursing care plans (some patients had several care plans in their medical records) identified major areas of ineffective patient behaviors in the aggressive-protective (n = 348) and dependency subsystems (n = 241). In contrast, the ingestive (n = 42) and sexual subsystems (n = 4) were infrequently the patient's primary problematic behavior. There were an average of 6.4 PPOs per patient. Eighty percent (n = 1619) were
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Table 4. Percentage Improvement from Admission to Discharge of Patients with Behavioral Category Rating of 4 at Admission Subsystem
n
Aggressive-protective Dependency Affiliative Achievement
73 38 24 24
Percentage Lowered Same 85 79 75 75
15 21 25 25
achieved by discharge. Sixty-three percent of the patients (n = 238) had a length of stay less than 30 days. Although overall 80% of the PPOs were achieved, the percent of goals met increased from 33% for patients with a length of stay of 1 or 2 weeks to 44% for a length of stay of 3 weeks to 50% to 55% for lengths of stay over 3 weeks.
Acuity On admission, most (82%, n = 311) of the patients were rated at least an overall behavioral score of 3 on a 4-point scale. The subsystems having the greatest impact on the patient's overall acuity scores were the dependency (64°/6, n = 243), affiliative (59%, n = 224), achievement (57%, n = 216), and aggressive-protective (55%, n = 209). Although patients displayed inefficient behaviors in numerous subsystems, nursing care plans specifically "targeted" an average of two to three behaviors requiring immediate individual intervention beyond that provided for all patients as part of the milieu program. Problem behaviors in nontargeted subsystems were addressed by standard milieu intervention and were not specifically mentioned in the nursing care plans. There was greater improvement in subsystem scores for the achievement and the aggressive-protective subsystems when the nursing care plan specifically targeted those subsystems. The dependency subsystem improved approximately at the same rate whether or not the subsystem was targeted. The affiliative subsystem, howPoster, Dee, & Randell
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Table 5. Subsystem Improvement of 60% or Better By Psychiatric Diagnosis Psychiatric diagnosis
Subsystem improved
Depression
Ingestive Eliminative Aggressive-Protective Ingestive Eliminative Restorative Ingestive Eliminative Sexual Restorative
Anxiety disorder
Bipolar manic
ever, showed greater improvement when the subsystem was not addressed by the nursing care plan. The geriatric population also reflected a similar pattern with substantial improvement w h e n the achievement subsystem was targeted but no difference w h e n the aggressive-protective subsystem was targeted. Eighty-six percent of the PPOs identified in the nursing care plans were achieved by patients who were admitted with a rating of 4 in any of the eight subsystems. In addition, 79% of the PPOs were achieved by those patients admitted with behavioral subsystem scores of 2 or 3. Also, 53% of the patients with an overall behavioral category score of 2 or 3 at admission showed improvement at discharge. All patients admitted with an overall behavioral category score of 4 at admission (n = 16) improved. The greatest i m p r o v e m e n t w a s n o t e d in the restorative (58%, n = 241), ingestive (57%, n = 227), a g g r e s s i v e - p r o t e c t i v e (57%, n = 300), and eliminative (55%, n = 184) subsystems (Table 3). At discharge 43% of all patients had an overall b e h a v ioral score of 3, and an additional 45% had an overall behavior score of 2. Behaviors that improved most during hospitalization w e r e ingestive, eliminative, aggressive-protective, restorative, and sexual. The only s u b s y s t e m that did not i m p r o v e significantly by discharge was the achievement subsystem for the geriatric and child patients. The most acutely ill patients on admission had varied psychiatric diagnoses (Table 4). Forty-one percent of the sample (n = 159) had a lower overall behavioral category rating at discharge. Forty-one percent of the sample (n = 159) had a rating of 4 on admission in at least one subsystem (Table 5). The behavioral category score showed improvements in 75% to 85% of these subsystems at the time 78
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of discharge, with the most improvement in the aggressive-protective subsystem. PPOs were not significantly related to level of psychosocial stressors as measured by GAF scores on axis 5 (American Psychiatric Association, 1994). Even for those patients with extreme and catastrophic stressors (n = 38), 84% of the PPOs were met at discharge.
DISCUSSION Documentation The mission of the hospital's department of nursing is to provide exemplary patient care based on a conceptual framework, which guides the professional practice of nursing. One of the current problems in demonstrating nursing effectiveness is lack of "nursing sensitive" patient outcome measures (Hinshaw, 1992, p. 10). The PPOs in this study were directly linked to nursing interventions as separate from the interventions of other members of the multidisciplinary team as discussed in the nursing care plan. Having a nursing theoretic framework in place made it possible for nurses to prescribe nursing care, which focused on their distinct contribution to the patient's overall care. This study demonstrated that nursing interventions are effective in achieving positive outcomes of hospitalized psychiatric patients. This finding supports the belief that psychiatric patients benefit from a therapeutic environment that is structured to meet their needs and support achievement of behavioral goals. This is especially so for most acutely ill patients admitted to inpatient settings because they are exhibiting aggressive-protective behavior and are a danger to themselves or others. The influence of length of stay on PPOs in the achievement subsystem may attest to the nature of
Nursing care during relatively short hospitalizations increases patients' abilities to keep themselves safe and meet their basic needs. these behaviors. Achievement behaviors such as mastery of self-help/independent living, problem solving, and decision making include cognitive tasks, which are complex in nature and not amenable to rapid change. Vol. 3, No. 3
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Acuity The frequency of the patient problems related to the aggressive-protective subsystem and identified in the nursing care plan clearly demonstrated the nature of the patient's behaviors requiring immediate and close attention to safety. These behaviors are consistent with
This study has illustrated the importance of the nursing database in the medical record. a major criterion for hospital admission, that is, patients' inabilities to maintain their own safety in the community. The patients demonstrating the most ineffective behaviors (category 4), either overall or in specific subsystems, indicated the most improvement. Standard nursing interventions on each unit, which reflect the milieu program, are provided to all patients. The therapeutic milieu, which offers containment, support, involvement, validation, and structure, may account for the striking improvement in all age groups (Gunderson, 1978). Improvement in nontargeted subsystems cannot be attributed to an absence of intervention but to a milieu program on all units that ensures that patients attend meals, receive adequate nutrition, and experience assistance in modifying inappropriate mealtime behaviors. For example, only in situations where ingestive behavior is extremely ineffective (e.g., refusal to eat resulting in severe weight loss) is this subsystem targeted for immediate individual attention. It is clear that nursing care has the greatest impact on patients' safety, sleep, eliminative, and eating behaviors. Nursing care during relatively short hospitalizations increases patients' abilities to keep themselves safe and meet their basic needs. The behaviors that require more long-term intervention such as socialization (affiliative) skills, dependency issues, and achievement behaviors may not show significant improvement over the course of a short inpatient hospitalization. Although these more complex behaviors were most frequently targeted in nursing care plans, the 4-point scale did not have sufficient variability to capture the subtle changes in these behaviors, which were reflected in narrative charting. Patients on the child and geriatric units did not have significant positive changes in the achievement,
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affiliative, and dependency subsystems. For example, on the child unit (n = 56) evaluation of dependency behaviors showed that 3 patients became worse, 40 showed no change, and 13 improved. However, more than four times as many patients improved as became worse, thus suggesting that this finding is not likely due to chance (p = .01). Although improvement is a desired outcome, the fact that severely disturbed patients maintained their level of functioning during hospitalization might suggest that nursing intervention prevented further deterioration. Ineffective behaviors in the dependency subsystem require not only nursing intervention during hospitalization but also longterm approaches such as parent effectiveness training. This finding is consistent with a previous study demonstrating the need for intervention after discharge in adolescent patients' achievement and dependency behaviors (Poster & Beliz, 1992). The achievement of behavioral goals documented as a consequence of the nursing interventions reflect realistic expectations of gains that are possible during an inpatient length of stay. Although psychosocial stressors are a factor in the patient's need for inpatient hospitalization, these stressors may have a less direct influence on patient behavior when the patient is no longer in the stressful environment. For example, the adolescent who was sexually abused and suicidal at the time of admission can reach the goal of talking with staff about suicidal thoughts within 3 days of admission.
CONCLUSION This study was conducted with the medical record documentation of nurses. There may be incongruities between patient outcomes as defined by caregivers and the patients themselves. To further strengthen the measurement of patient outcomes, it is important to include the patient's perspective. This study has illustrated the importance of the nursing database in the medical record. The qualitative and quantitative documentation provided a rich source, which could be analyzed and used to demonstrate the effectiveness of nursing care. The authors stressed the importance of maintaining the nursing care plan or similar documents to permit a vehicle by which nurses prescribe and document their distinct contributions to the care of the patient. Without a specific part of the medical record that includes the nurses' prescription for interventions and a method for evaluation, the blurring of the professional roles will increase in the multidisciplinary-focused psychiPoster, Dee, & Randell
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atric setting. P r o g r e s s i v e limitations o f t h e p r a c t i c e o f nursing by hospital administrators and nonnursing h e a l t h c a r e p r o f e s s i o n a l s a r e a l r e a d y in e v i d e n c e . T h e u s e o f a t h e o r e t i c f r a m e w o r k , in this c a s e t h e Johnson Model, provided a nursing department with t h e ability to g e n e r a t e a c o n c e p t u a l l y s o u n d p a t i e n t o u t c o m e e v a l u a t i o n study. T h e a u t h o r s s t r o n g l y a d v o c a t e t h e u s e o f a n u r s i n g t h e o r e t i c f r a m e w o r k to d e scribe, p r e d i c t , a n d structure clinical p h e n o m e n a to achieve and measure positive patient outcomes.
The authors thank thefollowing nursesf o r their involvement as data collectors: Joann Rigali, Joyce Reinholdt, Joanne Clendenning, Karen Kay, Pam Koller, Jan Halliday, a n d Thelma Saddul.
REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (p. 32). Washington, DC: Author. Auger, J. (1976). Behavioral systems in nursing. Inglewood Cliffs, NJ: Prentice Hall. Auger, J., & Dee, V. (1983). A patient classification system based on the behavioral systems model of nursing, Part 1. Journal of Nursing Administration, 14(4), 38-43. Beard, M., & Scott, P. (1975). The efficacy of group therapy by nurses for hospitalized patients, Nursing Research, 24, 120-125. Bird, J., Marks, I., & Lindley, P. (1979). Nurse therapists in psychiatry: Developments, controversies and implications. BritishJourhal of Psychiatry, 135, 321-326. Bond, S., & Thomas, L. S. (1991). Issues in measuring outcomes of nursing. Journal of Advanced Nursing, 16, 1492-1502. Dee, V. (1986). Validation of a patient classification instrument for psycbiamc patients based on the Johnson Model for Nursing. Unpublished doctoral dissertation, University of California, San Francisco, CA. Dee, V. (1990). Implementation of the Johnson Model: One hospital's experience. In M. Parker (Ed.), Nursing theory in practice. New York: National League for Nursing.
Dee, V., & Auger, J. (1983). A patient classification system based on the behavioral systems model of nursing, Part II.Journal of Nursing Administration, 13(5), 18-23. Flaskerud, J. (1987). Evaluation of the impact of psychiatric/mental health nursing through research. In L. Birckhead (Ed.), Psychiatric~mental health nursing (pp. 717-731). New York: Lippincott. Gunderson, J. G. (1978). Defining the therapeutic processes in psychiatric milieus. Psychiatry, 41, 327-335. Higgins, M., McCaughan, D., Griffins, M., & Cart-Hill, R., (1992). Assessing the outcomes of nursing care. Journal of Advanced Nursing, 17, 561-568. Hinshaw, A. S. (1992). Patient outcomes research: Examining the effectiveness of nursing practice. Proceeding of the State of the Science Conference (p. 10). Washington, DC: US Department of Health and Human Services. Johnson, D. (1980). The behavioral system model of nursing. In J. Riehl & C. Roy (Eds.), Conceptual models of nursing practice (2nd ed.). New York: Appleton-Century Crofts. Lieb, A., Underwood, P., & Glick, I. (1976) The staff nurse as a primary therapist: A pilot study. Journal of Psychiatric Mental Health Services, 14(11), 16-21. Marek, K. D. (1989). Outcomes measurement in nursing. Journal of Nursing Quality Assurance, 4(1), 1-9. Merwin, E. (1994, November). Current trends in psychiatric outcome research. Paper presented at the meeting of Society of Research and Education in Psychiatric Mental Health Nursing. Rockville, MD. Poster, E. C. (1991). A nursing quality assurance perspective. In S. Mirin, M. Grob, & J. Gossett (Eds.), Psychiatric treatment: Advances in outcome research (pp. 279-292). Washington, DC: APA Press. Poster, E. C., & Beliz, L. (1992). The use of the Johnson Behavioral System Model to measure changes during adolescent hospitalization. International Journal of Adolescence and Youth, 4, 7384. Poster, E. C., & RandeU, B. A. (1992). The Predicted Patient Outcome Instrument. Los Angeles: University of California Los Angeles, Neuropsychiatric Hospital, Nursing Department. Slavinsky, A., & Krauss, J. (1982). Two approaches to the management of long-term psychiatric outpatients in the community. Nursing Research, 31, 294-303.
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