The predictive factors of moral courage among hospital nurses.

BACKGROUND: Having moral courage is a crucial characteristic for nurses to handle ethical quandaries, stay true to their professional obligations towards patients, and uphold ethical principles. This concept can be influenced by various factors including personal, professional, organizational, and leadership considerations. The purpose of this study was to explore the predictors of moral courage among nurses working in hospitals. METHODS: In 2018, an observational cross-sectional study was carried out on 267 nurses employed in six hospitals located in the northern region of Iran. The participants were selected through a simple random sampling technique. To collect data, a demographic information form was used along with two questionnaires. The first questionnaire was a standard survey on moral courage, while the second questionnaire was designed to assess the ethical climate. Linear regression was used to assess the predictors of moral courage. RESULTS: Nurses had an average moral courage score of 87.07 ± 15.52 and an average moral climate score of 96.12 ± 17.17. The study showed that 16% of the variation in moral courage scores among nurses was explained by ethical climate and monthly overtime hours. CONCLUSION: This study underscores the significance of establishing an ethical work environment and minimizing overtime hours in order to enhance moral courage among nurses. These findings carry weight for both nursing practice and organizational policies focused on fostering ethical conduct within healthcare settings.

Psychometric evaluation of the Persian version of the perception of conscience questionnaire in Iranian nurses.

Conscience is defined as the cornerstone of ethics and is considered a valuable asset. There is, however, little evidence about how Iranian nurses perceive conscience. The purpose of this study was to psychometrically evaluate the Persian version of the Perception of Conscience Questionnaire (PCQ) in Iranian nurses. In this cross-sectional and descriptive study, a psychometric evaluation of the PCQ was conducted on Iranian nurses in 2022. A total of 300 nurses participated in this study to validate the PCQ. At first, the initial translation and determination of face validity was done, and content validity was assessed using the Content Validity Index and Content Validity Ratio. Reliability was determined by intra-class correlation coefficient and Cronbach's alpha coefficient. The construct validity of the PCQ was determined by exploratory factor analysis, which led to the extraction of five factors of warning signal, valuable asset, spiritual power, burden and conscience outcomes from the initial 14 factors of the questionnaire. Reliability of the whole questionnaire was calculated to be 0.80 using Cronbach's alpha. While an intra-class correlation coefficient of 0.58 indicated average stability, the five-factor construct of the PCQ showed good validity and reliability. Therefore, our findings proved that this tool is suitable for assessing Iranian nurses' perception of conscience.

Diagnostic Values of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients: A Comparative Study.

Background: Pain assessment in unconscious patients is a major challenge for healthcare providers. This study aims to compare the diagnostic value of the critical-care pain observation tool (CPOT) and the behavioral pain scale (BPS) for pain assessment among unconscious patients. Materials and methods: This cross-sectional study was conducted in 2019. Forty-five unconscious patients were selected randomly from four general intensive care units (ICUs) in the north of Iran. The discriminant validity of CPOT and BPS were evaluated for pain during a nociceptive and a nonnociceptive procedure. For reliability assessment, interrater agreement was obtained using Lin's concordance correlation coefficient and weighted kappa coefficient. Results: Patients who had been hospitalized in ICU due to surgery or trauma (57.70%) or medical problems (42.30%) were studied. During the nociceptive procedure, the mean scores of CPOT and BPS and all their dimensions, except for the compliance with ventilator dimension, were significantly greater than the nonnociceptive procedure (p <0.05) although the effect size of both instruments was small (0.32 vs 0.18). The Lin's concordance correlation coefficient in nonnociceptive and nociceptive procedures was respectively 0.67 and 0.62 for CPOT and 0.74 and 0.88 for BPS. Conclusion: CPOT and BPS have acceptable discriminant validity in differentiating nonnociceptive and nociceptive procedural pain although the effect size of CPOT is larger than that of BPS. Although both instruments have low reliability, the reliability of BPS is better. How to cite this article: Nazari R, Froelicher ES, Nia HS, Hajihosseini F, Mousazadeh N. Diagnostic Values of the Critical Care Pain Observation Tool and the Behavioral Pain Scale for Pain Assessment among Unconscious Patients: A Comparative Study. Indian J Crit Care Med 2022;26(4):472-476.

Effect of Tracheal Suctioning on Cuff Pressure in Mechanically Ventilated Patients: a Quasi-Experimental Study.

BACKGROUND: Endotracheal tube cuff pressure must be kept in an optimal range, but it might change during some nursing procedures. If the cuff pressure gets outside the normal range, it can cause mucosal damage, insufficient ventilation, and microaspiration. This study aimed to determine the effect of endotracheal suctioning on cuff pressure in patients during mechanical ventilation. MATERIALS AND METHODS: This is a quasi-experimental study utilizing repeated measures with a within-subject design. Using a simple convenience sampling method, 61 patients were studied during intubation on mechanical ventilation. Baseline cuff pressure was adjusted to 25 cm H 2 O. Then, at 15, 30, and 60 minutes' intervals, cuff pressures were measured once without suctioning and again after suctioning. RESULTS: The results showed a significant change in the mean endotracheal tube cuff pressure during suctioning (p<0.001, d=7.47). During suctioning, cuff pressure exceeded the normal range in 64% of the patients. After suctioning, although endotracheal tube cuff pressure decreased in both conditions, it decreased more significantly (F (2.17, 260.55)=238.19, p<0.001, ν=0.665, d=1.37) in the suctioning condition. CONCLUSION: The results suggest that endotracheal tube cuff pressure increases suddenly and briefly during suctioning, but within 60 minutes after suctioning, it becomes more reduced in suctioning conditions than without suctioning. Therefore, patients are at risk of mucosal damage and microaspiration after and during suctioning, respectively. It is suggested that nurses use continuous cuff pressure regulation methods to prevent potential risks.

The Relationship Between Spirituality Dimensions and Death Anxiety among Iranian Veterans: Partial Least Squares Structural Equation Modeling Approach.

The purpose of the present study was to examine the relationship among spiritual intelligence, spiritual well-being and death anxiety among Iranian veterans. In this predictive correlational study, 211 veterans completed King and DeCicco's Spiritual Intelligence Scale, Paloutzian and Ellison's Spiritual Well-being Scale and Templer's Death Anxiety Scale-Extended. After confirming the reliability of the constructs using intra-class correlation coefficient, partial least squares structural equation modeling method was utilized to assess the impact of spiritual well-being and spiritual intelligence on death anxiety. This study found a significant positive relationship between spiritual intelligence and death anxiety after controlling for the effects of age, education level and disability. However, there was a significant negative relationship between spiritual well-being and death anxiety among Iranian veterans. Negative relationships were found between spiritual well-being and death anxiety among Iranian veterans. However, spiritual intelligence had a positive impact on death anxiety.

Effect of Head Position Change on Endotracheal Cuff Pressure in Mechanically Ventilated Patients: A Quasi-Experimental Study.

BACKGROUND: Endotracheal cuff pressure may be affected by various factors and interventions. Therefore, this study was conducted to investigate the effect of head position change on cuff pressure of the endotracheal tube whilst undergoing mechanical ventilation. MATERIALS AND METHODS: In this semi-experimental study, 61 intubated patients undergoing mechanical ventilation were studied. Each subject was used as their own control group. First, each patient was placed in starting position and the cuff pressure was adjusted in the range of 20-30 cmH2O. Then, the head position was placed in anterior flexion, hyperextension, left lateral flexion, right lateral flexion, left rotation, and right rotation without separating the manometer from the pilot cuff. The cuff pressure was recorded and analyzed at each stage. RESULTS: The endotracheal cuff pressure increased in all six head positions. The highest difference in pressure was observed in the anterior flexion and left rotation positions (p<0.001). The observed increases in cuff pressure were higher than the normal range (30 cmH2O) in a significant number of patients. CONCLUSION: Changing the head position in mechanically ventilated patients increases endotracheal cuff pressure. Therefore, it is suggested that the cuff pressure should be re-examined and adjusted after each head position change while avoiding unnecessary movements of the head and neck of the intubated patients.

Prevalence of Acute Myocardial Infarction and Changing Meteorological Conditions in Iran: Fuzzy Clustering Approach.

BACKGROUND: The prevalence of Acute Myocardial Infarction (AMI) varies from region to region caused by seasonal climate changes and temperature variation. This study aimed to assess the relationship between changing meteorological conditions and incidence of AMI in Iran. METHODS: This retrospective prevalence study was based on medical records of the heart center of Mazandaran Province on all patients diagnosed with AMI in Mazandaran, northern Iran between 2013 and 2015. Patients' sex and the day, month, year and time of hospital admission were extracted from patients' records. Moreover, the meteorological reports were gathered. RESULTS: A statistically significant difference was found between the distributions of AMI cases across 12 months of the year (P < 0.01). Fuzzy clustering analysis using 16 different climatic variables showed that March, April, and May were in the same cluster together. The other 9 months were in different clusters. CONCLUSION: Significant increase in AMI was seen in March, April and May (cold to hot weather).

The Changes of Endotracheal Tube Cuff Pressure during Manual and Intermittent Controlling in Intensive Care Units.

BACKGROUND: Usually, the endotracheal tube cuff pressure is controlled by cuff pressure monitoring. However, the intermittent pilot-manometer connection and disconnection may cause a change in the adjusted pressure. This study aimed to investigate changes in the endotracheal tube cuff pressure using both manual and intermittent controls. MATERIALS AND METHODS: A semi-experimental within-subject design was conducted. Fifty-nine intubated patients in the Mazandaran Intensive Care Units (ICUs) participated through convenience sampling in 2018. In the control condition, first, the cuff pressure was adjusted in 25 cm H2O then it was measured without manometer-pilot disconnection at 1 and 5 min intervals. In the intervention condition, cuff pressure was immediately adjusted in 25 cm H2O then it was measured with manometer-pilot disconnection in the 1st and 5th minutes. Data analysis was performed using Independent t-test, Chi-square test, and Phi coefficient. RESULTS: The mean and Standard Deviation (SD) change of cuff pressure after 1 minute, from 25 cm H2O, in the intervention condition was 20.22 (3.53) cm H2O. The mean (SD) of this change in the control condition was 25.22 (3.39) cm H2O. This difference was significant (t 116 = 7.83, p < 0.001, d = 1.44). The mean (SD) change of cuff pressure after 5 minutes, from 25 cm H2O, in the intervention condition was 19.11 (2.98) cm H2O. The mean (SD) of this change in the control condition was 25.47 (4.53) cm H2O. This difference was significant (t 116 = 9.24, p < 0.001, d = 1.70). CONCLUSIONS: The tracheal tube cuff pressure has been significantly reduced during manual intermittent measuring. Therefore, it is suggested that continuous cuff pressure monitoring and regulation should be used.

Weather fluctuations: predictive factors in the prevalence of acute coronary syndrome.

Background: Meteorological parameters and seasonal changes can play an important role in the occurrence of acute coronary syndrome (ACS). However, there is almost no evidence on a national level to suggest the associations between these variables and ACS in Iran. We aim to identify the meteorological parameters and seasonal changes in relationship to ACS. Methods: This retrospective cross-sectional study was conducted between 03/19/2015 to 03/18/2016 and used documents and records of patients with ACS in Mazandaran ProvinceHeart Center, Iran. The following definitive diagnostic criteria for ACS were used: (1) existence of cardiac enzymes (CK or CK-MB) above the normal range; (2) Greater than 1 mm ST-segment elevation or depression; (3) abnormal Q waves; and (4) manifestation of troponin enzyme in the blood. Data were collected daily, such as temperature (Celsius) changes, wind speed and its direction, rainfall, daily evaporation rate; number of sunny days, and relative humidity were provided by the Meteorological Organization of Iran. Results: A sample of 2,054 patients with ACS were recruited. The results indicated the highest ACS events from March to May. Generally, wind speed (18 PM) [IRR = 1.051 (95% CI: 1.019 to1.083), P=0.001], daily evaporation [IRR = 1.039 (95% CI: 1.003 to 1.077), P=0.032], daily maximum (P<0.001) and minimum (P=0.003) relative humidity was positively correlated withACS events. Also, negatively correlated variables were daily relative humidity (18 PM) [IRR =0.985 (95% CI: 0.978 to 0.992), P<0.001], and daily minimum temperature [IRR = 0.942 (95%CI: 0.927 to 0.958), P<0.001]. Conclusion: Climate changes were found to be significantly associated with ACS; especially from cold weather to hot weather in March, April and May. Further research is needed to fully understand the specific conditions and cold exposures.

The Meaning of Managerial Competency of ICU Head Nurses in Iran: A Phenomenological Study.

BACKGROUND: The health system in Iran faces specific challenges as the managerial role of head nurses have changed. The importance of this role cannot be underestimated for the healthcare organizations' success. The present study was conducted to explore the meaning of managerial competence of head nurses in intensive care units (ICU) in Iran. MATERIALS AND METHODS: This study used a qualitative approach. We extracted the lived experience of ten Iranian ICU head nurses. Data were collected through unstructured in-depth interviews from 2014 to 2015. Interviews were recorded and transcribed verbatim and were interpreted using Van Manen's six-step approach. RESULTS: The expansion and clustering of 442 initial themes led to the emergence of 35 secondary themes, nine subthemes, and three main themes. Managerial competence - theme included "self-excellence," "ward excellence," and "intensive care excellence." CONCLUSIONS: The "managerial competence of ICU head nurses" is a dynamic concept that reflects the psychological and functional capability of head nurses in contributing towards excellence in their own critical care practice as well as that of the ward. A competent head nurse has outstanding personal and nursing attributes and holistic knowledge, and is also committed to the ongoing professional improvement of him/herself. Using their ability to facilitate interpersonal and interprofessional communication effectively, a head nurse seeks the psychological, physical, and human optimization of the ward in which he/she works. Therefore, the goal of providing insightful critical care through smart organization and planning of nurses and other personnel can be achieved.

Religious coping and death depression in Iranian patients with cancer: relationships to disease stage.

PURPOSE: The study investigated relationships among the extent of disease, religious coping, and death depression in Iranian patients with cancer. METHOD: A descriptive cross-sectional study was conducted with a convenience sample of 482 Iranian cancer patients. Participants completed demographic and health, death depression, and religious coping surveys. RESULTS: After controlling for demographic and health characteristics, positive and negative religious coping behaviors were significantly related to the experience of death depression. There was an interaction effect between negative religious coping and extent of disease with significant positive relationships to the experience of death depression. CONCLUSIONS: Negative religious coping was found to be more closely associated with death depression in patients with earlier stage disease than those with advanced stages of cancer in this sample of patients with cancer from Iran. Findings support assessing patients for use of religious coping strategies. Muslim patients who are religiously alienated and have existential anguish may be vulnerable and need heightened support following diagnosis and during treatment of early stage cancer.

Behavioral Pain Indicators in Patients with Traumatic Brain Injury Admitted to an Intensive Care Unit.

Introduction: A consistent approach to pain assessment for patients admitted to intensive care unit (ICU) is a major difficulty for health practitioners due to some patients' inability, to express their pain verbally. This study aimed to assess pain behaviors (PBs) in traumatic brain injury (TBI) patients at different levels of consciousness. Methods: This study used a repeated-measure, within-subject design with 35 patients admitted to an ICU. The data were collected through observations of nociceptive and non-nociceptive procedures, which were recorded through a 47-item behavior-rating checklist. The analyses were performed by SPSS ver.13 software. Results: The most frequently observed PBs during nociceptive procedures were facial expression levator contractions (65.7%), sudden eye openings (34.3%), frowning (31.4%), lip changes (31.4%), clear movement of extremities (57.1%), neck stiffness (42.9%), sighing (31.4%), and moaning (31.4%). The number of PBs exhibited by participants during nociceptive procedures was significantly higher than those observed before and 15 minutes after the procedures. Also, the number of exhibited PBs in patients during nociceptive procedures was significantly greater than that of exhibited PBs during the non-nociceptive procedure. The results showed a significant difference between different levels of consciousness and also between the numbers of exhibited PBs in participants with different levels of traumatic brain injury severity. Conclusion: The present study showed that most of the behaviors that have been observed during painful stimulation in patients with traumatic brain injury included facial expressions, sudden eye opening, frowning, lip changes, clear movements of extremities, neck stiffness, and sighing or moaning.

The estimate of average age at the onset of acute myocardial infarction in Iran: A systematic review and meta-analysis study.

BACKGROUND: Research indicates that the age of onset of first acute myocardial infarction (AMI) is an essential element in the life expectancy that has been decreasing in developing countries. There are various studies performed in Iran reporting a range of ages at time of AMI. Thus, this meta-analysis study is designed to determine the mean age at first AMI in the Iranian population. METHODS: All studies that met the inclusion and exclusion criteria were reviewed using standard keywords in the databases from 2000 to 2016. Two raters verified a total of 658 articles. Sixteen studies met the inclusion criteria of this study for meta-analysis. Cochran test and I-squared (I2) were used for samples' homogeneity. Pooled estimates of mean were calculated using the random effects inverse-variance model. RESULTS: The mean age of AMI varied between 55.9 to 62.9 years among the primary studies. The pooled mean age of first AMI with a 95% confidence interval (CI) for the total sample, men, and women were 59 (58.9, 60.4), 58.7 (58.3, 59.2), and 64.2 (63.5, 64.8), respectively. CONCLUSION: Our meta-analysis shows that the mean age of first onset of AMI in Iranian people is slightly lower than that reported elsewhere; and it is lower for men than for women.

"Where Withstanding is Difficult, and Deserting Even More": Head Nurses' Phenomenological Description of Intensive Care Units.

INTRODUCTION: The intensive care unit is one of the specialized units in hospitals where head nurses are responsible for both motivating the personnel and providing high quality care. Understanding of the lived experiences of head nurses could help develop new assumptions of the ICU. The present study was therefore conducted to describe the lived experiences of head nurses working in ICU. METHODS: In this phenomenological study, data were collected through unstructured in-depth interviews with 5 ICU head nurses in Northern Iran and then analyzed using 7 steps Colaizzi's method. RESULTS: Despite the "distressing atmosphere of the ICU", the "difficulty of managing the ICU" and the "difficulty of communication in the ICU", which encourages the "desire to leave the unit" among ICU head nurses, the "desire to stay in the unit" is stronger and head nurses are highly motivated to stay in the unit because the unit "develops a feeling of being extraordinary", "creates an interest in providing complicated care to special patients", "facilitates the spiritual bond", "develops a professional dynamism" and "creates an awareness about the nature of intensive care" among them. CONCLUSION: According to the result, ICU head nurses are still inclined to work in the unit and achieve success in spite of the problems that persist in working in the ICU. As the individuals' motivation can be the backbone of organizations, and given that individuals with a high enthusiasm for success are productive, hospital managers can take advantage of this strength in choosing their head nurses.

Effects of hand massage on anxiety in patients undergoing ophthalmology surgery using local anesthesia.

INTRODUCTION: Anxiety is a common disorder in patients before surgery. Inappropriately managed anxiety can cause psychological and physiological reactions and will affect the process of surgery and recovery. Therefore, this study examined the effects of hand massage on anxiety in patients undergoing ophthalmology surgery using local anesthesia. METHODS: In this interventional study, 52 patients who were supposed to undergo ophthalmology surgery using local anesthesia were studied. Patients were randomly assigned to two groups of intervention, who received hand massage before surgery (n = 27) and control (n = 25). Massaging lasted for 5 minutes (2.5 minutes on each hand) before surgery. Stroking and scrubbing methods were performed by 2 trained researchers. Anxiety level, blood pressure, heart rate, and respiratory rate were measured before and after the intervention in both groups. Anxiety was evaluated using Spielberger State-Trait Anxiety Inventory. Data was analyzed by chi-square, independent samples t-test, and paired t-test. RESULTS: There were no significant differences in mean anxiety, systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate between the two groups before the intervention (p > 0.05). However, there was a significant differenc in the mean stress level between the two groups after the intervention (p < 0.05). The two groups did not differ significantly in terms of physiological variables (p > 0.05). CONCLUSION: Our findings suggested that 5 minutes of hand massage before ophthalmology surgery (under local anesthesia) could reduce anxiety. Therefore, this method can be used to increase patient comfort and reduce anxiety before surgical interventions.