Unheard voices: The sexual challenges of families of patients with bipolar disorder: A qualitative content analysis.

OBJECTIVES: The aim of this study was to explore the voices of the family members of Bipolar Disorder (BD) patients about the challenges ahead of them. METHODS: In this qualitative study, 22 participants shared their experiences of sexual challenges of patients with BD through in-depth, face-to-face, semi-structured interviews. Qualitative content analysis was used for data analysis. RESULTS: An overarching theme entitled "Unheard voices" reflected this experience. It comprised four main categories include sexual promiscuity, a change in sexual patterns, sexual support, and sexual indifference. The results revealed that the families of patients with BD have to deal with sexual promiscuity and change in sexual patterns in their family, and the family system attempts to respond to these changes by sexual support mechanisms and sexual indifference. CONCLUSIONS: Given the significant impact of healthy sexual behaviors on the quality of life of both the individual and the family, therapists and family support systems are advised to strengthen and educate families to support their patients' sexual health and needs and protect their sexual existence; they should also address the sexual challenges faced by these families as a diagnostic and therapeutic priority, and early sexual health interventions should be provided to these families.

The Effects of Spiritual Care with and Without Aromatherapy on the Sleep Quality of Prisoners Referred to the Emergency Department of the Prison Clinic in Iran: A Randomized Clinical Trial.

Rest and sleep are health fundamentals and essential phases of human life rhythms. Sleep disturbances can negatively affect an individual's physical and mental balance. Due to the psychological pressure resulting from problems, prisoners experience more sleep disturbances than other people. Therefore, this study aimed to compare the effects of spiritual care with and without aromatherapy on the sleep quality of prisoners in the emergency department of the central prison clinic in Sanandaj County. A single-blind clinical trial was conducted on 90 male prisoners of the emergency department of the central prison clinic in Sanandaj, Kurdistan-Iran, and they were randomly assigned to three groups: spiritual care (intervention 1), spiritual care with aromatherapy (intervention 2), and control group. Spiritual care and aromatherapy, along with spiritual care interventions, were performed using lavender essence for one month. Data collection was performed using a demographic checklist and the pittsburgh sleep quality index before and after the interventions. The collected data were analyzed using descriptive and analytical statistical methods in SPSS.26. The mean age of the prisoners was 34.99 ± 7.011 years, 75.6% had a diploma or lower education level, and 46.7% had been imprisoned for more than one year. At baseline, the mean sleep quality score was 9.33 ± 3.55 in intervention group 1, 9.53 ± 4.06 in intervention group 2, and 10.50 ± 3.59 in the control group, with no significant difference between the groups (p = 0.413). After the interventions, the mean sleep quality score was 8.40 ± 2.94 in intervention group 1, 7.86 ± 4.90 in intervention group 2, and 11.23 ± 3.81 in the control group, showing a significant difference between the groups (p = 0.002). According to findings, aromatherapy, along with spiritual care, significantly improved the sleep quality of prisoners (p = 0.003), but spiritual care alone was not effective (p = 0.137). Aromatherapy-based spiritual care improved the sleep quality of prisoners; hence, considering the congruency of spirituality with pleasant scents symbolizing cleanliness and aligning with human nature and religious recommendations, the combination of these two interventions can be used to enhance the sleep quality of prisoners.

The Effect of the Holy Quran Recitation on Inflammatory Markers in Hemodialysis Patients in Iran: A Randomized Clinical Trial.

Increased inflammation is a common complication in chronic hemodialysis (HD) patients. Addressing the psychological symptoms of patients may help reduce inflammation and its negative impact on the body. Considering the calming effects of listening to the Holy Quran, this may help reduce mental, psychological, and physical problems in Muslim patients. The present study sought to examine the effects of listening to Holy Quran recitation on the level of inflammatory markers in HD patients. This was a randomized controlled trial involving 50 HD patients at Kowsar Hospital in Semnan, Iran, in 2019-2020. The participants were divided into experimental and control groups using simple randomization by sealed envelopes. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin-6 (IL-6) levels in blood were measured before the intervention. The participants in the experimental group listened by headphones to the Holy Quran being recited three times a week, 20 min each time, for one month. For those in the control group, headphones were placed but on silent mode. At the end of the intervention one month later, inflammatory markers were measured again for participants in both groups. Data were analyzed in SPSS-16 using descriptive and inferential statistics (t test, Wilcoxon, and Mann-Whitney U). Mean IL-6 level decreased by 20.2 pg/ml, mean ESR level by 16.8 mm/hr, and mean CRP level by 19.9 mg/dl in the experimental group, while these values increased in the control group. The between-group differences in the intervention and control groups at follow-up were significant for all three inflammatory markers (p < 0.05). Listening to the Holy Quran being recited is recommended as a complementary therapy for reducing systemic inflammation (as indicated by inflammatory markers) in Muslim HD patients.Trial registration: Iranian Registry of Clinical Trials, Trial No: IRCT20120109008665N9. Registered 4 Nov 2019.

Strategies used by Iranian nursing students for adjusting to internship: a qualitative study.

BACKGROUND: The internship setting is a highly challenging one for nursing students, and working in such an environment requires adjustment. Knowledge of the adjustment strategies used by students enhances the body of nursing knowledge and can help nursing officials adopt appropriate decisions to strengthen the students' effective adjustment skills and increase the benefits reaped from their internship. The present study was conducted to explore the strategies used by nursing students to adjust to internship. METHODS: A total of 19 senior nursing interns (7 Female, and 12 Male) were selected by purposive sampling with maximum variation from one of the nursing and midwifery schools affiliated to a large metropolitan medical university in northern Iran. Data were collected using audio-taped semi-structured face-to-face interviews over an 18-month period and were carefully transcribed and analyzed using the Graneheim & Lundman qualitative conventional content analysis approach. The researchers analyzed the data in MAXQDA 10 software. RESULTS: Four main categories and eight subcategories emerged from the data analysis. Main categories include efforts to achieve clinical competency, efforts to be sociable or accepted, self-management and reaction to conflicts. CONCLUSION: All the participants attempted to attain adjustment by adopting strategies such as achieving clinical competence, trying to be sociable or accepted, self-management, and reaction to conflicts depending on the conditions of internship. Officials should help nursing students use effective strategies and achieve adjustment.

Barriers to and Facilitators of Adjustment Among Iranian Multiple Sclerosis Patients: A Qualitative Study.

Patients with multiple sclerosis (MS) experience various physical symptoms and psychosocial problems that disrupt their normal life, and adapting to these conditions is vital for them. Many factors that serve as facilitators of and barriers to achieving adjustment should be identified to be able to help the patients. This study was conducted to explain the experiences of patients with MS regarding the facilitators of and barriers to adjustment using conventional content analysis. The participants consisted of 18 patients, one nurse, one physician, and one patient companion, who were selected from the Multiple Sclerosis Clinic of BouAli, northern Iran, through purposive sampling. Data were collected through individual, in-depth, and semi-structured interviews and analyzed using the method recommended by Elo and Kyngäs (2008). The data analysis generated five subcategories as facilitators and five subcategories as barriers. The subcategories of facilitators included family's appropriate behavior with the patient, occupation, studying and information gathering, religious beliefs, and turning attitude into disease simplification and optimism. The subcategories of barriers were concerns about the uncertain future of the disease, physicians' poor communication and behavior, society's poor attitude, economic problems, and unsatisfactory support by the government and insurance companies. The results showed that a set of individual, environmental, and social factors serves as facilitators of or barriers to the process of adjustment to MS in patients. Gaining knowledge about these factors in congruence with the sociocultural context of the society, as derived from people's real experiences, can help healthcare staff and the family of these patients provide more efficient assistance to the patients for achieving adjustment earlier.

The association between workload and quality of work life of nurses taking care of patients with COVID-19.

BACKGROUND: The COVID-19 epidemic has brought significant changes and complexities to nurses' working conditions. Given the crucial role of health workers, particularly nurses, in providing healthcare services, it is essential to determine the nurses' workload, and its association with the quality of work life (QWL) during COVID-19 epidemic, and to explain the factors predicting their QWL. METHODS: A total of 250 nurses, who provided care for patients with COVID-19 in Imam Hossein Hospital of Shahrud, and met the inclusion criteria, were considered the samples in the present cross-sectional study in 2021-2022. Data were collected using the demographic questionnaire, NASA Task Load Index (TLX), and Walton's QWL questionnaire, which were analyzed using SPSS26 and based on descriptive and inferential statistical tests. A p-value less than 0.05 was considered significant for all cases. RESULTS: The nurses' mean scores of workload and QWL were 71.43 ± 14.15 and 88.26 ± 19.5, respectively. Pearson's correlation test indicated a significant inverse relationship between workload and QWL (r=-0.308, p < 0.001). The subscales with the highest perceived workload scores were physical demand and mental demand (14.82 ± 8.27; 14.36 ± 7.43), respectively, and the subscale with the lowest workload was overall performance (6.63 ± 6.31). The subscales with the highest scores for QWL were safety and health in working conditions and opportunity to use and develop human capabilities (15.46 ± 4.11; 14.52 ± 3.84), respectively. The subscales with the lowest scores were adequate and fair compensation, work and total living space (7.46 ± 2.38; 6.52 ± 2.47), respectively. The number of children (ß = 4.61, p = 0.004), work experience (ß= -0.54, p = 0.019), effort (ß = 0.37, p = 0.033) and total workload (ß= -0.44, p = 0.000) explained 13% of the variance of nurses' QWL. CONCLUSIONS: The study's findings showed that a higher workload score is associated with nurses' lower perception of QWL. In order to improve the QWL of nurses, reducing the physical and mental demands of their workload and strengthening overall performance is necessary. Additionally, when promoting QWL, adequate and fair compensation and the work and living space should be considered. The researchers suggest that hospital managers should make more significant efforts to develop and promote the QWL of nurses. To achieve this goal, organizations can pay attention to other influential factors, primarily by increasing organizational support.

The effect of a family-based participatory care program on anxiety in patients with acute coronary syndrome in coronary care units: A randomised controlled clinical trial.

BACKGROUND: Admission to the coronary care units (CCUs) and the patient's reduced interaction with family are regarded as important sources of anxiety. Family participation in care programs is pivotal to patient outcomes. OBJECTIVES: The present study was conducted to determine the effect of a care program based on family participation on anxiety in patients with acute coronary syndrome. METHODS: This randomised controlled trial was conducted on 90 patients in CCUs and their families. The patients were randomly assigned to one of the following three groups: routine care, control, and intervention. Routine care measures were provided to the routine care group, increased participation of the family was ensured in the control group, and a family-based participatory care program was implemented in the intervention group with the interaction of the nurse, patient, and family based on five principles, including presence, determination of needs, communication, participation in decision-making, and cooperation in care. The patients' anxiety was measured in the three groups on day 1 and 3 days after the admission to the CCU using the Spielberger State-Trait Anxiety Inventory. RESULTS: The patients' mean state anxiety score before the intervention was 44.4 ± 12.7, 46.6 ± 12.4, and 45.5 ± 12.1 in the routine care, control, and intervention groups, respectively, with no significant differences between them (P = 0.81). After adjusting for anxiety before the intervention and study hospital, the mean (before-after) changes in anxiety score in the three groups showed that anxiety was significantly lower in the intervention group than in the other groups (P < 0.05). CONCLUSION: Increased family presence alone has no effect on the patients' anxiety, but the family's participation and interaction with the care team can affect anxiety levels in cardiac patients in CCUs and improve the care processes. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, Trial No. IRCT201105146481N1.

Perceived professional identity and related factors in Iranian nursing students: a cross-sectional study.

BACKGROUND: Professional identity, an important process in the development and expansion of the nursing profession, is built over time and includes gaining insight into professional performances and fostering ideals and values for the profession. Several factors influence the formation of professional identity. This study investigates the level of professional identity in nursing students and its predictors using a localized tool. METHODS: This cross-sectional study recruited 195 nursing students at Semnan University of Medical Sciences, Semnan, Iran, who were selected by census sampling in 2020. Data were collected using a researcher-made professional identity questionnaire and were then analyzed in SPSS-18 using descriptive and inferential (logistic regression) statistics. RESULTS: The mean total score of the students' perceived professional identity was 316.72, indicating a strong professional identity. The students' professional identity had a significant relationship with variables including GPA above 16 (OR = 2.65, P = 0.002), choosing the field out of interest (OR = 2.15, P = 0.015), and having work experience while studying (OR = 3.10, P = 0.006). CONCLUSION: The findings showed that selecting the field of nursing out of interest, having a GPA above 16 and work experience while studying are associated with a higher perception of professional identity among nursing students. The professional identity of nursing students can be enhanced through reinforcing the mentioned factors and further attention to their role in the promotion and consolidation of professional identity. The researchers recommend that educational directors, nursing professors, and clinical nursing educators make greater efforts to develop and promote the professional identity of nursing students.

Nursing Students' Professional Competence in Providing Spiritual Care in Iran.

Providing spiritual care as a dimension of holistic nursing care is a task that requires competent caregivers. The present study seeks to examine the relationship of personal characteristics with perceived competence in Iranian nursing students and their professional competence in providing spiritual care. This cross-sectional study was conducted on all the nursing students at Semnan University of Medical Sciences, Semnan, Iran, using the census method (n = 224). The research sample consisted of 179 students who met the eligibility criteria. Data were collected using the Spiritual Care Competence Scale (SCCS). The mean SCCS score for respondents was 3.66. Using the cutoff point of >3.5, approximately three quarters of respondents (72.1%) perceived themselves to be competent in delivering spiritual care. The scores of competence and its domains were not significantly different in terms of history of participation in ethics training workshops, gender and marital status (P > 0.05). The scores were also not significantly correlated with age, semester and work experience. Although more than 70% of the nursing students perceived themselves competent in providing spiritual care, nursing curriculum planners should seek to promote the spiritual capacity and competence of nursing students in providing spiritual care through education and training.

The relationship between mental workload and job performance among Iranian nurses providing care to COVID-19 patients: A cross-sectional study.

AIMS: To evaluate the relationship between mental workload and job performance among nurses providing care to patients with COVID-19, and to explain the factors predicting their performance. BACKGROUND: The increased workload of health care workers in the COVID-19 pandemic affects their job performance, causes medical errors, contributes to patients' mortality and is a major concern for all health care organisations in the world. METHODS: This cross-sectional study recruited 139 nurses selected from the ICUs, infectious disease wards and emergency units of two hospitals in Iran. The NASA-Task Load Index and Paterson's job performance questionnaire were used. RESULTS: Mean scores of mental workload and job performance of the nurses were 67.14 ± 30.53 and 37.37 ± 7.36, respectively. A total of 71.95% and 96.4% of the nurses had high mental workload and job performance levels, respectively. The results indicated a weak positive correlation between mental workload and the mean score of job performance(r = .057). Unlike the mental demand (r = .175, p = .04) and temporal demand (r = .307, p < .001) that had a significant positive correlation with job performance, frustration had a significant negative correlation with job performance (r = -.183, p = .032). The following variables explained 33% of the variance of nurses' job performance: age, gender, type of ward, working shift, experience of providing care to patients with COVID-19 and frustration. CONCLUSION: The nurses' mental workload increased during the COVID-19 pandemic. Given the negative effect of mental workload on the nurses' behaviour and performance, the rise in their job performance and its weak positive correlation with their mental workload should be further addressed. IMPLICATIONS FOR NURSING MANAGEMENT: The present study results support the need for focusing on implementing strategies such as providing social and psychological support to moderate mental workload and improve job performance of nurses who provide care to patients with COVID-19.

The Effect of Spiritual Care Based on the Sound Heart Model on the Spiritual Health of Patients with Acute Myocardial Infarction.

Meeting the spiritual needs of patients with cardiovascular diseases has a significant effect on their speed of recovery and spiritual health, especially in coronary care units (CCUs). The present study was conducted to investigate the effect of spiritual care based on the sound heart model on the spiritual health of patients with acute myocardial infarction (AMI) admitted to the CCU of Chamran Hospital in Isfahan, Iran, in 2016. This clinical trial was conducted on 92 patients with AMI selected by convenience sampling and randomly assigned to the intervention (n = 46) and control (n = 46) groups. The spiritual care program based on the sound heart model was regularly carried out for the intervention group over 3 days at 5-8 PM during their hospital stay, and continued for 1 month at home after discharge from the hospital, and the control group only received routine nursing interventions. The patients completed Paloutzian and Ellison's Spiritual Well-Being Scale at baseline and a month after the intervention. Data were ultimately analyzed using Fisher's exact test, Mann-Whitney's test, the Chi-square test, and the t test. The spiritual care program was able to improve the mean scores of religious health (7.8), existential health (9.3) and the total score of spiritual health (17.1) in the intervention group, while these scores reduced to 0.9, 3.4 and 4.2 in the control group. A significant difference was found between the intervention and control groups in terms of the spiritual health score (P < 0.001). The present findings confirmed the effect of spiritual care based on the sound heart model on promoting spiritual health in patients with AMI. Its application as a holistic care approach is therefore recommended for improving the signs and dimensions of spiritual health in patients with coronary artery disease, especially MI.

Attitudes Toward Spirituality and Spiritual Care among Iranian Nurses and Nursing Students: A Cross-Sectional Study.

Addressing spiritual needs is taken into account as an integral part of holistic health care and also an important component of nursing practice. The aim of present study is to evaluate attitudes toward spirituality and spiritual care among nurses and nursing students at Semnan University of Medical Sciences in Iran. In this cross-sectional study, all nurses (n = 180) working in the teaching hospitals affiliated to Semnan University of Medical Sciences as well as senior nursing students (n = 50) selected by the census method. Finally, 168 individuals meeting the inclusion criteria were evaluated as the study sample. The data collection instrument was the Spirituality and Spiritual Care Rating Scale. The mean and standard deviation scores of attitudes toward spirituality and spiritual care among nurses and nursing students were 59 ± 10.9, and the scores obtained by the majority of study population (64.3%) ranged between 32 and 62 which were at a moderate and relatively desirable level. Nurses and nursing students working in aforementioned hospitals reported positive attitudes to spirituality and spiritual care. Given the importance of spiritual care and also the moderate level of spirituality and spiritual care among nurses and nursing students in this study, institutionalization of the concept of spirituality, provision of an appropriate context to deliver such care, and also implementation of interventions in order to improve spiritual care along with other nursing skills were assumed of utmost importance.

The Effect of Holy Qur'an Recitation on Depressive Symptoms in Hemodialysis Patients: A Randomized Clinical Trial.

Patients with advanced renal failure often face considerable sociopsychological stress as a result of lifestyle changes due to the disease and its treatment. The aim of the present study is to examine the effect of the Holy Qur'an recitation on depressive symptoms in hemodialysis patients. In this clinical trial, 54 hemodialysis patients were randomized to either an experimental (n = 27) or a control (n = 27) group. Patients completed the Beck Depression Inventory-II (BDI-II) at baseline and at 1 month after the intervention. Participants in the experimental group listened to recitation of the Holy Qur'an, while those in the control group received no intervention. The mean BDI-II score at baseline was 33.6 (±6.7) for the experimental group and 29.3 (±9.0) for the control group; at the end of treatment, BDI-II scores in the experimental and control groups were 14.5 (±4.8) and 31.6 (±9.2), respectively. Results from the repeated-measures general linear model controlling for baseline differences indicated a significant treatment effect (F = 9.30, p = 0.004, Cohen's d = 0.85). Holy Qur'an recitation has a significant effect on lowering depressive symptoms in hemodialysis patients. Holy Qur'an recitation is an easy-to-implement and cost-effective strategy that may be used to supplement the treatment of depression in this setting in Iran.

The Effect of Holy Qur'an Recitation on Anxiety in Hemodialysis Patients: A Randomized Clinical Trial.

Kidney disease and its related psychological costs have significantly increased in recent years. The aim of this study was to investigate the impact of Qur'an recitation on anxiety in hemodialysis patients. Sixty hemodialysis patients were randomized to either Qur'an recitation or a control group. Spielberger's State-Trait Anxiety Inventory (STAI) was completed by patients at baseline and 1 month afterward. The intervention involved listening to the recitation of the Qur'an in traditional cantillation voice. The control group received no intervention. The data were analyzed using Student's t test and general linear models. Recitation of the Qur'an was effective in reducing anxiety in the intervention group, decreasing STAI score at baseline from 128.5 (SD = 13.0) to 82.1 (SD = 11.3), compared to the control group which experienced no change in anxiety scores from baseline to follow-up (118.3, SD = 14.5, vs. 120.1, SD = 14.4, respectively. Between-subject comparison at follow-up, after adjusting for baseline differences, indicated a significant reduction in anxiety in the intervention versus the control group (F = 15.5, p = 0.0002, Cohen's d = 1.03). Listening to the Holy Qur'an being recited is an effective intervention for anxiety in patients undergoing hemodialysis in Iran.

A Comparison of the Effects of Acupressure and Music on Venipuncture Pain Intensity in Children: A Randomized Controlled Clinical Trial.

Pain from injections is common in children of all ages, and more than 90% of hospitalized children experience invasive and painful procedures such as venipuncture. In light of the complications associated with pain relief medications, nonpharmacological and complementary medicine approaches have gained attention. This study aims to compare the effects of acupressure and music on venipuncture pain intensity in children. This randomized controlled clinical trial involved 180 children aged 3-6 years who sought treatment at the Children's Medical Center Hospital Emergency Department at Tehran University of Medical Sciences, Iran. The children were randomly assigned to one of three groups: acupressure, music, or control. The interventions were given within 5 minutes, starting 3 minutes before the venipuncture and continuing until completion. The interventions included playing music through headphones and applying acupressure to the Hugo point. Venipuncture was carried out under identical conditions using an Angiocath 24G needle. Pain intensity was assessed using the Oucher scale. Data were analyzed using SPSS 24, employing the Kruskal-Wallis, chi-square, and Bonferroni pairwise comparison tests, with a significance level of 0.05. The mean pain intensity was 3.32 ± 1.44 in the music group, 4.82 ± 1.51 in the acupressure group, and 8.32 ± 1.10 in the control group. Pain intensity significantly differed among the three groups (p < 0.001). Specifically, pain intensity was lower in the music group compared to both the acupressure (p < 0.001) and control (p < 0.001) groups. Furthermore, pain intensity was lower in the acupressure group than in the control group (p < 0.001). Based on the results, music and acupressure methods effectively reduce pain intensity during venipuncture in children. Considering that music demonstrated a more pronounced effect in alleviating venipuncture pain than acupressure, the recommendation is to utilize music as a method of pain management during venipuncture in children. Iranian Registry of Clinical Trials, Trial No. IRCT20120109008665N15, was registered on 6 December 2021.

The health literacy level and its related factors in Iranian women with breast cancer undergoing chemotherapy.

Background: Breast Cancer (BC) is the most common cause of female mortality throughout the world. Promoting public awareness about this disease is the most crucial method of its prevention or control. The present study was carried out to determine the health literacy level and its related factors in women with BC. Methods: This cross-sectional study was conducted on BC patients undergoing chemotherapy in two teaching hospitals affiliated to Zahedan University of Medical Sciences in 2020. A total of 210 patients referred to these chemotherapy centers were selected by purposive sampling. The data collection tools included a demographic information form and a health literacy questionnaire for Iranian women with BC. The collected data were analyzed using descriptive and inferential statistics (logistic regression) in SPSS-22. p-values less than 0.05 were considered statistically significant. Results: The mean total score of the health literacy of women with BC undergoing chemotherapy was 40.35 ± 19.01, which suggests an insufficient health literacy. The health literacy had a significant relationship with variables including university education (OR = 4.41, p = 0.005) and supplementary insurance coverage (OR = 5.83, p < 0.001). Conclusion: The findings showed that university education and supplementary insurance coverage are associated with a higher health literacy among women with BC. Improving these factors and paying further attention to their role in the promotion of health literacy can help enhance the health literacy of women with BC.

The relationship between moral courage and providing safe care in nurses: A cross-sectional study.

BACKGROUND: Moral courage is one of the moral virtues, which can have a great impact on the provision of safe care for patients. Providing safe care is one of the most significant and fundamental principles of healthcare. This study aimed to determine the relationship between moral courage and safe care among nurses and explain the factors predicting safe care. MATERIALS AND METHODS: This is a cross-sectional study conducted on 172 nurses who worked in selected hospitals affiliated with the Iran University of Medical Sciences in 2019. For this purpose, self-report questionnaires on moral courage and safe nursing care were used. The collected data were analyzed in the Statistical Package for Social Sciences (SPSS) version 23.0 using descriptive (mean, standard deviation, percentage, and frequency) and inferential (Pearson's correlation coefficient and multiple linear regression) statistics. P values less than 0.05 were considered statistically significant. RESULTS: Mean scores of nurses' moral courage and safe care were desirable (407.57 ± 53.97) and satisfactory (311.31 ± 39.48), respectively. There was a significant correlation between the scores of nursing safe care and moral courage (r = 0.69, P < 0.001). Moral courage, gender, and work experience explained 54% of the variance of nursing safe care. CONCLUSION: The results showed that there is a positive and significant relationship between safety care and moral courage. It seems that increasing nurses' awareness of ethical principles leads to their courageous ethical behaviors, and safety and high-quality care should be one of the goals of all healthcare professionals. Also, the results of this study support the need to improve the knowledge and awareness of nurses and nurse managers regarding the importance of moral courage in providing safe nursing care and improving patient safety.

Comparison of the Effect of EMLA™ Cream and the Valsalva Maneuver on Pain Severity during Vascular Needle Insertion in Hemodialysis Patients: A Controlled, Randomized, Clinical Trial.

Background: Pain due to vascular needle insertion has been reported in 40-60% of hemodialysis (HD) patients. Evidence suggests that there is typically no single method for relieving the pain of inserting vascular needles in HD patients. This study aimed to compare the effectiveness of EMLA cream and Valsalva maneuver (VM) on pain severity during vascular needle insertion in HD patients. Methods: This randomized, controlled, clinical trial was conducted on 90 patients undergoing hemodialysis in the hemodialysis unit of Kowsar Hospital, affiliated with Semnan University of Medical Sciences, in Semnan, Iran. Patients were selected via convenience sampling and were randomly assigned to one of the three groups (EMLA, VM, and control groups). For the patients in the EMLA group, 2.5 g of EMLA cream was applied 60 minutes before the start of dialysis. For patients in the VM group, a maneuver was performed for 16-20 seconds before the needle was inserted. Patients in the control group received only routine care without any additional interventions. The pain severity in the three groups was measured using the visual analog scale (VAS) two minutes after vascular needle insertion. Results: The results showed that the mean pain severity during cannulation was 2.06 ± 2.19 in the EMLA group, 3.2 ± 30.42 in the VM group, and 6.20 ± 1.49 in the control group, suggesting a significant difference between the groups (P < 0.001). Pairwise comparison of the mean pain severity showed that it differed significantly in the EMLA and VM groups from the control group (P < 0.001), but no significant difference was found between the EMLA and VM groups (P=0.067). Conclusion: According to the results, EMLA cream was as effective as VM in reducing the pain severity caused by arteriovenous fistula (AVF) cannulation. Therefore, the use of EMLA cream and VM is recommended for reducing the severity of AVF cannulation pain. Trial Registration. Iranian Registry of Clinical Trials, Trial No : IRCT20120109008665N12, registered on 3 June 2020.

Barriers to and facilitators of coping with spinal cord injury for Iranian patients: a qualitative study.

The purpose of the present study was to explore the perspectives and experiences of Iranian patients regarding barriers and facilitators to their ability to cope with spinal cord injury (SCI). A qualitative design, based on the content analysis approach, was used to collect and analyze the experiences of 18 patients with spinal cord injury in two centers in Tehran, Iran. After using purposeful sampling for selection of the participants, semi-structured interviews were held for data collection. Lack of "knowledge", "financial resources", "employment opportunities", "suitable facilities and accessibility" as well as "societal acceptance and support" emerged as barriers; and having "self-confidence", "religious beliefs", "support networks" and "positive thinking" emerged as facilitators in coping with spinal cord injury. Participants believed that with these hindering factors in place, adapting to their new condition had been difficult, therefore they can only manage to adapt partially to their situation. Additional multidisciplinary endeavors are needed to help this group cope adequately and further research is required to influence policy making and legislation processes efficiently.

The Effect of Rhythmic Breathing on the Severity of Sternotomy Pain after Coronary Artery Bypass Graft Surgery: A Randomized Controlled Clinical Trial.

BACKGROUND: Moderate-to-severe pain is reported in up to 75% of the patients in the first 48 hours after cardiac surgery. Evidence suggests that distraction is an effective nursing intervention for controlling short-term and transient pain. Distraction can be achieved by various techniques, including progressive muscle relaxation, meditation, and rhythmic breathing (RB). The present research aimed at evaluating the impacts of RB on the severity of sternotomy pain after Coronary Artery Bypass Graft (CABG). METHODS: This randomized, controlled clinical trial was conducted on 60 patients after CABG surgery at the open-heart surgery Intensive Care Unit (ICU) of Kowsar Hospital, affiliated to Semnan University of Medical Sciences in Semnan, Iran. The patients were selected through convenience sampling and randomly assigned to two groups, including (1) intervention or RB and (2) control groups. RB was performed in the intervention group every 12 hours (9 a.m. and 9 p.m.) for three consecutive days after the surgery. The control group received only routine care for pain control (opioid analgesics) with no additional interventions. The severity of pain was measured every day in both groups of patients before and after the interventions using the Visual Analog Scale (VAS). RESULTS: The mean postintervention pain scores were significantly different from the mean preintervention scores in the intervention group (p < 0.05). The changes in the mean pain score in the intervention group were also significantly different from the corresponding changes in the controls (p < 0.05). CONCLUSION: Based on the results, the severity of pain after the intervention was significantly lower in the RB group compared to the control. RB was found to be an effective technique for reducing the patients' pain and is therefore recommended as a post-CABG pain control technique. Iranian Registry of Clinical Trials: this trial is clinically registered with IRCT20120109008665N7, registered 3 September 2018.