Delegating care as a double-edged sword for quality of nursing care: a qualitative study.

BACKGROUND: Considering the significance of care delegation in enhancing the quality of nursing care and ensuring patient safety, it is imperative to explore nurses' experiences in this domain. As such, this study aimed to explore the experiences of Iranian nurses regarding the delegation of care. METHODS: This qualitative study was conducted between 2022 and 2023, employing the content analysis method with a conventional approach. The study utilized purposeful sampling method to select qualified participants. Data collection was carried out through in-depth and semi-structured interviews utilizing open-ended questions. The data analysis process followed the steps proposed by Graneheim and Lundman (2004) and involved the use of MAXQDA version 12 software. To ensure the trustworthiness of the data, the study employed the four rigor indices outlined by Lincoln and Guba (1985). RESULTS: In the present study, a total of 15 interviews were conducted with 12 participants, the majority of whom were women. The age range of the participants fell between 25 and 40 years. Through qualitative data analysis, eight subcategories and three main categories of "insourcing of care", "outsourcing of care" and "delegating of care to non-professionals" were identified. Additionally, the overarching theme that emerged from the analysis was "delegation of care, a double-edged sword". CONCLUSIONS: The results of the study revealed that the delegation of care occurred through three distinct avenues: to colleagues within the same unit, to colleagues in other units, and to non-professionals. Delegating care was found to have potential benefits, such as reducing the nursing workload and fostering teamwork. However, it was also observed that in certain instances, delegation was not only unhelpful but also led to missed nursing care. Therefore, it is crucial to adhere to standardized principles when delegating care to ensure the maintenance of high-quality nursing care.

Challenges of Budgeting and Public Financial Management in Iran's Health System: A Qualitative Study.

Background: Efficient and effective management of budgets and financial resources is critical for health systems to achieve their goals; in this regard, countries may face budgetary and financial challenges owing to the weak prediction of resources and consumptions, and lack of prioritization for their budget. This study aims to identify the most critical policies and events that have affected public financial management and health budgeting and existing challenges in Iran. Methods: We conducted the present study in 2022 using a 2-stage qualitative method. First, by reviewing upstream documents and laws, we identified evidence related to health budgeting. Then, we conducted 13 semi-structured interviews with informed people in the health budgeting field that led us toward the main challenges through thematic content analysis. Results: After reviewing 48 upstream documents related to health budgeting, we identified 85 policies. After reviewing the articles, we achieved 11 themes and 71 subthemes. The most critical challenges of the budgeting cycle were as follows: (I) budget formulation, including inappropriate budget structure, conflicts of interest and infringement, lack of financial sustainability, and transparency; (II) budget execution, including a nonexecutable approved budget, complicated allocation process, and ineffective allocations; and (III) monitoring, reporting, and evaluation (MR&E), including fragmentation of MR&E processes, ineffective monitoring and evaluation, weak evaluation of platforms, and inadequate transparency. Conclusion: Most challenges in the health budgeting system are related to the budget formulation and approval stage that have their roots in implementation, monitoring, and reporting. In addition, Iran's macroeconomic and financial issues have also damaged the budgeting of the health sector. Budget problems affect the goals and outcomes of this sector, especially the health system.

Rationing of nursing care: A concept analysis.

Rationing of nursing care (RONC) refers to necessary nursing tasks that nurses refuse or fail to do because of limited time, staffing level, or skill mix. As an important process factor, it affects the quality of patient care. The concept of rationing of nursing care has not yet been clearly defined and analyzed and there are different views regarding this issue. Using Walker and Avant's eight-step method, this concept analysis was conducted to analyze the meaning, attributes, dimensions, antecedents, and consequences of nursing care rationing. The literature was collected by searching in electronic databases including PubMed, ScienceDirect, Web of Science, Scopus, and Google Scholar with no date limitation. Both qualitative and quantitative studies on rationing of nursing care, which were open-access and published in English, were included in this study. Thirty-three articles were investigated in the present study. The four defining attributes of RONC included the duty of performing nursing care, dealing with problems of doing nursing care, decision-making and prioritizing, and outcome. The antecedents included nurse-related, organization-related, care-related, and patient-related antecedents. A theoretical definition and a conceptual model of RONC were developed. The attributes, antecedents, and consequences of RONC identified in this study can be used in nursing education, research, and managerial and organizational planning.

A Systematic Review on the Economic Evaluations Evidence of Enhanced External Counter-Pulsation (EECP) for Managing Chronic Stable Angina.

Background: Chronic Stable Angina (CSA) does not respond to clinical interventions always. Therefore, enhanced external counter pulsation (EECP) has been approved by the Food and Administration Drug (FDA) as an effective technology. This study aimed to synthesize evidence on the economic evaluation of EECP in managing CSA through a systematic approach. Methods: In this systematic review study, PubMed/Medline, Cochrane Library, Web of Sciences, Scopus, National Institute for Health Research Journals Library, and the University of York Centre for Review and Dissemination (CRD) were searched. The targeted population was people who suffered from CSA, and the main therapeutic intervention was EECP. The comparators were not limited to any particular ones. Outcomes were changes in the Canadian Cardiovascular Society grading of angina pectoris, quality of life, and any other investigated relevant outcomes in the retrieved studies. The quality of studies was assessed through Philips et al and Joanna Briggs Institute Critical Appraisal tools. We synthesized data through a narrative approach. Results: We retrieved 7821 studies; among which 3 studies were included in the final phase. Two studies were systematic reviews and the Markov model economic evaluation. Another study was a partial economic evaluation. Conclusion: All studies only considered direct costs. EECP is a cost-effective technology in managing CSA, however, the sensitivity analysis of the studies showed the cost-effectiveness ratio is varied considerably and further studies are needed to extrapolate its economic value.

Decomposing inequality in financial protection situation in Iran after implementing the health reform plan: What does the evidence show based on national survey of households' budget?

BACKGROUND: Lack of well-designed healthcare financing mechanisms and high level of out-of-pocket payments in Iran over the last decades led to implementing Health Transformation Plan, in 2014. This study aims to decompose inequality in financial protection of Iranian households after the implementation of the Health Transformation Plan. METHODS: The data of Statistical Center of Iran (SCI) Survey on Rural and Urban Households Income-Expenditure in 2015 to 2016 were used. The headcount ratio of catastrophic health expenditures was calculated. The corrected concentration index was estimated. The role of contributors on inequality in the exposure to catastrophic health expenditures among poor and nonpoor households was calculated using Farelie's model. RESULTS: The headcount ratio of the exposure to catastrophic health expenditures in urban and rural households was 2.5% (2.43% - 2.64%) and 3.6% (3.48% - 3.76%), respectively. The difference in households' income levels was the main contributor in explaining the inequality in facing catastrophic health expenditures between poor and nonpoor households. [Correction added on 02 June 2018, after first online publication: The "Results" section of the Abstract of the published article has been correctly updated on this version.] CONCLUSION: Even after implementing the HTP, the headcount ratios of catastrophic health expenditure are still considerable. The results show that income is the greatest determinant of inequality in facing catastrophic health expenditure and in urban households.

The Barriers to Achieve Financial Protection in Iranian Health System: A Qualitative Study in a Developing Country.

BACKGROUND: The move to universal health coverage and consequently health promotion is influenced by political, socio-economic and other contextual factors in a country. Iran, as a developing country with an upper-middle national income, has developed policies to achieve universal health coverage through financial protection. This study aims to investigate barriers to develop financial protection as a requirement to achieve universal health coverage. MATERIALS AND METHODS: This qualitative study was conducted using 20 in-depth interviews with experts in social welfare, health insurance and financing. The framework analysis method was used to analyze the data. RESULTS: The results have been categorized in three major themes that were extracted from ten sub-themes. The major themes included the political, social and economic context of the country, the context and structure of healthcare system and dimensions of UHC. CONCLUSION: Achieving financial protection as a long-term objective should be considered as a priority among Iranian policy makers that requires an inter-sectoral collaboration with a defined in-charge body. Health policy makers in Iran should develop a more comprehensive benefits package for diseases and health conditions with catastrophic consequences. They also should develop a plan to cover the poor people.

Quality Management Systems Implementation Compared With Organizational Maturity in Hospital.

BACKGROUND: A quality management system can provide a framework for continuous improvement in order to increase the probability of customers and other stakeholders' satisfaction. The test maturity model helps organizations to assess the degree of maturity in implementing effective and sustained quality management systems; plan based on the current realities of the organization and prioritize their improvement programs. OBJECTIVES: We aim to investigate and compare the level of organizational maturity in hospitals with the status of quality management systems implementation. MATERIALS & METHODS: This analytical cross sectional study was conducted among hospital administrators and quality experts working in hospitals with over 200 beds located in Tehran. In the first step, 32 hospitals were selected and then 96 employees working in the selected hospitals were studied. The data were gathered using the implementation checklist of quality management systems and the organization maturity questionnaire derived from ISO 10014. The content validity was calculated using Lawshe method and the reliability was estimated using test - retest method and calculation of Cronbach's alpha coefficient. The descriptive and inferential statistics were used to analyze the data using SPSS 18 software. RESULTS: According to the table, the mean score of organizational maturity among hospitals in the first stage of quality management systems implementation was equal to those in the third stage and hypothesis was rejected (p-value = 0.093). In general, there is no significant difference in the organizational maturity between the first and third level hospitals (in terms of implementation of quality management systems). CONCLUSIONS: Overall, the findings of the study show that there is no significant difference in the organizational maturity between the hospitals in different levels of the quality management systems implementation and in fact, the maturity of the organizations cannot be attributed to the implementation of such systems. As a result, hospitals should make changes in the quantity and quality of quality management systems in an effort to increase organizational maturity, whereby they improve the hospital efficiency and productivity.

Effects of a multimodal preparation package on vital signs of patients waiting for coronary angiography.

BACKGROUND: Patients waiting for coronary angiography are often anxious and worried, experiencing considerable emotional problems before the procedure, which can result in an increase in blood pressure (BP), heart rate, respiratory rate and the myocardial oxygen demand. Such maladaptive responses may not only increase the patients need for sedative drugs, but also could increase the length of post angiography hospitalization. Therefore, it is important to implement some supportive actions to decrease the patients' anxiety and to stabilize their vital signs before coronary angiography. OBJECTIVES: This study aimed to investigate the effects of a multimodal preparation package on vital signs of patients undergoing coronary angiography. PATIENTS AND METHODS: A matched trial was conducted on 66 patients waiting for coronary angiography. Patients were assigned in intervention (n = 33) and control (n = 33) groups. A multimodal preparation package was implemented in intervention group, two hours before angiography. The data collection instrument consisted of questions on demographic characteristics and a table for recording the patients' vital signs including systolic BP (SBP) and diastolic BP (DBP), heart rate, respiratory rate and body temperature. Vital signs were measured three times, the day before angiography, 30 minutes before and 30 minutes after the angiography, using a thermometer and a monitoring device. Data analysis was performed using the Kolmogo-Smirnov test, t test and Mann-Whitney U test. RESULTS: From the total number of 66 patients, the 63.3% were male and married. No significant differences were observed between the mean of SBP and DBP and also the heart rate in the intervention and control groups, on the day before angiography. However, the mean SBP and DBP and heart rate of the intervention group were significantly lower compared to the control group, both 30 minutes before and 30 minutes after angiography. The intervention did not significantly change the respiration rate and temperature in the intervention group. CONCLUSIONS: The study showed that preparation package was effective in decreasing SBP and DBP, as well as heart rate. Therefore, using multimodal comprehensive preparation packages, such as the package used in the present report, is suggested.

Quality of working life of nurses and its related factors.

BACKGROUND: Nurses as the largest group of health care providers should enjoy a satisfactory quality of working life to be able to provide quality care to their patients. Therefore, attention should be paid to the nurses' working life. OBJECTIVES: This study aimed to investigate the quality of nurses' working life in Kashans' hospitals during 2012. MATERIALS AND METHODS: This cross-sectional study was conducted on 200 nurses during 2012. The data-gathering instrument consisted of two parts. The first part consisted of questions on demographic information and the second part was the Walton's quality of work life questionnaire. Data were analyzed using the SPSS software. For statistical analysis T test and one way ANOVA were used. RESULTS: The results of the study showed that 60% of nurses reported that they had moderate level of quality of working life while 37.1% and 2% had undesirable and good quality of working life, respectively. Nurses with associate degrees reported a better quality of working life than others. A significant relationship was found between variables such as education level, work experience, and type of hospital with quality of working life score (P < 0.05). No significant differences were observed between quality of working life score of nurses with employment status (P = 0.061), salary (P = 0.052), age, gender and marital status (P > 0.05). CONCLUSIONS: Nurses' quality of work life was at the moderate level. As quality of work life has an important impact on attracting and retaining employees, it is necessary to pay more attention to the nurses' quality of work life and its affecting factors.

Association of health and food expenditures inequality with health outcomes: a case study on Iranian rural households.

BACKGROUND: Inequality in households' and individuals' consumption expenditures is one of the most important aspects of health status difference among households and individuals. OBJECTIVES: We investigated the impact of some macro-economic factors specially inequality factors on the Iranian rural health status since 1986 through 2012. PATIENTS AND METHODS: We conducted a longitudinal ecological and analytical study. The average sample size was 14602 households whom Iranian Statistics Center selected by a multi-stages clustering sampling approach. All required data has been collected from Iranian Statistics Centre and Deputy for Curial Affaires of Iranian Ministry of Health. We calculated the Gini coefficients for the rural food and health expenditures, then conducted a transloge autoregressive order one (AR1) to investigate the association between the Iranian rural households' key mortality rates and the food and health expenditure Gini coefficients, time trend, GDP per capita (PPP), and GDP per capita Gini coefficients. RESULTS: The mean of Gini coefficients were 0.137 and 0.21 for the rural food expenditures inequality based on current and constant price, respectively. In addition, the mean of Gini coefficients were 0.26 and 0.31 for the rural health expenditures inequality based on current and constant price, respectively. The time trend, transloged form of Gini coefficients for health expenditures and GDP per capita Gini coefficients presented a significant negative correlation with transloged form of neonatal mortality rate. With regard to the transloged form of under five mortality we observed a significant negative correlation with time trend and transloged form of Gini coefficients for health expenditure and GDP per capita. Finally, there was a significant negative correlation between transloged forms of maternal mortality rate. CONCLUSIONS: Iranian policy makers should consider the rural health and food expenditures inequality and try to adopt more effective policies and plans to decrease it. In addition, they should improve the macro-economic factors to improve the rural households' health status.

Quality of care for patients with traction in shahid beheshti hospital in 2012.

BACKGROUND: With increasing incidence of traumatic fractures, the use of orthopedic intervention such as traction has increased. Inappropriate traction care may cause substantial morbidity and delay the patient rehabilitation. OBJECTIVES: This study was conducted to evaluate the quality of care for patients with traction in the orthopedic unit of Kashan's Shahid Beheshti Hospital, Kashan, Iran. PATIENTS AND METHODS: This observational study was conducted on 100 patients with traumatic fractures of hip and femur bones who were admitted to Kashan Shahid-Beheshti Hospital during the first 6 months of 2012, and for whom skeletal or skin traction was performed. Data were collected using a checklist including questions about the personal characteristics and 23 items related to care for patients with tractions. These items were in three domains including caring while establishing traction, recording care and patient's education. Descriptive statistics were calculated and data were analyzed using the independent sample t-test and Pearson correlation coefficient. RESULTS: The mean age of patients was 51.16 ± 23.28 years and 66% of them were male. In total, 47% of the patients were treated by skin traction and 53% by skeletal traction. The overall mean score of quality of care was 10.20 ± 2.64. Quality of establishing traction was good in 55% of patients, but the quality of care was poor in the domains of recording care (88%) and patient education (96%). Total mean of quality of care was significantly different between male and female patients (P < 0.02). CONCLUSIONS: The quality of care of patients with traction was not optimal. Therefore it is necessary to improve measures in this area.