The impact of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing coronary artery bypass graft: a Randomized clinical trial

The impact of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing coronary artery bypass graft: a Randomized clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing coronary artery bypass graft: a Randomized clinical trial Sakineh Rostami, Shahram Molavynejad, Nasrin Elahi, Elham Maraghi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4331230/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2025 Read the published version in BMC Nursing → Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: Coronary artery bypass graft (CABG) is a very important intervention to relieve angina, improve quality of life, or increase life expectancy. This study aimed to determine the effect of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing CABG in Ahvaz teaching hospitals in 2022. Materials and methods: The present study was a clinical trial on 128 patients undergoing CABG admitted to the cardiac ICU and cardiac surgery department of teaching hospitals in Ahvaz city. The patients were selected based on the inclusion criteria, and they were assigned into intervention and control groups using permutation blocks. In the intervention group, a nursing care program based on Johnson's model was implemented for three weeks. The data collection tool was a researcher-made questionnaire developed based on Johnson's theory. Results: Before the intervention, the mean scores of the intervention group in terms of the seven subsystems of Johnson's model were as follows: achievement (-98.98 ± 75.77), affiliative (-87.34 ± 28.23), eliminative (-25.46 ± 33.27), ingestive (-135.67 ± 89.20), dependency (-122.26 ± 45.85), aggressive-protective (-62.18 ± 46.58), and restorative (-163.59 ± 62.03). After the intervention, the mean scores in the intervention group were as follows: achievement (-2.50 ± 71.55), affiliative (-66.33 ± 59.68), eliminative (19.29 ± 35.61), ingestive (152.75 ± 113.58, dependency (104.60 ± 53.42), aggressive-protective (52.18 ± 53.54), and restorative (198.43 ± 72.28), which shows the positive impact of the intervention (P > 0.05). No significant changes were observed in the sexual subsystem. Conclusion: The implementation of a nursing care plan based on Johnson's model positively affected the behavioral systems of patients undergoing CABG. Therefore, this model is recommended to be used as a framework for nursing care. Date of registration -05-12-2022 Trial registration number- IRCT20220831055838N1 care plan Johnson's model behavioral system CABG patients Figures Figure 1 Introduction Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Therefore, coronary artery bypass graft (CABG) is indicated for patients with angina and patients with left main coronary artery stenosis or patients with multi vessel coronary artery disease (MVD) [ 1 ]. Previous studies have reported that the quality of life of CABG patients after surgery is not satisfactory in all dimensions, especially physical and emotional well-being [ 2 , 3 ]. Patients who undergo surgery often experience anxiety and even depression due to the fear of permanent disability, sleep disturbance [ 4 ], changes in body image [ 5 ], reduced mobility, loss of health, slower wound healing, longer hospital stay [ 6 ], loss of physical control, loss of ability to work, pain, loss of sexual ability, inability to wake up after anesthesia, and death [ 3 , 7 , 8 ]. Postoperative complications can easily occur with an incidence of 15–30%. Possible complications include stroke, renal failure, prolonged intubation time, sternal wound infection [ 9 , 10 ], and postoperative pulmonary infections (e.g., atelectasis, pleural effusion, pneumonia, pulmonary edema, cardiogenic pulmonary edema, acute respiratory distress syndrome, pulmonary embolism, phrenic nerve damage, pneumothorax, and mediastinitis) [ 11 ]. Studies show that changing behavior and modifying lifestyle after open heart surgery can reduce the risk of complications [ 12 ]. However, patients often have difficulty modifying their behaviors and adhering to new behaviors because it is difficult to change behaviors that have already been internalized throughout life. A useful strategy to facilitate behavior modification among patients is their active participation in the care process using interactive nursing theories [ 13 ]. Nursing theories create a framework and structure for thinking and thus help nurses to better analyze situations, organize their thinking, and make the best decisions for patient care. Some theories also help to achieve standards of care, reduce health care costs, and improve quality of life [ 14 ]. The application of nursing models makes nursing interventions shift from service-oriented activities to client-centered ones. These models not only guarantee a targeted, regular, controlled, and effective care of the patient, but also provide the possibility of high quality care and lead to the development of professional nursing [ 15 ]. One important model is the behavior system model of nursing developed by Dorothy E. Johnson who believed that in order to prevent illness, there should be efficient and effective behavioral functioning in the patient. However, such models have rarely been adopted to investigate behavioral changes in patients undergoing CABG. More particularly, there is limited information about the effects Johnson's model on behavioral changes in CABG patients. Therefore, the present study was conducted to investigate the effects of a care program based on Johnson's behavioral model in patients undergoing CABG. Theoretical framework One of the significant models in nursing literature is Johnson's behavioral systems model. This model is derived from Nightingale's premise that the goal of nursing is to help people prevent or recover from illness. Johnson envisioned a nursing client as a behavioral system. An orderly behavioral system includes interrelated and interdependent biological and behavioral subsystems. Johnson's behavioral systems model includes 8 sub-systems including: achievement, affiliative, eliminative, ingestive, dependency, aggressive-protective, sexual, and restorative [ 16 ]. This model sees people as behavioral systems that always want to achieve balance and stability, both in the internal and external environments, and they also have the desire to adjust and adapt to the effects they create [ 17 ]. These subsystems have similar components, structure, and function. Each of these subsystems has components that distinguish them from each other and make that subsystem definable. Structural components are: drive, set, action, and choice. The first component is the drive of the subsystem, which shows the reason and motivation behind the behavior. Drives that have different meanings are different for different people, they induce different meanings at different times for the same person, and they are not visible. The second component of the structure is set or tendency, which is the regular and normal behavior with which the client prefers to fulfill the goal of the subsystem. The next structural component of a subsystem is choice. Choices show the set and repository available to a person in order to achieve specific goals [ 18 ]. In this model, Johnson divides nursing diagnoses into dominance, incompatibility, insufficiency and discrepancy based on the patient's problems. Nursing practices are the actions that the nurse performs to solve the problem, which in Johnson's behavioral model, are divided into four categories, namely restricting, defending, inhabiting, and facilitating [ 18 ]. Method Design This single-blind randomized clinical trial was conducted in Ahvaz, Iran, in 2023. Sampling The participants were 144 patients undergoing CABG who were admitted to two teaching hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Patients who were aged between 18–75 years, were oriented to time and identity, had the ability to communicate, had undergone CABG, had a companion who knew about their condition, and had a telephone line were eligible to participate in the study. Exclusion criteria included the patient's unwillingness to cooperate at any time of the research, situations that require immediate intervention (e.g., decreased level of consciousness, sudden and progressive drop in blood oxygen saturation, etc.), and death of patients after surgery. The stages of the research are shown in Fig. 1 . Sample size We calculated the necessary sample size on the basis of our main primary outcome measure, with an expected 38.6 unit increase in the mean change of restorative score (total score). These calculations were based on previous study (16). To detect this difference with 80% power, typeI error of 5% and S 1 = S 2 = 77.43, 64 patients for whom data could be analyzed were needed in each group. $$n=\frac{{\left({Z}_{1-\frac{\alpha }{2}}+{Z}_{1-\beta }\right)}^{2}\left({s}_{1}^{2}+{s}_{2}^{2}\right)}{{\left(\text{d}\right)}^{2}}=\frac{{(1.96+1.04)}^{2}\times 2\times {\left(73.89\right)}^{2}}{{\left(44.67\right)}^{2}}\cong 64$$ With an assumption of 10% withdrawals or protocol violations, we aimed to recruit 72 patients in each group. Randomization This was a RCT in which 128 patients undergoing coronary artery bypass graft were recruited and randomly divided into two groups of intervention or control using an allocation ratio of 1:1 and the block randomization with a random block size of four, six and eight. Blinding Due to the nature of this study, blinding of researchers and participants was not possible, but neither the patients nor the researcher were aware of the allocation order until the commencement of the intervention. Instruments The tools used in this study included a demographic information form, patient medical records, and a researcher-made evaluation tool based on Johnson's theory to evaluate the behavioral system of patients undergoing CABG. The content validity of the new tool was verified: CVR > 0.6 and CVI > 0.7 in each subsystem. Also, the alpha coefficient reliability was calculated to be 0.86. The questionnaire used to evaluate the behavioral system of patients was a scale including 37 questions in eight sub-systems: restorative, ingestive, eliminative, aggressive-protective, dependency, sexual, affiliative, and achievement. Each item in each sub-system was answered by the patient according to three aspects. One aspect was related to changes in symptoms or ability to function. The patient responded by indicating an increase or decrease or no change. Then this change was identified as negative or positive. Finally, the magnitude of these changes was scored on a scale of 0-100 and considered positive or negative. A total score was calculated for each subsystem, and the nurse focused on care in the subsystem with the worst score. Data collection Data were collected in this study by the lead researcher between December 2022 and December 2023. To this aim, demographic and medical information forms were read to the patients by the lead researcher who then scored the form based on the patient's response. The tool for examining the behavioral system of patients after CABG was completed by the lead researcher at two intervals according to the patient's response: the first time when the patient was hospitalized in the ward and the second time was two weeks after the operation, when the patient was discharged and followed up by phone. Intervention: A Nurse-Led Care Program All patients were transferred to the ICU after CABG and were admitted to the cardiac ICU for an average of 2 days. After being discharged from the ICU, they were admitted to the cardiac surgery department for an average of 3–4 days, and were discharged from the department in case they had no problems. To this aim, the first step was to assess the existence of problems by analyzing the findings obtained from the behavioral assessment tool. In the evaluation, the performance and purpose of each subsystem was taken into account. Equilibrium state in each subsystem was checked by analyzing: a) whether there was any change in the structure or function of the subsystem, b) whether the patient feels the change positively or negatively, and c) how important this change is for the patient. Based on the overall equilibrium state of each subsystem, the scores were sorted from the lowest to the highest. The researcher and one of the nurses in the cardiac ICU and cardiac surgery department managed the patients' problems through nursing processes, and then based on the NANDA system, nursing diagnoses were made. The diagnoses were expressed in two ways: 1- Internal problems in each subsystem: any failure to meet functional requirements or the existence of incompatibility between the structural components of the subsystems. 2- Inter-system problem: the dominance of one or two subsystems in the entire behavioral system or the existence of conflict between two or more subsystems. In the second step, the lead researcher gave the necessary training to the nurses of the cardiology and cardiac surgery department in three 60-minute sessions. This included information about how to: use Johnson's behavioral system model, evaluate patients using tools designed to examine patients' behavioral systems, write nursing diagnoses, and take the necessary measures to manage patients' problems. The patient's companion was also included in these sessions. The care model was implemented by the lead researcher in the morning shift and by trained nurses in the evening and night shifts. The care program for each patient was implemented for two weeks. After discharge, care recommendations were provided over phone. The care program of the patients started about 24 hours after the operation when they were able to sit. Patients were examined first, and according to each sub-system, stable and unstable behaviors were determined. Depending on unstable behaviors and nursing diagnoses, interventions were made, and the final evaluation was done by completing the questionnaire. Interventions were performed based on Johnson's behavioral model in eight subsystems. The control group received only routine care. Subsystem Session 1 Session 2 Session 3 Session 4 Restorative 1- Coughing and deep breathing training 2- Proper sleep training 3- Correct walking training 1- Coughing and deep breathing training 2- Proper sleep training 3- Correct walking training 4- The importance of chest physiotherapy 5- Teaching relaxation techniques and expressing emotions 6- Teaching the use of incentive spirometry Telephone follow up on previous cares and emphasizing their implementation. Telephone follow up on previous cares and emphasizing their implementation. Ingestive 1- The importance of consuming fluids and adequate and appropriate diet 2- Methods of increasing appetite 3- The ability to tolerate food 4- Proper diet training 1- The importance of adequate and proper fluid intake and diet 2- Methods of increasing appetite 3- The ability to tolerate food 4- The importance of daily weighing 5- Providing drug information and drug precautions 6- Proper diet training 7- Teaching active and passive movements in the range of joints 8- Pain control 9- Giving information about recommended sports and rest Telephone follow up on previous cares and emphasizing their implementation. Telephone follow up on previous cares and emphasizing their implementation. Achievement 1- Importance of compliance with diet, medication, and exercise 1- Importance of compliance with diet, medication, and exercise 2- Getting feedback from the patient regarding training related to diet, medication and exercise 3- Teaching how to check blood sugar and blood pressure and get feedback 4- Teaching the correct use of varicose socks 5- Explaining the stress associated with surgery and teaching how to deal with it 6- Giving the patient a chance to freely express their feelings and concerns 7- The correct way of praying Telephone follow up on previous cares and emphasizing their implementation. Telephone follow up on previous cares and emphasizing their implementation. Eliminative 1- Controlling the absorption and excretion of liquids and electrolytes 2- Asking about defecation problems and teaching how to prevent constipation 1- Controlling the absorption and excretion of fluids and electrolytes 2- Asking about defecation problems and teaching how to prevent constipation 3- Fever control 4- Giving the patients the ability to express feelings and motivating them to do simple tasks 5- Requesting the patient's family to support them for the purpose of treatment Telephone follow up on previous cares and emphasizing their implementation. Telephone follow up on previous cares and emphasizing their implementation. Affiliative 1- Emphasizing minimum family visits at first and increasing them over time 1- Emphasis on minimum family visits at first and increasing them over time 2- Giving the patient the ability to communicate with family and friends and encouraging them to express their concerns with family members 3- Emphasizing the importance of daily changing of clothes Telephone follow up on previous cares and emphasizing their implementation. Telephone follow up on previous cares and emphasizing their implementation. Dependency 1- Emphasizing the importance of changing activities upon exhaustion 2- Training on the correct way of bathing and emphasizing its brevity, not using body brushes, and using lukewarm water 1- Emphasizing the importance of changing activities upon exhaustion 2- Telling the patient to avoid heavy work and stressing that in the first days after discharge, the activities allowed should be like at hospital 3- Emphasizing the necessity of a doctor's order to resume work, drive, and travel 4- Correct bathing 5- Providing emotional support to the patient and stating that the feeling of depression is fleeting 6- Emphasizing the importance of having a plan to perform appropriate activities in the first days after discharge 7- Feeling the need for religious activity and encouraging the patient to express religious beliefs, pray, and supplicating Telephone follow up on previous cares and emphasizing their implementation Telephone follow up on previous cares and emphasizing their implementation. Protective 1- Maintaining skin hygiene and the importance of having a dry skin surface and checking body areas under pressure 2- Maintaining the level of mobility and activity 3- Emphasizing the importance of changing position 4- Checking pulse and blood pressure to prevent possible bleeding 5- Chest tube control 6- Emphasizing the importance of wearing appropriate clothes and shoes to prevent falls 7- Keeping feet shoulder width apart while walking 1- Maintaining skin hygiene and the importance of having a dry skin surface 2- Maintaining the level of mobility and activity 3- The importance of changing position 4- Checking pulse and blood pressure to prevent possible bleeding 5- Teaching the correct use of walking aids 6- The correct way to walk to avoid falling 7- Teaching what medicines cause blood pressure drop and the related precautions 8- Encouraging the patient to enjoy music 9- Emphasizing the importance of controlling mental emotions and listening to the patient's problems and strengthening healthy changes 10- Encouraging the patient to do their favorite hobby Sexual 1- Sexual activity should be after 2–4 weeks after the operation depending on the patient's ability 1- Avoiding eating heavy food before intercourse 2- Stopping sexual activity upon exhaustion 3- Avoiding putting pressure on the ribs 4- Emphasizing the importance of doing sexual activity in the morning and after a night's rest Telephone follow-up and care re-education Telephone follow-up and care re-education Statistical analysis The quantitative variables were reported using mean and standard deviation, and qualitative variables, using frequency (percentage). The normality of the distribution of quantitative variables was assessed by the Shapiro–Wilk test. The comparison of qualitative variables in the two groups, was done using Fisher’s exact test or chi-square test. The quantitative variables in the two groups were compared using the independent samples t-test or Mann–Whitney test. Univariate effects of intervention condition on posttest outcome measures after adjustment for age as a confounder were examined using between-subjects analysis of covariance (ANCOVA), adjusting for pretest scores. The significance level of the tests was considered as 0.05. All tests were two sided. Data analysis was done using SPSS version 26. Result In this study, 128 patients undergoing coronary artery bypass graft were recruited were recruited. In Table 1 the demographic and clinical characteristics of the two groups are presented. Table 1 Demographic and clinical characteristics of participants in the intervention and control groups. Variable Control Group Intervention Group P-value Age; year 61.78 ± 8.25 57.39 ± 7.57 0.002 € Gender; n (%) 0.690 Male 44(8.8) 47(73.4) Female 20 (31.3) 17(26.6) Education; n (%) Illiterate 26(40.6) 17(26.6) 0.160 Primary 19(29.7) 25(39.1) Intermediate 2(3.1) 7(10.9) High school 3(4.7) 1 (1.6) Diploma 6 (9.4) 9 (14.1) Academic 8(12.5) 5(7.8) Hyperlipidemia; n (%) 0.360 Yes 29 (45.3) 23(35.9) No 35(54.7) 41 (64.1) Hypertension; n (%) 0.840 Yes 46(71.9) 44(68.8) No 18(28.1) 20(31.3) Diabetes; n (%) 0.280 Yes 40(62.5) 33 (51.6) No 24(37.5) 31 (48.4) € Two independent samples t test. The comparison of qualitative variables in the two groups, was done using Fisher’s exact test or chi-square test. The mean familiarity subsystem score reduced from baseline to after intervention in both groups (Table 2 ). After adjustment for age and pretest score, there was a significant difference between two groups (P-value = 0.0002). Table 2 Descriptive statistics and ANCOVA results for the outcome measures. Outcome Control Group Intervention Group F ¥ P-value Affiliative 10.49 0.002 0.07 Before -27.65 ± 39.62 -23.28 ± 34.87 After -90.00 ± 47.86 -68.59 ± 33.63 Restorative 171.056 0.58 > 0.0001 Before -153.43 ± 92.66 -163.59 ± 62.03 After 12.89 ± 97.64 198.43 ± 72.28 Aggressive/protective 70.46 0.362 > 0.0001 Before -56.40 ± 50.65 -62.18 ± 46.58 After -19.45 ± 59.94 52.18 ± 53.54 Dependency 88.54 0.417 > 0.0001 Before -90.85 ± 45.59 -122.26 ± 45.85 After -22.81 ± 76.93 104.60 ± 53.42 Eliminative 47.30 0.276 > 0.0001 Before -38.35 ± 58.71 -25.46 ± 33.27 After -16.40 ± 4.53 19.29 ± 35.61 Ingestive 115.23 0.482 > 0.0001 Before -128.45 ± 100.59 -135.67 ± 89.20 After -51.81 ± 115.16 152.75 ± 113.58 Achievement 45.70 0.269 > 0.0001 Before -86.25 ± 76.99 -98.98 ± 75.77 After -96.32 ± 82.03 -2.5 ± 71.55 Sexual 0.049 0.000 0.825 Before -15.23 ± 39.62 -20.31 ± 39.74 After -137.96 ± 67.73 -130.39 ± 68.07 ¥ Effect Size Data are presented as mean ± SD. Adjustment is considered for age and pretest scores. The patterns of change in energy saving subscale scores differed significantly in the two groups (P-value < 0.0001). Compared to the control group, the intervention group had a greater incretion in the mean energy saving subscale score from before intervention to after intervention. In the intervention group, the mean score of protection subscale increased from baseline to after intervention. In the control group, the mean score of protection subscale increased was reached to -19.45 throughout the study. However, the pattern of change in this subscale was similar in the two groups, but intervention group had greater changes between after intervention (P-value < 0.0001). The mean dependency subscale increased from baseline to after intervention in the two groups. In addition, compared to the control group, the intervention group had a greater and significant incretion in the mean score (104.60 vs – 22.81; P-value < 0.0001). The mean eliminative score in the intervention group and control group, increased after intervention (Table 2 ). There was a significant difference between the two groups in terms of the pattern of change of sleep duration over the time of study (P-value < 0.0001). The intervention group compared to the control group had an additional increase in the mean eliminative subscale score from baseline to after intervention. The patterns of change in the mean total eliminative score differ significantly in the two groups (P-value < 0.0001). Analysis of covariance showed that there is significant difference between two groups according to after intervention mean achievement score (P-value < 0.0001). But the sexual subscale score between two groups after intervention didn’t show a significant difference (P-value = 0.825). Discussion Our results suggest that the use of a nurse-led program based on Johnson's model can improve system equilibrium when individualized comprehensive care is provided even for patients undergoing CABG surgery. According to these results, the intervention based on Johnson's behavioral model reduced the patient's problems in terms of the affiliative sub-system. In their study determining the effect of a nursing care program using Johnson's behavioral system model in heart failure patients in Mashhad hospitals in 2020, Rahmani et al. observed no significant change in the two intervention and control groups as far as the affiliative subsystem was concerned [ 16 ], which is not consistent with the results of the present study. This discrepancy could be explained by a number of factors such as different research populations, intervention methods, lengths of intervention, care environments, and patients with different problems. The intervention in the present study also reduced the patient's problems in terms of the subsystem of aggressive-protective. These results are in agreement with those of Ghanbari Afra and Mohammad Hoseini who conducted a case study evaluating the effect of Johnson's behavioral system model on the care of a patient with heart failure in a hospital affiliated to Qom University of Medical Sciences. They showed that after using Johnson's model, the patient's unstable behaviors were reduced in terms of the aggressive-protective subsystem [ 19 ]. Johnson's behavioral system model emphasizes the evaluation of, and intervention with, the individual's behavioral system in a non-invasive manner. Therefore, in order to improve the disease symptoms, nursing interventions such as providing the patient with an opportunity to talk about their anger and using family support can reduce patient problems in this subsystem. Based on the findings of the present study, there was a decrease in the patient's problems with regard to the dependency subsystem. In line with the results of our study, Karkhah et al. reported improvement in the dependency subsystem as a result of a nursing care program based on Johnson's behavioral model in a patient with hematoma of the wrist joint who was admitted in Poursina Hospital in Rasht, Iran, in 2020 [ 20 ]. Suffering from heart disease is a source of stress for the patient and the family, and as a critical condition, it can disrupt the functioning and dynamics of the individual and the family. The nurse's reaction to the disease has therefore a profound effect on the patient's health and ultimately their recovery. Our results also showed a reduction in the patient's problems with respect to the eliminative subsystem. Nooraldini et al. studied the effect of a nursing process based on Johnson's behavioral system model in stroke patients, and detected inefficiency in the eliminative subsystem, which was related to the side effects of drugs causing constipation. Their nursing interventions included training on the consumption of laxative foods, increasing fluid intake to 6–8 glasses per day, drinking one glass of water on an empty stomach, walking for 30 minutes daily, and taking laxatives as prescribed by the doctor. At the end of the two-month period after the nursing intervention, the patient experienced improvement in terms of the eliminative subsystem and was able to control urine and feces [ 21 ], which is in line with the results of the present study. According to the results of this study, the patients' problems regarding the ingestive subsystem were reduced. In Karkhah et al., the interventions performed to diagnose anorexia included the following: checking the patient’s nutritional status, water and electrolytes, checking the patient's weight, asking the family for help in decorating the patient's food, and encouraging the patient to frequently consume food in small quantities. Based on their results, the patient's unstable behaviors regarding the ingestive subsystem were reduced following the use of Johnson's behavioral system model [ 20 ], which is in line with the results of the present study. Disease-associated malnutrition has detrimental effects on the healing process, leading to an increase in infection, delayed recovery, prolonged hospitalization, increased hospital costs, and mortality. Since the ingestive subsystem is concerned with the patient's ability to drink and eat sufficient liquids and food, have a proper appetite, and obtain dietary and medicinal information [ 22 ], it improves the nutritional status of the individual. Based on the findings of the present study, the patient's problems were improved in terms of the restorative sub-system. Payamani et al. evaluated a nursing process based on Johnson's behavioral system model in patients with multiple sclerosis. Fatigue related to muscle weakness from doing housework and spasm was diagnosed based on the client's statement. Their nursing interventions included learning to restore energy by resting between daily activities, stopping work before excessive fatigue, not doing heavy work and activities, dividing daily tasks into 24 hours, and taking prescribed medications on time. Their results showed that after nursing interventions, the client's muscle weakness and spasm improved [ 15 ], which is consistent with the results of the present study. Fatigue is one of the most common and uncomfortable side effects in heart patients, and when it becomes severe, it has an immense impact on daily functioning and quality of life. To manage fatigue, pharmacological and non-pharmacological interventions are performed. Johnson's behavioral system model is widely used as an effective non-pharmacological treatment in heart patients. The results of our study showed that the patient's problems were also reduced as far as the achievement subsystem was concerned. The results of Rahmani et al.'s study showed that positive changes in the dependency sub-system in the intervention group were significantly high, which is consistent with the results of the present study. Adherence to treatment, which is defined as the extent to which individuals' behavior conforms to health or treatment recommendations, regular use of medications, and adherence to therapist recommendations, is a complex behavioral process affected by factors such as therapist interaction and health care system. Care models not only guarantee the targeted, regular, controlled and effective care of the patient, but also provide the possibility of high and medium quality care by nurses [ 16 ]. Based on the results of this study, our intervention did not have a statistically significant effect on the sexual subsystem. In the study of Nooraldini et al., sexual dysfunction was diagnosed in relation to the complications of the disease (as determined by the patient's statement of decreased libido and sexual desire for the spouse). Their nursing interventions included teaching the clients to communicate verbally and non-verbally with their spouses, facilitating counseling with a clinical psychologist, and counseling with the spouses. Their results showed that at the end of the two-month period after the nursing process, the patient had improved in matters related to sexual activities, which is not consistent with our results [ 21 ]. This discrepancy can be explained by the fact that Nooraldini et al.'s study was a case report while ours is a clinical trial. The purpose of the sexual sub-system is to generate expectations in sexual relations, and its task is to expand the self-concept with sexual self-identity. Like all other subsystems, this subsystem changes constantly due to maturity, experience, and learning [ 23 ]. In the current study, the restorative sub-system was affected by the intervention more than other sub-systems. It seems that Johnson's behavioral systems model can help increase the restorative subsystem of patients by performing interventions such as "enhancing the ability to control and manage fatigue", which becomes the basis for regaining their strength. It important to note that the present study suffered from a number of limitations including the small sample size and conducting the intervention in only two hospitals, which may affect the generalizability of our findings. Therefore, similar studies using larger sample sizes and being conducted in multiple settings is recommended. Implications for practice One of the clinical implications that emerged from this study was that nursing care should include support, nurturing, restraint, inhibition, and facilitation, as these improve the behavioral system as a whole. A second clinical implication is to provide care based on the importance and severity of changes in the equilibrium state of each human behavioral subsystem since these changes ultimately affect the entire behavioral system. Declarations Acknowledgments This article was extracted from a master's thesis (U-01102) by Sakineh Rostami, a master's degree student in intensive care nursing, and has been registered in the Vice-Chancellor of Development and Research and Technology of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. The researchers hereby express their gratitude to all the people and organizations who helped them, in one way or another, in conducting this research. Authors’ contributions Study concept and design: S. R, S. M., N.E., and E.M; analysis and interpretation of data: E.M.; drafting of the manuscript: S. R, S. M., N.E., and E.M; critical revision of the manuscript for important intellectual content: S. R, S. M., N.E., and E.M. All authors have read and approved the manuscript. Funding This study funded by Ahvaz Jundishapur University of Medical Sciences. Availability of data and materials Data may be available by request submitted to the corresponding author. Ethics approval and consent to participate This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz (IR.AJUMS.REC. 1401.201). Participants were briefed on the purpose of the study and were assured of their freedom to voluntarily withdraw from the study. Then informed consent was obtained from all participants. This study was registered in the Iranian Registry of Clinical Trials (IRCT20220831055838N). Consent for publication Not applicable. Competing interests All authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. References Sweity EM, Alkaissi AA, Othman W, Salahat A: Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial . Journal of cardiothoracic surgery 2021, 16 (1):241. Muthukrishnan A, Tayyib NA, Alsolami FJ, Ramaiah P, Lathamangeswaric C: Anxiety and Quality of Life Outcomes After Coronary Artery Bypass Graft Surgery - A Prospective Cohort Study . Current problems in cardiology 2023, 48 (2):101474. Wang SR, Zhou K, Zhang W: Application progress of nursing intervention in cardiac surgery . 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Xue J, Li J, Sun D, Sheng L, Gong Y, Wang D, Zhang S, Zou Y, Shi J, Xu W et al : Functional Evaluation of Intermediate Coronary Lesions with Integrated Computed Tomography Angiography and Invasive Angiography in Patients with Stable Coronary Artery Disease . Journal of translational internal medicine 2022, 10 (3):255-263. Ball L, Costantino F, Pelosi P: Postoperative complications of patients undergoing cardiac surgery . Current opinion in critical care 2016, 22 (4):386-392. Song X, Wang H, Kashani KB, Wang C: Extracorporeal Membrane Oxygenation using a Modified Cardiopulmonary Bypass System . Journal of translational internal medicine 2022, 10 (2):175-177. Mali S, Haghaninejad H: Pulmonary complications following cardiac surgery . Archives of medical sciences Atherosclerotic diseases 2019, 4 :e280-e285. Safabakhsh L, Jahantigh M, Nosratzehi S, Navabi S: The Effect of Health Promoting Programs on Patient's Life Style After Coronary Artery Bypass Graft-Hospitalized in Shiraz Hospitals . Global journal of health science 2015, 8 (5):154-159. Hadi F, Molavynejad S, Elahi N, Haybar H, Maraghi E: King's Theory of Goal Attainment: Quality of Life for People With Myocardial Infarction . Nurs Sci Q 2023, 36 (3):250-257. Roy C, Jones D: Nursing knowledge development and clinical practice. Springer Publishing Company ; 2011. Payamani F, Khatiban M, Soltanian A, Ghiasian M, Borzou SR: The effect of applying the nursing process based on the Theory of Goal Attainment on activities of daily living and quality of life in persons with multiple sclerosis during COVID-19 pandemic: a clinical trial . Irish journal of medical science 2023, 192 (3):1361-1369. Rahmani B, Aghebati N, Esmaily H, Florczak KL: Nurse-led Care Program with Patients with Heart Failure Using Johnson's Behavioral System Model: A Randomized Controlled Trial . Nurs Sci Q 2020, 33 (3):204-214. Alligood MR: Nursing Theorists and Their Work , 8 edn: Mosby; 2013. Meleis AI: Theoretical nursing: Development and progress , 5 edn: Lippincott Williams & Wilkins; 2011. Ghanbari Afra L, Haji Mohammad Hoseini M: Implementing Johnson’s Behavioral System Model in a Patient With Heart Failure: A Case Study . Journal of Vessels and Circulation 2020, 1 (4):45-52. Karkhah S, Ghazanfari MJ, Norouzi M, Khaleghdoust T, Mirzaee S, Taheri Z, ghanbari A: Designing a nursing care plan based on Johnson's behavioral model in patients with wrist joint hematoma: A case study . pre print 2020. Nooreddini A, Cheraghi F, Borzou SR, Khatiban M: Nursing Process based on the Johnson’s Behavioral Model in Patient with CVA: Case Report . Journal of Nursing Education 2021, 10 (2):54-61. Hussain SMA, Harky A: Complications of Coronary Artery Bypass Grafting . International Journal of Medical Reviews 2019, 6 (1):1-5. Holaday B: Dorothy Johnson’s behavioral system model and its applications. Nursing theories and nursing practice 2015:89-104. Additional Declarations No competing interests reported. Supplementary Files CONSORT2010Checklist.doc Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 01 Nov, 2024 Reviews received at journal 21 Jul, 2024 Reviews received at journal 18 Jul, 2024 Reviewers agreed at journal 09 Jul, 2024 Reviewers agreed at journal 07 Jul, 2024 Reviewers agreed at journal 18 May, 2024 Reviewers agreed at journal 16 May, 2024 Reviewers invited by journal 16 May, 2024 Editor invited by journal 14 May, 2024 Submission checks completed at journal 10 May, 2024 Editor assigned by journal 10 May, 2024 First submitted to journal 26 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4331230","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":304010563,"identity":"7b3155a1-c4fb-400a-8e0c-6cfc2d50e613","order_by":0,"name":"Sakineh Rostami","email":"","orcid":"","institution":"Ahvaz Jundishapur University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sakineh","middleName":"","lastName":"Rostami","suffix":""},{"id":304010565,"identity":"9c52efe6-3166-4220-8d23-15c806557419","order_by":1,"name":"Shahram Molavynejad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYDACCQY2EJUA5nyAcCDiRGlhnEGyFmYeYtwlP7v52eOKmm15/LMPP/5sU8OXuLb/AOOHHwwW+bi0GNw5Zm545tjtYolzaQbGOcfYErfdSGCW7GGQsGzApUUiwUyyge12YsMZBoPkHDaQFgYGaaCDDXA6bEb6N8mGf7cT559h/3DY4h9Qy/kDzL/xaWG4kWMm2dh2O3HDGR7DZsY2oJYDCWx4bTG4kVMm2dh3u9jwDE8xY28fm/G2G4ltlj0GeB22TbLh2+08uTPsmz/8+HZMdtv5w4dv/Kiow+0wNHAMiBkbgLYTq4GBoYZ4paNgFIyCUTBiAADLOFfp0qYAegAAAABJRU5ErkJggg==","orcid":"","institution":"Ahvaz Jundishapur University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Shahram","middleName":"","lastName":"Molavynejad","suffix":""},{"id":304010566,"identity":"d7071ae7-d518-47d1-8eda-d57fe03ee755","order_by":2,"name":"Nasrin Elahi","email":"","orcid":"","institution":"Ahvaz Jundishapur University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nasrin","middleName":"","lastName":"Elahi","suffix":""},{"id":304010567,"identity":"29049ece-403c-4cbc-b8e9-893c71594826","order_by":3,"name":"Elham Maraghi","email":"","orcid":"","institution":"Ahvaz Jundishapur University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elham","middleName":"","lastName":"Maraghi","suffix":""}],"badges":[],"createdAt":"2024-04-26 18:32:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4331230/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4331230/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-03019-7","type":"published","date":"2025-04-03T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56889013,"identity":"06360c65-1fe7-4afa-983a-9fefb66764cb","added_by":"auto","created_at":"2024-05-21 19:05:11","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":657947,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart of the study groups\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4331230/v1/7ca02796ca7c945fe99ce5e9.jpeg"},{"id":80082233,"identity":"3e17cce9-d65e-4af2-8a8e-c49b3e32a643","added_by":"auto","created_at":"2025-04-07 16:07:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2434452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4331230/v1/8cb0201c-7695-4c31-9e75-a0e3b64bd03e.pdf"},{"id":56889661,"identity":"9f20d795-e702-47af-9349-4b2fc73ce3a1","added_by":"auto","created_at":"2024-05-21 19:13:11","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":224256,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2010Checklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-4331230/v1/dc70ecca98ca0851db2d2252.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing coronary artery bypass graft: a Randomized clinical trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCoronary artery disease (CAD) is a leading cause of death and disability worldwide. Therefore, coronary artery bypass graft (CABG) is indicated for patients with angina and patients with left main coronary artery stenosis or patients with multi vessel coronary artery disease (MVD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Previous studies have reported that the quality of life of CABG patients after surgery is not satisfactory in all dimensions, especially physical and emotional well-being [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients who undergo surgery often experience anxiety and even depression due to the fear of permanent disability, sleep disturbance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], changes in body image [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], reduced mobility, loss of health, slower wound healing, longer hospital stay [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], loss of physical control, loss of ability to work, pain, loss of sexual ability, inability to wake up after anesthesia, and death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePostoperative complications can easily occur with an incidence of 15\u0026ndash;30%. Possible complications include stroke, renal failure, prolonged intubation time, sternal wound infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and postoperative pulmonary infections (e.g., atelectasis, pleural effusion, pneumonia, pulmonary edema, cardiogenic pulmonary edema, acute respiratory distress syndrome, pulmonary embolism, phrenic nerve damage, pneumothorax, and mediastinitis) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies show that changing behavior and modifying lifestyle after open heart surgery can reduce the risk of complications [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, patients often have difficulty modifying their behaviors and adhering to new behaviors because it is difficult to change behaviors that have already been internalized throughout life. A useful strategy to facilitate behavior modification among patients is their active participation in the care process using interactive nursing theories [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nursing theories create a framework and structure for thinking and thus help nurses to better analyze situations, organize their thinking, and make the best decisions for patient care. Some theories also help to achieve standards of care, reduce health care costs, and improve quality of life [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The application of nursing models makes nursing interventions shift from service-oriented activities to client-centered ones. These models not only guarantee a targeted, regular, controlled, and effective care of the patient, but also provide the possibility of high quality care and lead to the development of professional nursing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. One important model is the behavior system model of nursing developed by Dorothy E. Johnson who believed that in order to prevent illness, there should be efficient and effective behavioral functioning in the patient. However, such models have rarely been adopted to investigate behavioral changes in patients undergoing CABG. More particularly, there is limited information about the effects Johnson's model on behavioral changes in CABG patients. Therefore, the present study was conducted to investigate the effects of a care program based on Johnson's behavioral model in patients undergoing CABG.\u003c/p\u003e\n\u003ch3\u003eTheoretical framework\u003c/h3\u003e\n\u003cp\u003eOne of the significant models in nursing literature is Johnson's behavioral systems model. This model is derived from Nightingale's premise that the goal of nursing is to help people prevent or recover from illness. Johnson envisioned a nursing client as a behavioral system. An orderly behavioral system includes interrelated and interdependent biological and behavioral subsystems. Johnson's behavioral systems model includes 8 sub-systems including: achievement, affiliative, eliminative, ingestive, dependency, aggressive-protective, sexual, and restorative [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This model sees people as behavioral systems that always want to achieve balance and stability, both in the internal and external environments, and they also have the desire to adjust and adapt to the effects they create [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese subsystems have similar components, structure, and function. Each of these subsystems has components that distinguish them from each other and make that subsystem definable. Structural components are: drive, set, action, and choice. The first component is the drive of the subsystem, which shows the reason and motivation behind the behavior. Drives that have different meanings are different for different people, they induce different meanings at different times for the same person, and they are not visible. The second component of the structure is set or tendency, which is the regular and normal behavior with which the client prefers to fulfill the goal of the subsystem. The next structural component of a subsystem is choice. Choices show the set and repository available to a person in order to achieve specific goals [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this model, Johnson divides nursing diagnoses into dominance, incompatibility, insufficiency and discrepancy based on the patient's problems. Nursing practices are the actions that the nurse performs to solve the problem, which in Johnson's behavioral model, are divided into four categories, namely restricting, defending, inhabiting, and facilitating [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eDesign\u003c/p\u003e \u003cp\u003eThis single-blind randomized clinical trial was conducted in Ahvaz, Iran, in 2023.\u003c/p\u003e \u003cp\u003eSampling\u003c/p\u003e \u003cp\u003eThe participants were 144 patients undergoing CABG who were admitted to two teaching hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Patients who were aged between 18\u0026ndash;75 years, were oriented to time and identity, had the ability to communicate, had undergone CABG, had a companion who knew about their condition, and had a telephone line were eligible to participate in the study. Exclusion criteria included the patient's unwillingness to cooperate at any time of the research, situations that require immediate intervention (e.g., decreased level of consciousness, sudden and progressive drop in blood oxygen saturation, etc.), and death of patients after surgery.\u003c/p\u003e \u003cp\u003eThe stages of the research are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eWe calculated the necessary sample size on the basis of our main primary outcome measure, with an expected 38.6 unit increase in the mean change of restorative score (total score). These calculations were based on previous study (16). To detect this difference with 80% power, typeI error of 5% and S\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;S\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;77.43, 64 patients for whom data could be analyzed were needed in each group.\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$n=\\frac{{\\left({Z}_{1-\\frac{\\alpha }{2}}+{Z}_{1-\\beta }\\right)}^{2}\\left({s}_{1}^{2}+{s}_{2}^{2}\\right)}{{\\left(\\text{d}\\right)}^{2}}=\\frac{{(1.96+1.04)}^{2}\\times 2\\times {\\left(73.89\\right)}^{2}}{{\\left(44.67\\right)}^{2}}\\cong 64$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWith an assumption of 10% withdrawals or protocol violations, we aimed to recruit 72 patients in each group.\u003c/p\u003e \u003cp\u003eRandomization\u003c/p\u003e \u003cp\u003eThis was a RCT in which 128 patients undergoing coronary artery bypass graft were recruited and randomly divided into two groups of intervention or control using an allocation ratio of 1:1 and the block randomization with a random block size of four, six and eight.\u003c/p\u003e \u003cp\u003eBlinding\u003c/p\u003e \u003cp\u003eDue to the nature of this study, blinding of researchers and participants was not possible, but neither the patients nor the researcher were aware of the allocation order until the commencement of the intervention.\u003c/p\u003e \u003cp\u003eInstruments\u003c/p\u003e \u003cp\u003eThe tools used in this study included a demographic information form, patient medical records, and a researcher-made evaluation tool based on Johnson's theory to evaluate the behavioral system of patients undergoing CABG. The content validity of the new tool was verified: CVR\u0026thinsp;\u0026gt;\u0026thinsp;0.6 and CVI\u0026thinsp;\u0026gt;\u0026thinsp;0.7 in each subsystem. Also, the alpha coefficient reliability was calculated to be 0.86. The questionnaire used to evaluate the behavioral system of patients was a scale including 37 questions in eight sub-systems: restorative, ingestive, eliminative, aggressive-protective, dependency, sexual, affiliative, and achievement. Each item in each sub-system was answered by the patient according to three aspects. One aspect was related to changes in symptoms or ability to function. The patient responded by indicating an increase or decrease or no change. Then this change was identified as negative or positive. Finally, the magnitude of these changes was scored on a scale of 0-100 and considered positive or negative. A total score was calculated for each subsystem, and the nurse focused on care in the subsystem with the worst score.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eData were collected in this study by the lead researcher between December 2022 and December 2023. To this aim, demographic and medical information forms were read to the patients by the lead researcher who then scored the form based on the patient's response. The tool for examining the behavioral system of patients after CABG was completed by the lead researcher at two intervals according to the patient's response: the first time when the patient was hospitalized in the ward and the second time was two weeks after the operation, when the patient was discharged and followed up by phone.\u003c/p\u003e \u003cp\u003eIntervention: A Nurse-Led Care Program\u003c/p\u003e \u003cp\u003eAll patients were transferred to the ICU after CABG and were admitted to the cardiac ICU for an average of 2 days. After being discharged from the ICU, they were admitted to the cardiac surgery department for an average of 3\u0026ndash;4 days, and were discharged from the department in case they had no problems. To this aim, the first step was to assess the existence of problems by analyzing the findings obtained from the behavioral assessment tool. In the evaluation, the performance and purpose of each subsystem was taken into account. Equilibrium state in each subsystem was checked by analyzing: a) whether there was any change in the structure or function of the subsystem, b) whether the patient feels the change positively or negatively, and c) how important this change is for the patient. Based on the overall equilibrium state of each subsystem, the scores were sorted from the lowest to the highest.\u003c/p\u003e \u003cp\u003eThe researcher and one of the nurses in the cardiac ICU and cardiac surgery department managed the patients' problems through nursing processes, and then based on the NANDA system, nursing diagnoses were made. The diagnoses were expressed in two ways: 1- Internal problems in each subsystem: any failure to meet functional requirements or the existence of incompatibility between the structural components of the subsystems. 2- Inter-system problem: the dominance of one or two subsystems in the entire behavioral system or the existence of conflict between two or more subsystems.\u003c/p\u003e \u003cp\u003eIn the second step, the lead researcher gave the necessary training to the nurses of the cardiology and cardiac surgery department in three 60-minute sessions. This included information about how to: use Johnson's behavioral system model, evaluate patients using tools designed to examine patients' behavioral systems, write nursing diagnoses, and take the necessary measures to manage patients' problems. The patient's companion was also included in these sessions. The care model was implemented by the lead researcher in the morning shift and by trained nurses in the evening and night shifts.\u003c/p\u003e \u003cp\u003eThe care program for each patient was implemented for two weeks. After discharge, care recommendations were provided over phone. The care program of the patients started about 24 hours after the operation when they were able to sit. Patients were examined first, and according to each sub-system, stable and unstable behaviors were determined. Depending on unstable behaviors and nursing diagnoses, interventions were made, and the final evaluation was done by completing the questionnaire. Interventions were performed based on Johnson's behavioral model in eight subsystems. The control group received only routine care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsystem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSession 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSession 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSession 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSession 4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestorative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Coughing and deep breathing training\u003c/p\u003e \u003cp\u003e2- Proper sleep training\u003c/p\u003e \u003cp\u003e3- Correct walking training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Coughing and deep breathing training\u003c/p\u003e \u003cp\u003e2- Proper sleep training\u003c/p\u003e \u003cp\u003e3- Correct walking training\u003c/p\u003e \u003cp\u003e4- The importance of chest physiotherapy\u003c/p\u003e \u003cp\u003e5- Teaching relaxation techniques and expressing emotions\u003c/p\u003e \u003cp\u003e6- Teaching the use of incentive spirometry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIngestive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- The importance of consuming fluids and adequate and appropriate diet\u003c/p\u003e \u003cp\u003e2- Methods of increasing appetite\u003c/p\u003e \u003cp\u003e3- The ability to tolerate food\u003c/p\u003e \u003cp\u003e4- Proper diet training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- The importance of adequate and proper fluid intake and diet\u003c/p\u003e \u003cp\u003e2- Methods of increasing appetite\u003c/p\u003e \u003cp\u003e3- The ability to tolerate food\u003c/p\u003e \u003cp\u003e4- The importance of daily weighing\u003c/p\u003e \u003cp\u003e5- Providing drug information and drug precautions\u003c/p\u003e \u003cp\u003e6- Proper diet training\u003c/p\u003e \u003cp\u003e7- Teaching active and passive movements in the range of joints\u003c/p\u003e \u003cp\u003e8- Pain control\u003c/p\u003e \u003cp\u003e9- Giving information about recommended sports and rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchievement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Importance of compliance with diet, medication, and exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Importance of compliance with diet, medication, and exercise\u003c/p\u003e \u003cp\u003e2- Getting feedback from the patient regarding training related to diet, medication and exercise\u003c/p\u003e \u003cp\u003e3- Teaching how to check blood sugar and blood pressure and get feedback\u003c/p\u003e \u003cp\u003e4- Teaching the correct use of varicose socks\u003c/p\u003e \u003cp\u003e5- Explaining the stress associated with surgery and teaching how to deal with it\u003c/p\u003e \u003cp\u003e6- Giving the patient a chance to freely express their feelings and concerns\u003c/p\u003e \u003cp\u003e7- The correct way of praying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEliminative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Controlling the absorption and excretion of liquids and electrolytes\u003c/p\u003e \u003cp\u003e2- Asking about defecation problems and teaching how to prevent constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Controlling the absorption and excretion of fluids and electrolytes\u003c/p\u003e \u003cp\u003e2- Asking about defecation problems and teaching how to prevent constipation\u003c/p\u003e \u003cp\u003e3- Fever control\u003c/p\u003e \u003cp\u003e4- Giving the patients the ability to express feelings and motivating them to do simple tasks\u003c/p\u003e \u003cp\u003e5- Requesting the patient's family to support them for the purpose of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffiliative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Emphasizing minimum family visits at first and increasing them over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Emphasis on minimum family visits at first and increasing them over time\u003c/p\u003e \u003cp\u003e2- Giving the patient the ability to communicate with family and friends and encouraging them to express their concerns with family members\u003c/p\u003e \u003cp\u003e3- Emphasizing the importance of daily changing of clothes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Emphasizing the importance of changing activities upon exhaustion\u003c/p\u003e \u003cp\u003e2- Training on the correct way of bathing and emphasizing its brevity, not using body brushes, and using lukewarm water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Emphasizing the importance of changing activities upon exhaustion\u003c/p\u003e \u003cp\u003e2- Telling the patient to avoid heavy work and stressing that in the first days after discharge, the activities allowed should be like at hospital\u003c/p\u003e \u003cp\u003e3- Emphasizing the necessity of a doctor's order to resume work, drive, and travel\u003c/p\u003e \u003cp\u003e4- Correct bathing\u003c/p\u003e \u003cp\u003e5- Providing emotional support to the patient and stating that the feeling of depression is fleeting\u003c/p\u003e \u003cp\u003e6- Emphasizing the importance of having a plan to perform appropriate activities in the first days after discharge\u003c/p\u003e \u003cp\u003e7- Feeling the need for religious activity and encouraging the patient to express religious beliefs, pray, and supplicating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow up on previous cares and emphasizing their implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Maintaining skin hygiene and the importance of having a dry skin surface and checking body areas under pressure\u003c/p\u003e \u003cp\u003e2- Maintaining the level of mobility and activity\u003c/p\u003e \u003cp\u003e3- Emphasizing the importance of changing position\u003c/p\u003e \u003cp\u003e4- Checking pulse and blood pressure to prevent possible bleeding\u003c/p\u003e \u003cp\u003e5- Chest tube control\u003c/p\u003e \u003cp\u003e6- Emphasizing the importance of wearing appropriate clothes and shoes to prevent falls\u003c/p\u003e \u003cp\u003e7- Keeping feet shoulder width apart while walking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Maintaining skin hygiene and the importance of having a dry skin surface\u003c/p\u003e \u003cp\u003e2- Maintaining the level of mobility and activity\u003c/p\u003e \u003cp\u003e3- The importance of changing position\u003c/p\u003e \u003cp\u003e4- Checking pulse and blood pressure to prevent possible bleeding\u003c/p\u003e \u003cp\u003e5- Teaching the correct use of walking aids\u003c/p\u003e \u003cp\u003e6- The correct way to walk to avoid falling\u003c/p\u003e \u003cp\u003e7- Teaching what medicines cause blood pressure drop and the related precautions\u003c/p\u003e \u003cp\u003e8- Encouraging the patient to enjoy music\u003c/p\u003e \u003cp\u003e9- Emphasizing the importance of controlling mental emotions and listening to the patient's problems and strengthening healthy changes\u003c/p\u003e \u003cp\u003e10- Encouraging the patient to do their favorite hobby\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Sexual activity should be after 2\u0026ndash;4 weeks after the operation depending on the patient's ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Avoiding eating heavy food before intercourse\u003c/p\u003e \u003cp\u003e2- Stopping sexual activity upon exhaustion\u003c/p\u003e \u003cp\u003e3- Avoiding putting pressure on the ribs\u003c/p\u003e \u003cp\u003e4- Emphasizing the importance of doing sexual activity in the morning and after a night's rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTelephone follow-up and care re-education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTelephone follow-up and care re-education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe quantitative variables were reported using mean and standard deviation, and qualitative variables, using frequency (percentage). The normality of the distribution of quantitative variables was assessed by the Shapiro\u0026ndash;Wilk test. The comparison of qualitative variables in the two groups, was done using Fisher\u0026rsquo;s exact test or chi-square test. The quantitative variables in the two groups were compared using the independent samples t-test or Mann\u0026ndash;Whitney test. Univariate effects of intervention condition on posttest outcome measures after adjustment for age as a confounder were examined using between-subjects analysis of covariance (ANCOVA), adjusting for pretest scores. The significance level of the tests was considered as 0.05. All tests were two sided. Data analysis was done using SPSS version 26.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eIn this study, 128 patients undergoing coronary artery bypass graft were recruited were recruited. In Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e the demographic and clinical characteristics of the two groups are presented.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of participants in the intervention and control groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge; year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.78\u0026thinsp;\u0026plusmn;\u0026thinsp;8.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003csup\u003e\u0026euro;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35(54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u0026euro;\u003c/sup\u003eTwo independent samples t test.\u003c/p\u003e \u003cp\u003eThe comparison of qualitative variables in the two groups, was done using Fisher\u0026rsquo;s exact test or chi-square test.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean familiarity subsystem score reduced from baseline to after intervention in both groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After adjustment for age and pretest score, there was a significant difference between two groups (P-value\u0026thinsp;=\u0026thinsp;0.0002).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and ANCOVA results for the outcome measures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026yen;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffiliative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-27.65\u0026thinsp;\u0026plusmn;\u0026thinsp;39.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-23.28\u0026thinsp;\u0026plusmn;\u0026thinsp;34.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-90.00\u0026thinsp;\u0026plusmn;\u0026thinsp;47.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-68.59\u0026thinsp;\u0026plusmn;\u0026thinsp;33.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestorative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e171.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-153.43\u0026thinsp;\u0026plusmn;\u0026thinsp;92.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-163.59\u0026thinsp;\u0026plusmn;\u0026thinsp;62.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.89\u0026thinsp;\u0026plusmn;\u0026thinsp;97.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198.43\u0026thinsp;\u0026plusmn;\u0026thinsp;72.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAggressive/protective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-56.40\u0026thinsp;\u0026plusmn;\u0026thinsp;50.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-62.18\u0026thinsp;\u0026plusmn;\u0026thinsp;46.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-19.45\u0026thinsp;\u0026plusmn;\u0026thinsp;59.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.18\u0026thinsp;\u0026plusmn;\u0026thinsp;53.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-90.85\u0026thinsp;\u0026plusmn;\u0026thinsp;45.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-122.26\u0026thinsp;\u0026plusmn;\u0026thinsp;45.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-22.81\u0026thinsp;\u0026plusmn;\u0026thinsp;76.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104.60\u0026thinsp;\u0026plusmn;\u0026thinsp;53.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEliminative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-38.35\u0026thinsp;\u0026plusmn;\u0026thinsp;58.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-25.46\u0026thinsp;\u0026plusmn;\u0026thinsp;33.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-16.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.29\u0026thinsp;\u0026plusmn;\u0026thinsp;35.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIngestive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-128.45\u0026thinsp;\u0026plusmn;\u0026thinsp;100.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-135.67\u0026thinsp;\u0026plusmn;\u0026thinsp;89.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-51.81\u0026thinsp;\u0026plusmn;\u0026thinsp;115.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e152.75\u0026thinsp;\u0026plusmn;\u0026thinsp;113.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchievement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-86.25\u0026thinsp;\u0026plusmn;\u0026thinsp;76.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-98.98\u0026thinsp;\u0026plusmn;\u0026thinsp;75.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-96.32\u0026thinsp;\u0026plusmn;\u0026thinsp;82.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;71.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-15.23\u0026thinsp;\u0026plusmn;\u0026thinsp;39.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-20.31\u0026thinsp;\u0026plusmn;\u0026thinsp;39.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-137.96\u0026thinsp;\u0026plusmn;\u0026thinsp;67.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-130.39\u0026thinsp;\u0026plusmn;\u0026thinsp;68.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u0026yen;\u003c/sup\u003eEffect Size\u003c/p\u003e \u003cp\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003eAdjustment is considered for age and pretest scores.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe patterns of change in energy saving subscale scores differed significantly in the two groups (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Compared to the control group, the intervention group had a greater incretion in the mean energy saving subscale score from before intervention to after intervention.\u003c/p\u003e \u003cp\u003eIn the intervention group, the mean score of protection subscale increased from baseline to after intervention. In the control group, the mean score of protection subscale increased was reached to -19.45 throughout the study. However, the pattern of change in this subscale was similar in the two groups, but intervention group had greater changes between after intervention (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eThe mean dependency subscale increased from baseline to after intervention in the two groups. In addition, compared to the control group, the intervention group had a greater and significant incretion in the mean score (104.60 vs \u0026ndash; 22.81; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eThe mean eliminative score in the intervention group and control group, increased after intervention (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a significant difference between the two groups in terms of the pattern of change of sleep duration over the time of study (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eThe intervention group compared to the control group had an additional increase in the mean eliminative subscale score from baseline to after intervention. The patterns of change in the mean total eliminative score differ significantly in the two groups (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eAnalysis of covariance showed that there is significant difference between two groups according to after intervention mean achievement score (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). But the sexual subscale score between two groups after intervention didn\u0026rsquo;t show a significant difference (P-value\u0026thinsp;=\u0026thinsp;0.825).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our results suggest that the use of a nurse-led program based on Johnson's model can improve system equilibrium when individualized comprehensive care is provided even for patients undergoing CABG surgery. According to these results, the intervention based on Johnson's behavioral model reduced the patient's problems in terms of the affiliative sub-system. In their study determining the effect of a nursing care program using Johnson's behavioral system model in heart failure patients in Mashhad hospitals in 2020, Rahmani et al. observed no significant change in the two intervention and control groups as far as the affiliative subsystem was concerned [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which is not consistent with the results of the present study. This discrepancy could be explained by a number of factors such as different research populations, intervention methods, lengths of intervention, care environments, and patients with different problems.\u003c/p\u003e \u003cp\u003eThe intervention in the present study also reduced the patient's problems in terms of the subsystem of aggressive-protective. These results are in agreement with those of Ghanbari Afra and Mohammad Hoseini who conducted a case study evaluating the effect of Johnson's behavioral system model on the care of a patient with heart failure in a hospital affiliated to Qom University of Medical Sciences. They showed that after using Johnson's model, the patient's unstable behaviors were reduced in terms of the aggressive-protective subsystem [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Johnson's behavioral system model emphasizes the evaluation of, and intervention with, the individual's behavioral system in a non-invasive manner. Therefore, in order to improve the disease symptoms, nursing interventions such as providing the patient with an opportunity to talk about their anger and using family support can reduce patient problems in this subsystem.\u003c/p\u003e \u003cp\u003eBased on the findings of the present study, there was a decrease in the patient's problems with regard to the dependency subsystem. In line with the results of our study, Karkhah et al. reported improvement in the dependency subsystem as a result of a nursing care program based on Johnson's behavioral model in a patient with hematoma of the wrist joint who was admitted in Poursina Hospital in Rasht, Iran, in 2020 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Suffering from heart disease is a source of stress for the patient and the family, and as a critical condition, it can disrupt the functioning and dynamics of the individual and the family. The nurse's reaction to the disease has therefore a profound effect on the patient's health and ultimately their recovery.\u003c/p\u003e \u003cp\u003eOur results also showed a reduction in the patient's problems with respect to the eliminative subsystem. Nooraldini et al. studied the effect of a nursing process based on Johnson's behavioral system model in stroke patients, and detected inefficiency in the eliminative subsystem, which was related to the side effects of drugs causing constipation. Their nursing interventions included training on the consumption of laxative foods, increasing fluid intake to 6\u0026ndash;8 glasses per day, drinking one glass of water on an empty stomach, walking for 30 minutes daily, and taking laxatives as prescribed by the doctor. At the end of the two-month period after the nursing intervention, the patient experienced improvement in terms of the eliminative subsystem and was able to control urine and feces [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which is in line with the results of the present study.\u003c/p\u003e \u003cp\u003eAccording to the results of this study, the patients' problems regarding the ingestive subsystem were reduced. In Karkhah et al., the interventions performed to diagnose anorexia included the following: checking the patient\u0026rsquo;s nutritional status, water and electrolytes, checking the patient's weight, asking the family for help in decorating the patient's food, and encouraging the patient to frequently consume food in small quantities. Based on their results, the patient's unstable behaviors regarding the ingestive subsystem were reduced following the use of Johnson's behavioral system model [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which is in line with the results of the present study. Disease-associated malnutrition has detrimental effects on the healing process, leading to an increase in infection, delayed recovery, prolonged hospitalization, increased hospital costs, and mortality. Since the ingestive subsystem is concerned with the patient's ability to drink and eat sufficient liquids and food, have a proper appetite, and obtain dietary and medicinal information [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], it improves the nutritional status of the individual.\u003c/p\u003e \u003cp\u003eBased on the findings of the present study, the patient's problems were improved in terms of the restorative sub-system. Payamani et al. evaluated a nursing process based on Johnson's behavioral system model in patients with multiple sclerosis. Fatigue related to muscle weakness from doing housework and spasm was diagnosed based on the client's statement. Their nursing interventions included learning to restore energy by resting between daily activities, stopping work before excessive fatigue, not doing heavy work and activities, dividing daily tasks into 24 hours, and taking prescribed medications on time. Their results showed that after nursing interventions, the client's muscle weakness and spasm improved [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which is consistent with the results of the present study. Fatigue is one of the most common and uncomfortable side effects in heart patients, and when it becomes severe, it has an immense impact on daily functioning and quality of life. To manage fatigue, pharmacological and non-pharmacological interventions are performed. Johnson's behavioral system model is widely used as an effective non-pharmacological treatment in heart patients.\u003c/p\u003e \u003cp\u003eThe results of our study showed that the patient's problems were also reduced as far as the achievement subsystem was concerned. The results of Rahmani et al.'s study showed that positive changes in the dependency sub-system in the intervention group were significantly high, which is consistent with the results of the present study. Adherence to treatment, which is defined as the extent to which individuals' behavior conforms to health or treatment recommendations, regular use of medications, and adherence to therapist recommendations, is a complex behavioral process affected by factors such as therapist interaction and health care system. Care models not only guarantee the targeted, regular, controlled and effective care of the patient, but also provide the possibility of high and medium quality care by nurses [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the results of this study, our intervention did not have a statistically significant effect on the sexual subsystem. In the study of Nooraldini et al., sexual dysfunction was diagnosed in relation to the complications of the disease (as determined by the patient's statement of decreased libido and sexual desire for the spouse). Their nursing interventions included teaching the clients to communicate verbally and non-verbally with their spouses, facilitating counseling with a clinical psychologist, and counseling with the spouses. Their results showed that at the end of the two-month period after the nursing process, the patient had improved in matters related to sexual activities, which is not consistent with our results [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This discrepancy can be explained by the fact that Nooraldini et al.'s study was a case report while ours is a clinical trial. The purpose of the sexual sub-system is to generate expectations in sexual relations, and its task is to expand the self-concept with sexual self-identity. Like all other subsystems, this subsystem changes constantly due to maturity, experience, and learning [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current study, the restorative sub-system was affected by the intervention more than other sub-systems. It seems that Johnson's behavioral systems model can help increase the restorative subsystem of patients by performing interventions such as \"enhancing the ability to control and manage fatigue\", which becomes the basis for regaining their strength.\u003c/p\u003e \u003cp\u003eIt important to note that the present study suffered from a number of limitations including the small sample size and conducting the intervention in only two hospitals, which may affect the generalizability of our findings. Therefore, similar studies using larger sample sizes and being conducted in multiple settings is recommended.\u003c/p\u003e \u003cp\u003eImplications for practice\u003c/p\u003e \u003cp\u003eOne of the clinical implications that emerged from this study was that nursing care should include support, nurturing, restraint, inhibition, and facilitation, as these improve the behavioral system as a whole. A second clinical implication is to provide care based on the importance and severity of changes in the equilibrium state of each human behavioral subsystem since these changes ultimately affect the entire behavioral system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article was extracted from a master\u0026apos;s thesis (U-01102) by Sakineh Rostami, a master\u0026apos;s degree student in intensive care nursing, and has been registered in the Vice-Chancellor of Development and Research and Technology of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. The researchers hereby express their gratitude to all the people and organizations who helped them, in one way or another, in conducting this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept and design: S. R, S. M., N.E., and E.M; analysis and interpretation of data: E.M.; drafting of the manuscript: S. R, S. M., N.E., and E.M; critical revision of the manuscript for important intellectual content: S. R, S. M., N.E., and E.M. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study funded by Ahvaz Jundishapur University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData may be available by request submitted to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz (IR.AJUMS.REC. 1401.201). Participants were briefed on the purpose of the study and were assured of their freedom to voluntarily withdraw from the study. Then informed consent was obtained from all participants. This study was registered in the Iranian Registry of Clinical Trials (IRCT20220831055838N).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSweity EM, Alkaissi AA, Othman W, Salahat A: \u003cstrong\u003ePreoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial\u003c/strong\u003e. \u003cem\u003eJournal of cardiothoracic surgery \u003c/em\u003e2021, \u003cstrong\u003e16\u003c/strong\u003e(1):241.\u003c/li\u003e\n\u003cli\u003eMuthukrishnan A, Tayyib NA, Alsolami FJ, Ramaiah P, Lathamangeswaric C: \u003cstrong\u003eAnxiety and Quality of Life Outcomes After Coronary Artery Bypass Graft Surgery - A Prospective Cohort Study\u003c/strong\u003e. \u003cem\u003eCurrent problems in cardiology \u003c/em\u003e2023, \u003cstrong\u003e48\u003c/strong\u003e(2):101474.\u003c/li\u003e\n\u003cli\u003eWang SR, Zhou K, Zhang W: \u003cstrong\u003eApplication progress of nursing intervention in cardiac surgery\u003c/strong\u003e. \u003cem\u003eWorld journal of clinical cases \u003c/em\u003e2023, \u003cstrong\u003e11\u003c/strong\u003e(33):7943-7950.\u003c/li\u003e\n\u003cli\u003eMuthukrishnan A, Muralidharan TR, Subash J, Lathamangeswari C: \u003cstrong\u003eAssociation of poor sleep quality with risk factors after coronary artery bypass graft surgery-A prospective cohort study\u003c/strong\u003e. \u003cem\u003eJournal of vascular nursing : official publication of the Society for Peripheral Vascular Nursing \u003c/em\u003e2020, \u003cstrong\u003e38\u003c/strong\u003e(2):83-92.\u003c/li\u003e\n\u003cli\u003eBj\u0026oslash;rnnes AK, Lie I, Parry M, Falk R, Leegaard M, Rust\u0026oslash;en T, Valeberg BT: \u003cstrong\u003eAssociation between self-perceived pain sensitivity and pain intensity after cardiac surgery\u003c/strong\u003e. \u003cem\u003eJournal of pain research \u003c/em\u003e2018, \u003cstrong\u003e11\u003c/strong\u003e:1425-1432.\u003c/li\u003e\n\u003cli\u003eKurfirst V, Mokr\u0026aacute;ček A, Krupauerov\u0026aacute; M, Can\u0026aacute;dyov\u0026aacute; J, Bulava A, Pe\u0026scaron;l L, Ad\u0026aacute;mkov\u0026aacute; V: \u003cstrong\u003eHealth-related quality of life after cardiac surgery--the effects of age, preoperative conditions and postoperative complications\u003c/strong\u003e. \u003cem\u003eJournal of cardiothoracic surgery \u003c/em\u003e2014, \u003cstrong\u003e9\u003c/strong\u003e:46.\u003c/li\u003e\n\u003cli\u003ePrado-Olivares J, Chover-Sierra E: \u003cstrong\u003ePreoperatory Anxiety in Patients Undergoing Cardiac Surgery\u003c/strong\u003e. \u003cem\u003eDiseases (Basel, Switzerland) \u003c/em\u003e2019, \u003cstrong\u003e7\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eXue J, Li J, Sun D, Sheng L, Gong Y, Wang D, Zhang S, Zou Y, Shi J, Xu W\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eFunctional Evaluation of Intermediate Coronary Lesions with Integrated Computed Tomography Angiography and Invasive Angiography in Patients with Stable Coronary Artery Disease\u003c/strong\u003e. \u003cem\u003eJournal of translational internal medicine \u003c/em\u003e2022, \u003cstrong\u003e10\u003c/strong\u003e(3):255-263.\u003c/li\u003e\n\u003cli\u003eBall L, Costantino F, Pelosi P: \u003cstrong\u003ePostoperative complications of patients undergoing cardiac surgery\u003c/strong\u003e. \u003cem\u003eCurrent opinion in critical care \u003c/em\u003e2016, \u003cstrong\u003e22\u003c/strong\u003e(4):386-392.\u003c/li\u003e\n\u003cli\u003eSong X, Wang H, Kashani KB, Wang C: \u003cstrong\u003eExtracorporeal Membrane Oxygenation using a Modified Cardiopulmonary Bypass System\u003c/strong\u003e. \u003cem\u003eJournal of translational internal medicine \u003c/em\u003e2022, \u003cstrong\u003e10\u003c/strong\u003e(2):175-177.\u003c/li\u003e\n\u003cli\u003eMali S, Haghaninejad H: \u003cstrong\u003ePulmonary complications following cardiac surgery\u003c/strong\u003e. \u003cem\u003eArchives of medical sciences Atherosclerotic diseases \u003c/em\u003e2019, \u003cstrong\u003e4\u003c/strong\u003e:e280-e285.\u003c/li\u003e\n\u003cli\u003eSafabakhsh L, Jahantigh M, Nosratzehi S, Navabi S: \u003cstrong\u003eThe Effect of Health Promoting Programs on Patient\u0026apos;s Life Style After Coronary Artery Bypass Graft-Hospitalized in Shiraz Hospitals\u003c/strong\u003e. \u003cem\u003eGlobal journal of health science \u003c/em\u003e2015, \u003cstrong\u003e8\u003c/strong\u003e(5):154-159.\u003c/li\u003e\n\u003cli\u003eHadi F, Molavynejad S, Elahi N, Haybar H, Maraghi E: \u003cstrong\u003eKing\u0026apos;s Theory of Goal Attainment: Quality of Life for People With Myocardial Infarction\u003c/strong\u003e. \u003cem\u003eNurs Sci Q \u003c/em\u003e2023, \u003cstrong\u003e36\u003c/strong\u003e(3):250-257.\u003c/li\u003e\n\u003cli\u003eRoy C, Jones D: \u003cstrong\u003eNursing knowledge development and clinical practice. Springer Publishing Company\u003c/strong\u003e; 2011.\u003c/li\u003e\n\u003cli\u003ePayamani F, Khatiban M, Soltanian A, Ghiasian M, Borzou SR: \u003cstrong\u003eThe effect of applying the nursing process based on the Theory of Goal Attainment on activities of daily living and quality of life in persons with multiple sclerosis during COVID-19 pandemic: a clinical trial\u003c/strong\u003e. \u003cem\u003eIrish journal of medical science \u003c/em\u003e2023, \u003cstrong\u003e192\u003c/strong\u003e(3):1361-1369.\u003c/li\u003e\n\u003cli\u003eRahmani B, Aghebati N, Esmaily H, Florczak KL: \u003cstrong\u003eNurse-led Care Program with Patients with Heart Failure Using Johnson\u0026apos;s Behavioral System Model: A Randomized Controlled Trial\u003c/strong\u003e. \u003cem\u003eNurs Sci Q \u003c/em\u003e2020, \u003cstrong\u003e33\u003c/strong\u003e(3):204-214.\u003c/li\u003e\n\u003cli\u003eAlligood MR: \u003cstrong\u003eNursing Theorists and Their Work\u003c/strong\u003e, 8 edn: Mosby; 2013.\u003c/li\u003e\n\u003cli\u003eMeleis AI: \u003cstrong\u003eTheoretical nursing: Development and progress\u003c/strong\u003e, 5 edn: Lippincott Williams \u0026amp; Wilkins; 2011.\u003c/li\u003e\n\u003cli\u003eGhanbari Afra L, Haji Mohammad Hoseini M: \u003cstrong\u003eImplementing Johnson\u0026rsquo;s Behavioral System Model in a Patient With Heart Failure: A Case Study\u003c/strong\u003e. \u003cem\u003eJournal of Vessels and Circulation \u003c/em\u003e2020, \u003cstrong\u003e1\u003c/strong\u003e(4):45-52.\u003c/li\u003e\n\u003cli\u003eKarkhah S, Ghazanfari MJ, Norouzi M, Khaleghdoust T, Mirzaee S, Taheri Z, ghanbari A: \u003cstrong\u003eDesigning a nursing care plan based on Johnson\u0026apos;s behavioral model in patients with wrist joint hematoma: A case study\u003c/strong\u003e. \u003cem\u003epre print \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eNooreddini A, Cheraghi F, Borzou SR, Khatiban M: \u003cstrong\u003eNursing Process based on the Johnson\u0026rsquo;s Behavioral Model in Patient with CVA: Case Report\u003c/strong\u003e. \u003cem\u003eJournal of Nursing Education \u003c/em\u003e2021, \u003cstrong\u003e10\u003c/strong\u003e(2):54-61.\u003c/li\u003e\n\u003cli\u003eHussain SMA, Harky A: \u003cstrong\u003eComplications of Coronary Artery Bypass Grafting\u003c/strong\u003e. \u003cem\u003eInternational Journal of Medical Reviews \u003c/em\u003e2019, \u003cstrong\u003e6\u003c/strong\u003e(1):1-5.\u003c/li\u003e\n\u003cli\u003eHoladay B: \u003cstrong\u003eDorothy Johnson\u0026rsquo;s behavioral system model and its applications.\u003c/strong\u003e\u003cem\u003e Nursing theories and nursing practice \u003c/em\u003e2015:89-104.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"care plan, Johnson's model, behavioral system, CABG patients","lastPublishedDoi":"10.21203/rs.3.rs-4331230/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4331230/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Coronary artery bypass graft (CABG) is a very important intervention to relieve angina, improve quality of life, or increase life expectancy. This study aimed to determine the effect of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing CABG in Ahvaz teaching hospitals in 2022.\u003c/p\u003e\n\u003cp\u003eMaterials and methods: The present study was a clinical trial on 128 patients undergoing CABG admitted to the cardiac ICU and cardiac surgery department of teaching hospitals in Ahvaz city. The patients were selected based on the inclusion criteria, and they were assigned into intervention and control groups using permutation blocks. In the intervention group, a nursing care program based on Johnson's model was implemented for three weeks. The data collection tool was a researcher-made questionnaire developed based on Johnson's theory.\u003c/p\u003e\n\u003cp\u003eResults: Before the intervention, the mean scores of the intervention group in terms of the seven subsystems of Johnson's model were as follows: achievement (-98.98 ± 75.77), affiliative (-87.34 ± 28.23), eliminative (-25.46 ± 33.27), ingestive (-135.67 ± 89.20), dependency (-122.26 ± 45.85), aggressive-protective (-62.18 ± 46.58), and restorative (-163.59 ± 62.03). After the intervention, the mean scores in the intervention group were as follows: achievement (-2.50 ± 71.55), affiliative (-66.33 ± 59.68), eliminative (19.29 ± 35.61), ingestive (152.75 ± 113.58, dependency (104.60 ± 53.42), aggressive-protective (52.18 ± 53.54), and restorative (198.43 ± 72.28), which shows the positive impact of the intervention (P \u0026gt; 0.05). No significant changes were observed in the sexual subsystem.\u003c/p\u003e\n\u003cp\u003eConclusion: The implementation of a nursing care plan based on Johnson's model positively affected the behavioral systems of patients undergoing CABG. Therefore, this model is recommended to be used as a framework for nursing care.\u003c/p\u003e\n\u003cp\u003eDate of registration -05-12-2022\u003c/p\u003e\n\u003cp\u003eTrial registration number- IRCT20220831055838N1\u003c/p\u003e","manuscriptTitle":"The impact of implementing a nursing care program based on Johnson's model on the behavioral systems of patients undergoing coronary artery bypass graft: a Randomized clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-21 19:05:07","doi":"10.21203/rs.3.rs-4331230/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-01T07:24:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-21T18:10:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T12:47:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66428419850893931583490895999735183137","date":"2024-07-09T21:45:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115966704926485664855802454363427265131","date":"2024-07-07T17:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26439672546261225852618825298991868275","date":"2024-05-18T14:19:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191979621745747994277729509743931058165","date":"2024-05-16T13:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-16T12:35:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-14T06:01:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-10T12:02:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-10T12:02:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-04-26T18:30:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b93ddab-a336-4438-9f2d-dfd4352ea2c3","owner":[],"postedDate":"May 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T16:04:31+00:00","versionOfRecord":{"articleIdentity":"rs-4331230","link":"https://doi.org/10.1186/s12912-025-03019-7","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-04-03 15:57:38","publishedOnDateReadable":"April 3rd, 2025"},"versionCreatedAt":"2024-05-21 19:05:07","video":"","vorDoi":"10.1186/s12912-025-03019-7","vorDoiUrl":"https://doi.org/10.1186/s12912-025-03019-7","workflowStages":[]},"version":"v1","identity":"rs-4331230","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4331230","identity":"rs-4331230","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}