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Original research
Nursing core competencies for postresuscitation care in Iran: a qualitative study
  1. Mahnaz Zali1,
  2. Azad Rahmani1,
  3. Kelly Powers2,
  4. Hadi Hassankhani1,
  5. Hossein Namdar-Areshtanab3,
  6. Neda Gilani4
  1. 1Department of Medical-Surgical, Tabriz University of Medical Sciences, Tabriz, Iran
  2. 2School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
  3. 3Department of Psychology Nursing, Tabriz University of Medical Sciences, Tabriz, Iran
  4. 4Department of Statistics and Epidemiology, Tabriz University of Medical Sciences, Tabriz, Iran
  1. Correspondence to Dr Azad Rahmani; azad.rahmani{at}yahoo.com

Abstract

Objective This study explored nurses’ perceptions of the core competencies required for providing postresuscitation care in both in-hospital and out-of-hospital cardiac arrest.

Design Qualitative conventional content analysis.

Participants 17 nurses selected with purposeful sampling method.

Setting Three educational hospitals in northwest of Iran.

Data collection and analysis Semi-structured interviews were used for data collection and they were analysed using conventional content analysis.

Results Seven main categories have emerged from the data. The core competencies for nurses providing postresuscitation were identified as: quality assurance, providing evidence-based care, monitoring and presence, situation management, professionalism, positive attitude and providing family centred care.

Conclusions The postresuscitation period is a unique and critical time requiring highly competent nursing care. Several core competencies for providing high-quality nursing care during postresuscitation period were identified through nurses’ experience in caring for patients postresuscitation.

  • cardiopulmonary resuscitation
  • qualitative research
  • adult intensive & critical care

Data availability statement

Data are available on reasonable request. Data are available on reasonable request from the corresponding author. Due to participants’ privacy, sharing complete interview transcripts may be impossible, but additional anonymised illustrative quotations may be available.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Qualitative descriptive designs are a suitable method for exploring the rich experiences of participants, especially in topics that are less well known.

  • The participants in this study had rich experiences related to the phenomenon of interest, which helped identify their core competencies in providing postresuscitation care.

  • This study involved 17 nurses who shared their perceptions of postresuscitation nursing competencies.

  • The experiences of experts and nursing managers were not investigated.

Introduction

Many efforts have been made to improve the prognosis of cardiac arrest victims over the last several decades and resulting in a significant progress.1 A recent study found that the survival-to-discharge rate for in-hospital cardiac arrest was 11.7%, and this rate had increased from 2003 to 2013.2 Additionally, the survival-to-discharge rate for out-of-hospital cardiac arrest globally was 8.8%.1 The situation in Iran is less favourable, with 4.8% following in-hospital cardiac arrest and 4.1% following out-of-hospital cardiac arrest due to factors such as delays in initiating cardiopulmonary resuscitation and the length of resuscitation.3 4 The low rate of survival after resuscitation and early mortality is caused by the complex pathophysiological process known as postcardiac arrest syndrome, which leads to damage in many vital organs following whole-body ischaemia during cardiac arrest and subsequent reperfusion.5

To improve long-term survival and prevent complications of postcardiac arrest syndrome, providing high-quality care is vital.6 The main goal of postresuscitation care is to discharge cardiac arrest victims from the hospital with good neurological function.7 8 Since 2005, there has been a dramatic increase in focus on postresuscitation care, resulting in a significant rise in the number of articles published in this area.9 The latest edition of the European Resuscitation Council and European Society of Intensive Care Medicine guidelines has recently been published, providing detailed guidance on the specific care of different patient systems during the postresuscitation period.10

Postresuscitation care is progressing scientifically and involves coordinating the activities of all personnel involved in such care.11 Multiple studies have investigated the competencies required of nurses during resuscitation. These studies have reported that nurses’ ability to perform skills such as identifying cardiac arrest, detecting arrhythmias, administering chest compression and airway management during resuscitation are considered core competencies.12 13 There have also been studies conducted to identify the core competencies needed by critical care nurses.14–16 However, an extensive literature review revealed no international studies specifically describing the competencies expected of nurses when providing care in the postresuscitation period. Identifying competencies for postresuscitation care is important for selecting nurses who are competent in providing such care and to provide continuing education to enhance their skills. This study aimed to explore nurses’ perceptions of the core competencies required for providing postresuscitation care to both in-hospital and out-of-hospital patients with cardiac arrest.

Methods

Design and research question

This study used an exploratory-descriptive qualitative design and conventional content analysis approach. The guiding research question was: What competencies do nurses require to provide effective and optimal postresuscitation care?

Setting

The study was conducted at three educational hospitals affiliated with Tabriz University of Medical Sciences. These are referral hospitals for patients with critical conditions in the northwest region of Iran in East Azerbaijan Province.

Participants

The participants consisted 17 clinical nurses with extensive experience in providing care after patient resuscitation. All invited nurses agreed to participate in the study. All participants possessed at least a bachelor’s degree and had a minimum of 2 years of clinical experience. The average age of the participants was 36 years and 122 of them were female. On average, the participants had 6 years nursing work experience. Nine participants worked in intensive care units, four in the emergency ward and four in medical-surgical wards.

Purposive sampling method was used. The first three participants were selected based on their extensive experience of >5 years in postresuscitation care. Subsequent participants were chosen in a manner that aimed to address any questions and ambiguities that arose during the analysis of initial interviews. We used maximum variance sampling, taking into account age, gender and workplace variables while adhering the principles of purposive sampling. The sampling process continued until data saturation was reached, which was defined at the point as no new concepts, or new dimensions related to previous concepts emerged.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data collection

Data were collected through face-to-face, semi-structured interviews. The interviews were conducted from November 2021 to February 2022 by the first researcher (MZ) who is a nurse with previous experience in conducting qualitative interviews. After reaching an agreement with each participant regarding interview location and time, 14 participants were interviewed in a private setting within the selected hospitals, while 3 participants were interviewed in the first researcher’s office. During each interview, participants were initially asked general questions about their experiences in providing postresuscitation care to ensure that they had substantial experiences related to the research phenomenon and to enhance a sense of trust and encourage open reporting. Subsequently, questions addressing the research question of the study were asked: What kind of care do you provide after patient resuscitation? What are the main capabilities required to provide postresuscitation care? How do these capabilities contribute to provide optimal care? Based on participants’ responses, probing questions were asked to elicit further elaboration and clarification. Examples of such probing questions include can you provide more details and could you please give me an example? To address ambiguities that arose in some of the interviews, a second interview was conducted with four of the participants. The initial interviews lasted an average of 45 min (32–74 min), and follow-up interviews were an average of 22 min (13–32 min). The participants were interviewed in Azerbaijani or Persian languages, and all interviews were audio recorded and subsequently translated into Persian for analysis. Participants’ statements were then translated into English for this article.

Data analysis

Analysis of the data was performed simultaneously with collection of the data using conventional content analysis method by Graneheim and Lundman.17 First, all transcripts were returned to participants for comment or correction before analysis. Then, each interview’s text was read and reviewed several times to seize general understanding. Meaningful units were extracted from the interview texts, which included words, sentences or paragraphs that expressed various aspects of participants’ perspectives on the competencies required for providing postresuscitation care. These were labelled as primary codes, and a total of 923 primary codes were identified. These initial codes were then grouped based on similarities and differences, creating more abstract codes. This process continued until the final categories were reached.

The rigorous criteria by Lincoln and Guba for credibility, transferability dependability and confirmability were used.18 Credibility was achieved through the extended engagement of the first researcher (MZ) within the field of the study, as well as continuous discussion of the findings among the research team. Further credibility was attained through obtaining participants’ feedback on the findings. To promote transferability, the principles of maximum sampling were observed. Dependability was preserved by more than one researcher participating in the data analysis process (MZ, AR, HH). An audit trial of all research activities was recorded to promote confirmability.

Findings

The analysis of the data led to the emergence of seven main categories: quality assurance, providing evidence-based care, monitoring and presence, situation management, professionalism, positive attitude and providing family centred care.

Quality assurance

Ensuring the quality of nursing care was identified by participants as a core competency in providing postresuscitation care. Nurses must be able to accurately verify ongoing nursing and medical interventions for their patients. Examples of this include confirming the correct placement of an endotracheal tube, verifying the accuracy of ventilator settings, ensuring alignment between the patients’ condition and laboratory results and guaranteeing intravenous access. Such measures were deemed crucial in preventing medical errors.

Once a doctor had intubated the patient, I failed to check the tube. The cardiac arrest recurred because of incorrect tube placement. You have to check and verify everything; you can’t rely blindly on anyone at all. (P.2)

Offering suggestions to other nurses and even physicians about the treatment plan and the need for consultations is important to ensure quality care. Nurses also warn colleagues about outcomes that could result from care inconsistent with evidence-based guidelines. Furthermore, participants explained that obtaining the opinions and approval of experienced nurses is important in providing postresuscitation care. Full involvement in patient care, such as attending all consultations and visits and collaborating with others, is another key aspect of quality assurance in postresuscitation period.

While working in the general intensive care unit, we had a nurse who thoroughly examined patients and made suggestions to the nurses and physicians due to her extensive experience. She knew what was necessary and always ensured all procedures were correctly done for each patient. (P.12)

Another feature of quality assurance is predicting the need for equipment, medications and consultations. Participants felt nurses should anticipate medical needs to ensure necessary resources are available. If they can foresee potential consultation needs before request arise, quick action can be taken. These actions are important in preventing of certain postresuscitation complications. Continuous follow-up of all these care actions is also crucial to ensure completion.

The nurse should know what medications and equipment might be needed. When consulting with a surgeon, they often want a radiograph for a patient. It is better to suggest getting it done before the consultation. This could prevent many complications by saving the time. (P.12)

Quality assurance also entails having basic knowledge and skills to provide optimised postresuscitation care. Specifically, understanding the pathology of the postresuscitation period and essential medications and care measures is crucial. Additionally, participants highlighted the need to be skilled in performing necessary procedures postresuscitation, especially establishing and maintaining intravenous lines, managing airway, controlling vital signs, correcting electrolyte imbalances and monitoring the patient’s neurological condition. Furthermore, nurses should be proficient in using equipment like monitors, mechanical ventilators, defibrillators, pacemakers and infusion pumps. Quick implication of knowledge and skills during the postresuscitation period is vital due to patient instability.

After resuscitation, the patient’s condition can become complex, medications are initiated, and the nurse must be able to accurately calculate and administer medications doses promptly while easily using equipment. (P.8)

Providing evidence-based care

Nurses need to provide evidence-based care during the postresuscitation period. Participants indicated that for optimal postresuscitation care, nurses should stay updated with the latest relevant research findings.

We should study and find out about the latest research findings. Unfortunately, most retraining courses focus mainly on resuscitation itself rather than post-resuscitation care. (P.3)

Another aspect of evidence-based care is implementing care measures that consider the patient’s specific needs. Participants felt that care plans should be individually developed for each patient according to their needs. Furthermore, care plans should be prepared considering the preferences of the patients and their families; they should play an active role in developing these plans as much as possible.

I check patients’ underlying disease, allergies, and even socioeconomic status. I consider all these factors to determine patient needs. Apparently, each patient’s needs differ from others. (P.11)

Continuous monitoring and presence

Continuous monitoring of a patient’s condition is another core competency required for effective postresuscitation care. Participants explained that the most important investigation is to determine the primary cause of cardiac arrest, which is vital to prevent a second one from occurring. The next focus is to investigate possible injuries caused by the resuscitation, such as broken ribs or damage to the airway. Nurses should carefully and regularly monitor the respiratory, cardiovascular, neurological and renal status of patients by checking breathing and heart rate and rhythm, blood pressure, arterial blood gases results, pupil size and reaction and urinary output.

The patient’s lungs should be auscultated. After resuscitation, the patient’s ribs may be fractured. All of the patient’s vital systems should be regularly checked. (P.2)

Participants believed that nurses should interpret data from their continuous evaluations to identify irregularities or changes from a patient’s baseline. If the data show patient deterioration requiring special treatment, they should immediately inform the physician or other nurses.

Once, we identified a patient whose urinary output was 200 mL in the first hour, 100 mL in the second hour, and then dropped to 50 mL. While 50 mL might seem normal; it shows a sharp decrease for this patient after resuscitation and needed to be noticed quickly. (P.11)

Essential to continuous monitoring is the nurses’ presence. Nurses should constantly be with patients to prevent or quickly identify problems and intervene. Participants felt that nurses should not leave the patient alone with just a monitor or a mechanical ventilator during postresuscitation.

After all that effort, the patient should have been cared for, but he/she was left alone. Why? Immediately after resuscitation everyone dispersed, including the nurse in charge. As a result, we cannot prevent any problems. (P.5)

Situation management

According to participants’ perceptions, nurses should be able to skillfully manage the critical and complex situations that can arise in the postresuscitation period. The most important action for nurses is setting priorities due to the various needs of postresuscitation patients and time constraints. Nurses should be capable of providing necessary patient care promptly without wasting time.

After resuscitation, we must act quickly. The initial steps are very important; we must know the order of priority, first saving the patient’s vital organs. A nurse must be able to making such prioritization. (P.7)

Asking for assistance is another characteristic of situation management. It is especially important for nurses to ask colleagues for help when care pressure is high. According to participants, nurses need to ask for help from the supervisor or head nurse who can assist by coordinating and following up on some actions while the nurse provides patient care. Asking for help was deemed necessary to take care of patients during complex situations, particularly on internal or surgical wards where the nurse is responsible for many patients.

You should ask for help as soon as you need it. My colleagues should not think that if I ask for help, it means that I cannot do my job. Every nurse has many patients and limited time, thus needing assistance. (P.13)

Professionalism

Competent nurses demonstrate professionalism in postresuscitation care. A key aspect of this according to participants is the ability to provide independent nursing care. While knowing when to seek help is important, nurses should also be able to determine certain patient needs and implement independent interventions. Participants noted that due to the critical nature of the situation, there are times when nurses must independently initiate actions like administrating vital medications and adjusting ventilator settings.

We [nurses] have our own independent interventions and we must be able to implement them independently to prevent any deterioration in the patient’s condition. (P.1)

Another feature of professionalism was taking responsibility for patient care. Nurses should initiate to implement postresuscitation care immediately after the resuscitation ends. They should not delegate their responsibilities, such as communicating with family members or other caregiving duties to those who may be unqualified. Establishing effective communication with medical personnel including other nurses and physicians, following up on consultations and visits, and timely reporting of patients’ conditions are other behaviours that participants equated with demonstrating professionalism.

Communication techniques are important. Knowing whom to communicate with and how is essential, whether it’s informing a physician or dealing with family members or fellow nurses. After resuscitation, the nurse must coordinate various measures, and know exactly what steps to take. Everything should be in its proper place. (P.10)

Another aspect of professionalism highlighted by participant was demonstration of professional behaviour. Nurses should avoid inappropriate behaviour in the front of family members, such as making jokes or using discouraging language.

Sometimes, when nurse jokes with colleagues, the family of a critically ill patient may misinterpret this as neglect towards the patient. (P.3)

Positive attitude

The participants identified a positive attitude as another core nursing competency during the postresuscitation period. Nurses should exude hope and positivity, avoiding withholding necessary care or treatment based on premature judgements about patient condition. In addition, nurses should refrain from providing pretended care to gain family satisfaction.

We should not stop patient care. We have to do everything that we can until the last moment such as consulting with experts. Under no circumstances should we halt treatments. (P.5)

Another feature of maintaining a positive attitude is avoiding labelling the patient as terminal or beyond recovery. Participants felt that in educational centres, such patients might be labelled as study cases for nursing or medical students. They emphasised that nurses should refrain from such labelling and discourage others from adopting similar attitudes towards patient care.

We shouldn’t assume that a resuscitated patient will inevitably experience another cardiac arrest. We have to avoid labeling patients ‘goners’ or ‘dying’. (P.1)

Providing family centred care

Providing family centred care is a core competency for nurses caring for postresuscitation patients. Participants indicated that assessing family members is a priority, and the assessment should be as objective as possible using standard tools. Evaluating the supportive care needs of family members, their understanding of the patient’s condition and potential aggressive behaviour are among important assessments.

The family is anxious about the treatment procedures. They don’t know what is happening. We have to thoroughly assess their understanding of the patient’s condition to prevent any misconceptions. (P.4)

Participants also expressed that nurses should facilitate the presence of family members as much as possible during the postresuscitation period. They could even involve family members in certain aspects of patient care, such as personal hygiene tasks. Providing family centred care involves educating family members about the patients’ condition and ongoing care, treating them with kindness and empathy, listening to their concerns and empathising with their challenging situation. Nurses should provide emotional support to the families, especially in cases of deterioration.

Nurses should provide necessary explanations about the patient’s condition to family members and listen carefully to their concerns. Families often face difficult situations and this can greatly assist them in adapting. (P.5)

Discussion

This study is one of the first to outline the core competencies required by nurses who provide postresuscitation care. The competencies identified in the data accurately reflect the complex and critical nature of the postresuscitation period. As an extensive literature review did not reveal studies with a similar focus in the field of postresuscitation care, this discussion compares our findings with research conducted on nurse competencies for providing care during resuscitation and general critical care, which are comparable to the postresuscitation period.

Quality assurance has been identified as a core competency of nurses involved in postresuscitation care. This competency encompasses activities such as meticulous auditing, error prevention, offering suggestions versus warnings, active involvement in patient care, anticipation of equipment and care needs and possessing the knowledge and skills necessary to provide optimal postresuscitation care. In line with this, previous studies have identified competencies required by nurses in intensive care units, including conducting audits of care, particularly focusing on airway management, level of consciousness assessment and monitoring vital system functioning.19 Additionally, having a supervisory role in high-risk environments20 has also been recognised as an essential competency. Unfortunately, studies have indicated that both the period during cardiopulmonary resuscitation21 and the intensive care units environment22 are susceptible to medical errors. Furthermore, prior research has emphasised the significance of possessing fundamental knowledge and clinical skills as essential competencies for nurses working in critical care units.23–26 It is noteworthy that the participants in our study highlighted the importance of offering supportive suggestions to colleagues and even physicians, while also expressing the need to provide warning regarding potential outcomes if guidelines are not followed. The importance of both providing input and seeking it from experienced nurses emerged as a crucial aspect of effective nursing care, highlighting the participants’ strong emphasis on the key role that nurses play in ensuring the quality of postresuscitation care.

Another core competency identified for nurses in the field of postresuscitation care is the ability to provide evidence-based care which involves staying updated with the latest research findings and guidelines. Providing evidence-based care also entails avoiding nursing care that do not take into account the individual patient’s situation and fail to consider the needs and preferences of both patients and their family members. The American Association of Critical Care Nurses has highlighted evidence-based care as a central competency for critical care nurses,27 while studies have consistently emphasised its importance.16 However, research indicates that nurses in critical care units do not consistently provide evidence-based care as part of their routine practice.28

Participants emphasised the importance of continuous monitoring and presence. This involves initially investigating the causes of cardiac arrest, and then closely monitoring vital systems to promptly detect any changes. Health monitoring skills are fundamental in nursing care29 and are considered core competencies in the nursing education course.30 Additionally, evaluating health conditions and identifying health deviations is the first step of the nursing process to determine nursing diagnoses.31 In the latest guidelines from the European Resuscitation Council and European Society of Intensive Care Medicine, the investigation of cardiac, neurological and respiratory causes for cardiac arrest is emphasised as a significant aspect of postresuscitation care.32 However, despite the emphasis on monitoring as an essential skill and competency for nurses,30 31 33 studies indicate that nurses often perceive health monitoring to be limited to assessing patients’ vital signs and level of consciousness33 and it is also found that nurses may not perform clinical assessments before providing care.34 Participants in our study also highlighted that continuous monitoring requires nurses to be present at the patients’ bedside during the postresuscitation period. Previous studies have also emphasised the importance of attendance in critical care units.35 However, studies in Thailand36 and the USA37 have found that nurses in critical care units do not adequately provide presence with patients, resulting in insufficient prevention of their problems. It appears that monitoring and being present are crucial prerequisites to ensure quality care.

Situation management skills are considered another core competency for providing postresuscitation care. The key features of this competency include setting priorities, time management, promptly following-up on care and seeking assistance when needed. Setting priorities is vital for nurses due to lack of time38 and in this regard, time management also plays an important role in prioritising nursing care in critical care units.39 Research has demonstrated that time management skills are one of the main competencies of nurses who work in critical care units.14 26 Participants’ emphasis on situation management shows their understanding of the potential for rapidly changing postresuscitation conditions and the importance of quickly implement the necessary care.

Professionalism was deemed vital for providing postresuscitation care. This included providing independent nursing care, taking responsibility for the required patient care and maintaining professional behaviour. The importance of being able to provide independent nursing care has been well-documented in previous studies.40 However, a study found that critical care nurses considered a lack of professional autonomy despite having high professional responsibilities as one of the reasons for considering leaving critical care.41 The nurse participants in our study viewed professional autonomy and being accountable to such autonomy as essential aspects of providing high-quality postresuscitation care to both patients and their families.

One of the interesting results of this study was the emergence of positive attitude as a core competency of nurses in the postresuscitation period. Participants believed that nurses should always approach patient care with a positive attitude and avoid making premature judgements or viewing patient situations negatively without solid clinical evidence. Furthermore, nurses should refrain from labelling patients in such manner. Previous studies have also reported that hope is a moral competency42 and nurses’ understanding of the likelihood of patient survival are important factor in the quality of care provided by nurses in critical care units.43 It has also been found that nurses often express reluctance in caring for dying patients44 and may negatively label patients who have experienced cardiac arrest.45 The participants in this study emphasised the importance of maintaining a positive attitude and avoiding patient labelling as crucial factors in ensuring the quality of care.

Finally, providing family centred care was identified as a core competency necessary to provide postresuscitation care. This involves assessing the support needs of families, facilitating their presence and involvement, providing education and using an empathetic approach. The results of a systematic review showed that presence, education and support are important universal elements in providing family centred care.46 Although many studies have been conducted on the presence of family members during resuscitation,47 48 no studies regarding their presence in the postresuscitation period could be found. The postresuscitation period presents an opportune time for family presence as the patient physical condition has been partially stabilised and there is increased potential for communication between the patients and their family members.49 Providing family centred care has become an essential component of care delivery in critical care units.50

Limitations

This qualitative study has limitations, as it involved 17 nurses who shared their perceptions of postresuscitation nursing competencies. Therefore, findings may not be generalisable. Furthermore, it is important to note that the competencies reported in this study are based only on the perceptions of bedside nurses and do not include input from experts, nursing managers and medical doctors. Additionally, since this study was conducted in Iran, certain aspects of the identified competencies may not align with the perspective of nurses in countries with different organisational conditions.

Application

A review of the available scientific literature in the field of postresuscitation care demonstrates an emphasis on the medical care of patients’ vital systems, while the importance of the nurses’ role in providing postresuscitation care is discussed less. The core competencies gleaned from the nurse participants highlight the uniqueness of the postresuscitation period and the crucial care that nurses provide. To maintain and improve the quality of nursing care in the postresuscitation period, nursing managers must ensure that the nurses caring for these unique patients possess the necessary core competencies. These initial competencies can serve as an important basis for designing training courses for nurses, as well as developing tools to assess nurses’ competency in providing postresuscitation care. Further research is necessary to enhance understanding of the essential competencies required by nurses who care for patients postresuscitation.

Conclusion

Participants regarded the postresuscitation period as a distinct and crucial situation, which is reflected in the core nursing competencies. The key role of nurses in providing postresuscitation care was emphasised and nurses were considered to be the guarantors of quality care. Nurses should play an active and independent role in providing postresuscitation care, being able to effectively assess patients’ conditions, prioritise care, provide continuous follow-up and prevent further complications. Furthermore, nurses should provide postresuscitation care based on the latest research findings, while also considering the needs and preferences of patients and their family members. The findings of this study highlight the importance of in-service training programmes for nurses, with a specific focus on enhancing these core competencies to ensure high-quality nursing care during the postresuscitation period. Additionally, these results can serve as valuable guide for developing evaluation checklists aimed at measuring the quality of postresuscitation care.

Data availability statement

Data are available on reasonable request. Data are available on reasonable request from the corresponding author. Due to participants’ privacy, sharing complete interview transcripts may be impossible, but additional anonymised illustrative quotations may be available.

Ethics statements

Patient consent for publication

Ethics approval

Research Ethics Committees at Tabriz University of Medical Sciences (IR.TBZMED.REC.1399.1030) approved the study. Study participation was voluntary, and the confidentiality of the data was strictly maintained. Prior to each interview, participants were provided oral explanation of the study, and written informed consent was obtained from all participants.

Acknowledgments

This article presents a portion of the results from a doctoral thesis conducted in the Faculty of Nursing affiliated with Tabriz University of Medical Sciences. We would like to express our gratitude to all the nurses who participated in this study.

References

Footnotes

  • Contributors Conceptualisation: MZ and AR. Designing the study, formulating research question: MZ, AR, KP and HN-A. Data collection: MZ. Data analysis: MZ, AR and HH. Original draft preparation: MZ, AR, KP and NG. Review and editing: MZ, AR and KP. Guarantor: MZ.

  • Funding This study was conducted with the financial support of the research deputy of Tabriz University of Medical Sciences (grant number 66513).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.