Navigating Informed Consent Requirements and Expectations in Cluster Randomized Trials: Research Ethics Board Members' and Researchers' Views.

Informed consent is a cornerstone of ethical human research. However, as cluster randomized trials (CRTs) are increasingly popular to evaluate health service interventions, especially as health systems aspire toward the learning health system, questions abound how research teams and research ethics boards (REBs) should navigate intertwining consent and data-use considerations. Methodological and ethical questions include who constitute the participants, whose and what types of consent are necessary, and how data from people who have not consented to participation should be managed to optimize the balance of trust in the research enterprise, respect for persons, the promotion of data integrity, and the pursuit of the public good in the research arena. In this paper, we report the findings and lessons learned from a qualitative study examining how researchers and REB members consider the ethical dimensions of when data can be collected and used in CRTs in the evolving research landscape.

Palliative care providers' roles in medical assistance in dying decision-making triads with patients and families: A qualitative analysis.

OBJECTIVES: Research on medical assistance in dying (MAiD) decision-making indicates that family members and close friends are often involved in making decisions with patients and their care providers. This decision-making model comprising patients, family members, and palliative care providers (PCPs) has been described as a triad. The objective of this study is to understand PCPs' experiences engaging in MAiD-related decision-making triads with patients and their families in Canada. METHODS: Semi-structured qualitative interviews were analyzed using interpretive description. RESULTS: We interviewed 48 specialist PCPs in Vancouver (26) and Toronto (22). Interviews were audio-recorded, professionally transcribed, and coded using a coding framework. PCPs take on 5 notable roles in their work with family members around MAiD. They provide emotional support and counseling, balance confidentiality between patients and families, provide education, coordinate support, and mediate family dynamics. SIGNIFICANCE OF RESULTS: PCPs take on multiple roles in working with patients and families to make decisions about MAiD. As patients and families may require different forms of support throughout the MAiD pathway, PCPs can benefit from institutional and interprofessional resources to enhance their ability to support patients and families in decision-making and bereavement.

Women's autonomy for managing labour pain in a relational context: An interpretive description study.

AIM: To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors. BACKGROUND: Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions. DESIGN: We used an interpretative description approach to conduct this study. METHOD: A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist. RESULTS: Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences. CONCLUSIONS: Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth. RELEVANCE TO CLINICAL PRACTICE: Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain. PATIENT OR PUBLIC CONTRIBUTION: Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.

Intensive care unit professionals' responses to a new moral conflict assessment tool: A qualitative study.

BACKGROUND: Moral distress is a serious problem for health care personnel. Surveys, individual interviews, and focus groups may not capture all of the effects of, and responses to, moral distress. Therefore, we used a new participatory action research approach-moral conflict assessment (MCA)-to characterize moral distress and to facilitate the development of interventions for this problem. AIM: To characterize moral distress by analyzing responses of intensive care unit (ICU) personnel who participated in the MCA process. RESEARCH DESIGN: In this qualitative study, we invited all ICU personnel at 3 urban hospitals to participate in individual or group sessions using the 8-step MCA tool. These sessions were facilitated by either a clinical ethicist or a counseling psychologist who was trained in this process. During each session, one of the researchers took notes and prepared a report for each MCA which were analyzed using qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT: A total of 24 participants took part in 15 sessions, individually or in groups; 14 were nurses and nurse leaders, 2 were physicians, and 8 were other health professionals. ETHICAL CONSIDERATIONS: This study was approved by the Providence Health Care/University of British Columbia Behavioural Research Ethics Board. Each participant provided written informed consent. RESULTS: The main causes of moral distress related to goals of care, communication, teamwork, respect for patient's preferences, and the managerial system. Suggested solutions included communication strategies and educational activities for health care providers, patients, family members, and others about teamwork, advance directives, and end-of-life care. Participants acknowledged that using the MCA process helped them to reflect on their own thoughts and use their moral agency to turn a distressing situation into a learning and improvement opportunity. CONCLUSIONS: Using the MCA tool helped participants to characterize their moral distress in a systematic way, and to arrive at new potential solutions.

Assessing Safety Status of Pediatric Intensive Care Units of Tehran, Iran according to the World Health Organization's Safety Standards.

Introduction: Given that children in pediatric intensive care units (PICUs) are more vulnerable to safety risks, health care officials are required to identify the weaknesses and strengths of care and ensure the safety of these children. In this study, the safety status in PICUs of selected educational children's hospitals in Tehran, Iran, was examined and compared with standards proposed by the World Health Organization (WHO). Methods: In this descriptive study, the performance of nurses with a bachelor's degree or higher and minimum work experience of six months in the PICU was examined. The study environment included four selected educational hospitals located in Tehran, Iran. Data collection tools were eight safety observation checklists based on the safety standards of WHO. Data collection took five months and the nurses' performance was categorized into three groups of undesirable, relatively desirable, and desirable. The data were analyzed using SPSS software version 13, descriptive statistics, and regression analysis. Results: Consistency of nursing care for the safety of hospitalized children was found undesirable in hand hygiene in accordance with the WHO standards. Nurses' performance was relatively desirable in the fields of being more cautious about drugs with similar names or spelling to avoid medication errors, communication during patient hand-over, and performance of correct procedure at correct body site. Regarding other fields, the consistency was at a desirable level. Conclusion: Children's safety in the PICUs is not desirable in terms of observing health codes and there is a long way to go to meet the international standards.

Causes of futile care from the perspective of intensive care unit nurses (I.C.U): qualitative content analysis.

BACKGROUND: Medical care that has therapeutic effects without significant benefits for the patient is called futile care. Intensive Care Units are the most important units in which nurses provide futile care. This study aimed to explain the causes of futile care from the perspective of nurses working in Intensive Care Units are. METHOD: The study was conducted using a qualitative approach. Qualitative content analysis was used to analyze the data. Study participants were 17 nurses who were working in the Intensive Care Units are of hospitals in the north of Iran. They were recruited through a purposeful sampling method. Data was gathered using in-depth, semi-structured interviews from March to June 2021. Recruitment was continued until data saturation was reached. RESULTS: Two main themes, four categories, and thirteen subcategories emerged from the data analysis. The main themes were principlism and caring swamp. The categories were moral foundation, professionalism, compulsory care, and patient's characteristics. CONCLUSION: In general, futile care has challenged nursing staff with complex conflicts. By identifying some of these conflicts, nurses will be able to control such situations and plan for better management strategies. Also, using the findings of this study, nursing managers can adopt supportive strategies to reduce the amount of futile care and thus solve the specific problems of nurses in intensive care units such as burnout, moral stress, and intention to leave.

Medical assistance in dying legislation: Hospice palliative care providers' perspectives.

BACKGROUND: After over 4 years since medical assistance in dying legalization in Canada, there is still much uncertainty about how this ruling has affected Canadian society. OBJECTIVE: To describe the positive aspects of medical assistance in dying legalization from the perspectives of hospice palliative care providers engaging in medical assistance in dying. DESIGN: In this qualitative descriptive study, we conducted an inductive thematic analysis of semi-structured interviews with hospice palliative care providers. PARTICIPANTS AND SETTING: Multi-disciplinary hospice palliative care providers in acute, community, residential, and hospice care in Vancouver and Toronto, Canada, who have engaged in end-of-life care planning with patients who have inquired about and/or requested medical assistance in dying. ETHICAL CONSIDERATIONS: The research proposal was approved by University of British Columbia Research Ethics Board in Vancouver and University Health Network in Toronto. Participants were informed regarding the research goals, signed a written consent, and were assigned pseudonyms. RESULTS: The 48 participants included hospice palliative care physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health providers (n = 4). The average interview length was 50 min. Positive aspects of medical assistance in dying legalization were identified at (1) the individual level: (a) a new end-of-life option, (b) patients' last chance to express control over their lives, (c) patient and family comfort and relief, and (d) a unique learning experience for hospice palliative care providers; (2) the team level: (a) supportive collegial relationships, (b) broadened discussions about end-of-life and palliative care, and (c) team debriefs provide opportunities for education and support; and (3) the institutional level: (a) improved processes to facilitate the implementation logistics. CONCLUSION: While being involved in the medical assistance in dying process is complex and challenging, this study sheds light on the positive aspects of medical assistance in dying legalization from the hospice palliative care provider's perspectives. Medical Assistance in Dying legalization has resulted in improved end-of-life conversations between hospice palliative care providers, patients, and their families. Improved communication leads to a better understanding of patients' end-of-life care plans and bridges some of the existing gaps between hospice palliative care and medical assistance in dying.

How does Medical Assistance in Dying affect end-of-life care planning discussions? Experiences of Canadian multidisciplinary palliative care providers.

BACKGROUND: More than a dozen countries have now legalized some form of assisted dying, and additional jurisdictions are considering similar legislations or expanding eligibility criteria. Despite the persistent controversies about the relationship between medicine, palliative care, and assisted dying, many people are interested in assisted dying. Understanding how end-of-life care discussions between patients and specialist palliative care providers may be affected by such legislation can inform end-of-life care delivery in the evolving socio-cultural and legal environment. AIM: To explore how the Canadian Medical Assistance in Dying legislation affects end-of-life care discussions between patients and multidisciplinary specialist palliative care providers. DESIGN: Qualitative thematic analysis of semi-structured interviews. PARTICIPANTS: Forty-eight specialist palliative care providers from Vancouver (n = 26) and Toronto (n = 22) were interviewed in person or by phone. Participants included physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health professionals (n = 4). RESULTS: Qualitative thematic analysis identified five notable considerations associated with Medical Assistance in Dying affecting end-of-life care discussions: (1) concerns over having proactive conversations about the desire to hasten death, (2) uncertainties regarding wish-to-die statements, (3) conversation complexities around procedural matters, (4) shifting discussions about suffering and quality of life, and (5) the need and challenges of promoting open-ended discussions. CONCLUSION: Medical Assistance in Dying challenges end-of-life care discussions and requires education and support for all concerned to enable compassionate health professional communication. It remains essential to address psychosocial and existential suffering in medicine, but also to provide timely palliative care to ensure suffering is addressed before it is deemed irremediable. Hence, clarification is required regarding assisted dying as an intervention of last resort. Furthermore, professional and institutional guidance needs to better support palliative care providers in maintaining their holistic standard of care.

The challenges of using physical restraint in intensive care units in Iran: A qualitative study.

BACKGROUND: Physical restraint is widely used in intensive care units to ensure patient safety, manage agitated patients, and prevent the removal of medical equipment connected to them. However, physical restraint use is a major healthcare challenge worldwide. AIM: This study aimed to explore nurses' experiences of the challenges of physical restraint use in intensive care units. METHODS: This qualitative study was conducted in 2018-2019. Twenty critical care nurses were purposively recruited from the intensive care units of four hospitals in Tehran, Iran. Data were collected via in-depth semi-structured interviews, concurrently analyzed via Graneheim and Lundman's conventional content analysis approach, and managed via MAXQDA software (v. 10.0). FINDINGS: Three main themes were identified (i) organizational barriers to effective physical restraint use (lack of quality educations for nurses about physical restraint use, lack of standard guidelines for physical restraint use, lack of standard physical restraint equipment), (ii) ignoring patients' wholeness (their health and rights), and (iii) distress over physical restraint use (emotional and mental distress, moral conflict, and inability to find an appropriate alternative for physical restraint). CONCLUSION: Critical care nurses face different organizational, ethical, and emotional challenges in using physical restraint. Healthcare managers and authorities can reduce these challenges by developing standard evidence-based guidelines, equipping hospital wards with standard equipment, implementing in-service educational programs, supervising nurses' practice, and empowering them for finding and using alternatives to physical restraint. Nurses can also reduce these challenges through careful patient assessment, using appropriate alternatives to physical restraint, and consulting with their expert colleagues.

The Seismic Shift in End-of-Life Care: Palliative Care Challenges in the Era of Medical Assistance in Dying.

Background: Concerns regarding personal, professional, administrative, and institutional implications of medical assistance in dying (MAiD) are of particular interest to palliative and hospice care providers (PHCPs), who may encounter additional moral distress and professional challenges in providing end-of-life (EOL) care in the new legislative and cultural era. Objective: To explore PHCPs' encountered challenges and resource recommendations for caring for patients considering MAiD. Design: Qualitative thematic analysis of audio-recorded semistructured interviews with PHCPs. Setting/Subjects: Multidisciplinary PHCPs in acute, community, residential, and hospice care in Vancouver, Canada, with experience supporting patients who have made MAiD inquiries or requests. Measurements: Interviews were deidentified, transcribed verbatim, and coded by four researchers using a common coding scheme. Key themes were analyzed. Results: Twenty-six PHCP participants included physicians (n = 7), nurses (n = 12), social workers (n = 5), and spiritual health practitioners (n = 2). Average interview length was 52 minutes (range 35-90). Analysis revealed four broad challenges associated with providing EOL care after MAiD legalization: (1) moral ambiguity and provider distress, (2) family distress, (3) interprofessional team conflict, and (4) impact on palliative care. Participants also recommended three types of resources to support clinicians in delivering quality EOL care to patients contemplating MAiD: (1) education and training, (2) pre- and debriefing for team members, and (3) tailored bereavement support. Conclusions: PHCPs encountered multilevel MAiD-related challenges, but noted improvement in organizational policies and coordination. Resources to enhance training, pre- and debriefing, and tailored bereavement may further support PHCPs in providing high-quality EOL care as they navigate the legislative and cultural shifts.

Understanding childbirth pain in Brazilian women: A qualitative descriptive study.

BACKGROUND: The pain associated with childbirth is a cause of severe pain, and the literature suggests that it can be influenced by psychosocial influences, the environment, and cognitive processes, creating the overall experience of childbirth. Therefore, the investigation of women's childbirth pain experience is essential. AIM: The purpose of this study is to understand women's childbirth pain and determine which influences can contribute to building different experiences. METHOD: A qualitative descriptive approach was adopted to explore the women's childbirth pain experiences, by understanding the influences on their experiences. Data were collected through in-depth interviews with 21 women in a hospital setting in São Paulo, Brazil, and analysed by thematic analysis. RESULTS: Three major themes emerged from the analysis: (1) experiencing childbirth pain, (2) face-to-face with pain, and (3) empowerment needs. DISCUSSION: Many factors influence how Brazilian women manage pain and shape their experience during childbirth. The findings suggest that when women had a positive experience, they asked for minimal support, demonstrated balance, and expressed that the pain was manageable; when they had unfavourable experiences, they regarded pain as a threat and a punishment and associated it with unpleasant emotions. CONCLUSION: The results outlined concerns that should be addressed in the provision of specific, appropriate care for women, to support them in improving their experience during childbirth.

Moral neutralization: Nurses' evolution in unethical climate workplaces.

INTRODUCTION: Good quality of care is dependent on nurses' strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice. MATERIALS AND METHODS: This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews. RESULTS: The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: (1) feeling discouraged; (2) normalization; (3) giving up; (4) becoming a justifier; and (5) moral indifference. CONCLUSIONS: Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process.

Designing a truth-based communication model in patient ethical care process.

INTRODUCTION: Providing information based on truth is very important in patients' treatment-related decisions and reduces emotional and physical sufferings as well as patient costs. The aim of this study was to design a model that is based on the culture and health-care context of Iran in order to establish a truth-based communication and provide accurate information to patient. MATERIALS AND METHODS: This qualitative study was conducted in 2019. Data were collected through semi-structured interviews with 18 nurses who had been selected by purposeful sampling method. Data analysis was performed in two steps. In the first step, the participants' experiences were determined using the grounded theory approach. In the next step, using Walker and Evant's (2011) method, the concepts and statements were combined and presented in a central concept. RESULTS: The central concept in this study was "an attempt to establish a truth-based communication with patient," and then, a truth-based communication model was presented. The components of the model were presented in three parts: improving patient communication skills, managing the situation in which the truth is presented, and the patient's participation in decision-making. CONCLUSION: To present the truth of the treatment, which can sometimes be unpleasant and bitter, it is very important to improve communication skills and choose an effective communication strategy. To establish a truth-based communication, it is necessary to create a suitable ground for communication, which should be provided in clinical setting and community.

White lies in pediatric care: a qualitative study from nurses' perspective.

Communication and sharing information with ill children are challenging. To protect a child from the bitter reality, sometimes use of well-intended untruths, or white lies is necessary. This research aimed at studying the experiences of nurses about the use of white lies in in pediatric clinical setting. In this qualitative, content-analysis study, 24 on-duty pediatric nurses were interviewed in 2019. Data were collected through purposeful sampling using semi-structured interviews, and the collected data were analyzed according to Granheim and Landman's method using MAXQDA-10 software. Eighteen female and six male nurses with the mean age of 42 ± 3/7 years and mean work experience of 16 ± 4/1 years were selected to participate in this study. Data analysis showed that use of white lies depends on both situation and several other factors classified into five general categories: nature of data, childhood characteristics, family norms, treatment team's capabilities and organization policies. Treatment team members need to improve their communication skills to convey therapeutic information to the ill child's family appropriately. To do so, special guidelines should be prepared for healthcare staff in pediatric clinical setting.

Factors behind ethical dilemmas regarding physical restraint for critical care nurses.

BACKGROUND: Physical restraint is among the commonly used methods for ensuring patient safety in intensive care units. However, nurses usually experience ethical dilemmas over using physical restraint because they need to weigh patient autonomy against patient safety. AIM: The aim of this study was to explore factors behind ethical dilemmas for critical care nurses over using physical restraint for patients. DESIGN: This is a qualitative study using conventional content analysis approach, as suggested by Graneheim and Lundman, to analyze the data. METHODS: Seventeen critical care nurses were purposefully recruited from the four intensive care units in Tehran, Iran. Data were collected through in-depth semi-structured interviews and were concurrently analyzed through conventional content analysis as suggested by Graneheim and Lundman. ETHICAL CONSIDERATION: This study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran with the code: IR.IUMS.REC.1397.795. Before interviews, participants were provided with explanations about the aim of the study, the confidentiality of the data, their freedom to participate, and the right to withdraw the study, and their free access to the study findings. Finally, their consents were obtained, and interviews were started. RESULTS: Factors behind ethical dilemmas for critical care nurses over using physical restraint were categorized into three main categories, namely the outcomes of using physical restraint, the outcomes of not using physical restraint, and emotional distress for nurses. The outcomes of using physical restraint were categorized into the three subcategories of ensuring patient safety, physical damage to patients, and mental damage to the patient. The outcomes of not using physical restraint fell into two subcategories, namely the risks associated with not using physical restraint and legal problems for nurses. Finally, the two subcategories of the emotional distress for nurses main category were nurses' negative feelings about restraint use and uncertainty over the decision on physical restraint use. CONCLUSION: Decision-making for restraint use is often associated with ethical dilemmas, because nurses need to weight the outcomes of its use against the outcomes of not using it and also consider patient safety and autonomy. Health authorities are recommended to develop clear evidence-based guidelines for restraint use and develop and implement educational and counseling programs for nurses on the principles of ethical nursing practice, patient rights, physical restraint guidelines and protocols, and management of emotional, ethical, and legal problems associated with physical restraint use.

New visiting policy: A step toward nursing ethics.

BACKGROUND:: Patients' rights arise from their expectations of the healthcare system, which are rooted in their needs. Visitation is seen as a necessary need for patients and families in intensive care units. OBJECTIVES:: The authors attempted to design, implement, and evaluate a new visiting policy in the intensive care units. RESEARCH DESIGN:: This study was an action research, including two qualitative and quantitative approaches. PARTICIPANTS AND RESEARCH CONTEXT:: The viewpoints of 51 participants (patients, families, doctors, nurses, and guards) on how to change the limited visiting policy were explained through semi-structured interviews and focus groups. The new visiting policy (contractual visitation) was designed, implemented, and evaluated with the involvement of participants. ETHICAL CONSIDERATIONS:: The hospital ethics committee approval was gained and the informed consent was obtained from all the participants. FINDINGS:: The content of interviews was analyzed and classified into four categories: advantages and disadvantages of visiting policies, and barriers and facilitators of changing the limited visiting policy. After implementation of the new policy (contractual visitation), a significant difference observed in satisfaction status before and after the changes (p value < 0.001). DISCUSSION:: Nowadays, many countries' clinical guidelines recommend flexible visiting policy, which is consistent with the results of this study. CONCLUSION:: Changing the limited visiting policy was a necessary need for patients and families that established with the involvement of them and staff.

An Evolutionary Route for the Moral Development of Nursing Students: A Constructivist Grounded Theory.

BACKGROUND: Developing moral competency is a main aim of educational systems, especially in healthcare-related disciplines. PURPOSE: The aim of this study was to explore the moral development process in nursing students. METHODS: This study used a constructivist grounded theory. Twenty-five semistructured, face-to-face interview with 22 participants were conducted to gather the data. The participants were nursing students and educators attending three nursing schools in Tehran. RESULTS: Moral development evolves within nursing students following a stepwise progression. Within each step or phase, students experience specific changes with regard to both their practical skills and their moral capabilities and competencies. Three main steps were identified: moral transition, moral reconstruction, and moral internalization. Techno-scientific competence, biomedical competence, and nursing competence are developed in each step, respectively. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Moral competency in nursing students develops along with their competency as nursing practitioners. To facilitate progress through each phase, it needs to be ensured that the learning experiences that students are exposed to during each consecutive year of study facilitate as much as possible the development of moral competence.

Patients' and Families' Satisfaction With Visiting Policies in Cardiac Intensive Care Units.

BACKGROUND: Families play a vital role in the recovery of patients admitted to intensive care units. They can help patients to adapt themselves to the crisis and feel more satisfied. OBJECTIVE: In this study, we examined the patients' and families' satisfaction with the current visiting policies in cardiac intensive care units in the largest Cardiovascular Medical and Research Center of Iran. METHOD: This research used a cross-sectional descriptive design. To do so, 303 patients admitted to those cardiac intensive care units and their families responded to a 2-part questionnaire between September 2014 and March 2015. RESULTS: The results showed that 55.1% of the participants were dissatisfied with the limited visiting policies of the cardiac intensive care units, whereas the satisfaction rate was 14.2%. The remaining participants (30.7%) were slightly satisfied with the visiting policies in cardiac intensive care units. CONCLUSIONS: Patient-centered care is an expectation among patients and their families in the cardiac intensive care units. It seems that a change in visiting policies is necessary.

The quality of obtaining surgical informed consent.

BACKGROUND: Informed consent goes beyond signing a form; it is a process of providing necessary information, helping patients make an informed decision, and actively participate in their treatment. AIM/OBJECTIVE: This study aimed to assess the quality of obtaining surgical informed consent in hospitals affiliated with Tehran University of Medical Sciences. Research design/participants/context: In a cross-sectional, descriptive-analytical study, 300 patients were chosen through stratified sampling from seven hospitals affiliated with Tehran University of Medical Sciences. Data were collected using a questionnaire developed by the researchers and analyzed using descriptive and analytical statistics on SPSS software. Ethical considerations: Ethical approval of this study was granted by Tehran University of Medical Sciences research ethics committee. Written informed consent for participation was obtained. The participants were reassured that their information will be used anonymously and their answers will not affect their treatment and care. FINDINGS: The mean score of quality of acquisition of informed consent was 17.13 out of 35, indicating that the quality falls in the inappropriate category. The results indicate that 48% of the signatories do not even read the form before signing it. Among the 52% who did read the consent form, 61.3% mentioned varying degrees of incomprehensibility of the consent form and 94.2% mentioned the presence of incomprehensible technical, medical and legal vocabulary. Only 12% and 18% of respondents reported that they were not in hurry and they had no fear or anxiety, respectively, when signing the form. The quality of obtaining informed consent was higher in women, younger patients, patients with higher education, and those who had special surgeries. DISCUSSION: This study shows a poor practice in obtaining surgical informed consent in Iran. It seems necessary to consider fundamental changes in the process of acquiring consent based on the temporal and local conditions of the patients.

Becoming a nurse as a moral journey: A constructivist grounded theory.

BACKGROUND: Nursing students, during their study, experience significant changes on their journey to become nurses. A major change that they experience is the development of their moral competency. OBJECTIVE: The purpose of this study is to explore the process of moral development in Iranian nursing students. RESEARCH DESIGN: A constructivist grounded theory method was adopted. Twenty-five in-depth, semi-structured, face-to-face intensive interviews with 22 participants were conducted from September 2013 to October 2014. All interviews were audio-taped, transcribed, and analyzed using writing memos and the constant comparative method. Participants and research context: The setting was three major nursing schools within Tehran, the capital of Iran. Nineteen nursing students and three lecturers participated in the study. Ethical considerations: The study was approved by the Tehran University of Medical Sciences Committee for Medical Research Ethics (92/D/130/1781). It was explained to all participants that their responses would be treated with confidentiality and that they would not be identified in any way in the research and any publication ensuing from the research. All participants agreed to be interviewed and signed written consent forms agreeing to the recording and analyses of the interview data gathered. FINDINGS: Findings indicated three levels of moral development along with the formation of professional identity. The three levels of moral development, getting to know the identity of nursing (moral transition), accepting nursing identity (moral reconstruction), and professional identity internalization (professional morality), were connected to the levels of professional identity formation. DISCUSSION: The proposed model added a new insight to professionalism in nursing. CONCLUSION: From the findings, it was concluded that to enhance higher moral practice, nursing instructors should promote the professional identity of nursing students. Reinforcement of moral characteristics and professional identity within registered nurses occurs over a series of phases and, once fully integrated into the identity of nursing students, the moral characteristics that they acquire become part of their both professional and personal identities.