Cross-Cultural Patient Counseling and Communication in the Integrative Medicine Setting: Respecting the Patient's Health Belief Model of Care.

PURPOSE OF REVIEW: Communicating effectively with patients having a traditional, alternative or complementary medicine-related health-belief model is challenging in today's cross-cultural society. This narrative review explores the integrative medicine setting of care, focusing on insights from the integrative oncology daily practice, while addressing the relevance to the mental health setting. The way in which healthcare providers can enhance cultural-sensitive communication with patients and informal caregivers; recognize and respect health-beliefs to bridge cultural gaps; and generate an open, non-judgmental and mindful dialogue are discussed. RECENT FINDINGS: Identifying cross-cultural barriers to healthcare provider-patient communication is important in order to address the potential for conflict between conventional and "alternative" health beliefs; difficulties in creating a shared-decision making process; disagreement on therapeutic goals and treatment plan; and finally, the potential for non-compliance or non-adherence to the conventional oncology treatment. Acquiring intercultural competencies is needed at all stages of medical education, and should be implemented in medical and nursing curricula, as well as during specialization and sub-specialization. As with patient-centered paradigms of care, integrative medicine entails a dual patient-centered and sensitive-cultural approach, based on a comprehensive bio-psycho-social-spiritual model of care.

Quality of services in health education nurse-led clinics: an Iranian service providers and service recipients experience.

BACKGROUND: Patient education is a vital role of nurses in nurse-led clinics(NLCs). Since 2011, independent NLCs entitled health education Nurse-led clinics(HENLCs) have been established in Iran. In order for this newly developed service to be able to perform perfectly in implementation and evaluation, it should be explained based on one of the quality evaluation models. The objective of the study was to determine the dimension of service quality in HENLCs based on service providers' and service recipients' experience. METHODS: This research is a qualitative study of directed content analysis type conducted between May and November 2020. Twenty-nine participants who had rich experiences in the patient education in HENLCs were interviewed in this study. Asarroodi et al.'s (2018) qualitative content analysis method was used for data analysis, and MaxQDA software was used for data management. We used credibility, dependability, and Confirmability to confirm the trustworthiness of the study's findings. RESULTS: In this study service providers including managers, policymakers, decision-makers, nurses, physicians, and service recipients including patients and families participated. Seven generic categories, including (1) a competent and self-motivated nurse educator, (2) an easily accessible and comfortable environment, (3) informational-educational materials and health education equipment, (4) motivational facilities, (5) access to the health education support team, (6) organizational communication supporting the education process, and (7) receiving the patient education fee, constituted the main category of structure. Five generic categories, including (1) assessment and determination of the educational needs of the target group, (2) description of the nurse's duties, (3) teaching-learning methods, (4) patient referral, and (5) the process of preparing and publishing educational content, constituted the main category of process. One generic category called evaluation constituted the main category of outcome. CONCLUSION: Based on the results of this study, it is suggested to managers to pay attention to the dimensions of the quality model of Donabedian (SPO) in setting up and developing the performance of HENLCs, it is recommended that future quantitative studies based on the categories formed in this study evaluate the observance of the dimensions of structure, process and outcome.

Factors related to advance directives completion among cancer patients: a systematic review.

INTRODUCTION: Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS: A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS: Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION: The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

The development of practice standards for patient education in nurse-led clinics: a mixed-method study.

INTRODUCTION: Educating patients and families about self-care is one of the important roles of nurses in Nurse-led clinics (NLCs). NLCs need standards for guiding the practice of nurses. A standard is an authoritative statement that sets out the legal and professional basis of nursing practice. This paper seeks to report the development of practice standards for patient and family education in NLCs. METHODS: This project used a Sequential-Exploratory mixed methods design. Before the study, we conducted a literature review to identify gaps. Directed content analysis was used in phase 1. The second phase involved two focus groups. The third phase involves two rounds of modified Delphi. RESULTS: Twenty-nine participants were interviewed, and 1816 preliminary codes were formed in phase 1. 95 standards were grouped into three main categories (structure, process, and outcome). In the first focus group, experts eliminate 32 standards. Experts eliminate 8 standards after the second stage of the focus group. After two rounds of Delphi, the final version of the standard consists of 46 standards (13 structure, 28 process and 5 outcome). CONCLUSIONS: Nurses and institutions could benefit from practice standards for patient education in the NLCs, which consist of 46 statements in three domains, as a guide for clinical activities and a tool to gauge the quality of patient education in NLCs. The developed standards in this study can guide new and existing NLCs and help them evaluate ongoing activities. Providing patient education in NLCs based on standards can improve patients' outcomes and promote their health.

Challenges of Integrated Home-Based Palliative Care Services for Cancer Patients during the COVID-19 Pandemic: A Qualitative Content Analysis.

Given the situation of cancer patients as vulnerable patients and the threat of COVID-19 in the society, integration of home-based palliative care services into the healthcare system is essential. The aim of this qualitative study was to explore the current barriers of integration of palliative care services from hospital to home for cancer patients during the COVID-19 Pandemic and to provide suggestions to resolve them. Semi-structured interviews were conducted with 25 stakeholders in the healthcare system, including health policy makers, healthcare providers, clinical home healthcare experts, home healthcare researchers, university faculty members, clergy, family caregivers, and cancer patients. Data were analyzed using directed content analysis method based on the World Health Organization Public Health Strategy for Palliative Care. Challenges were extracted in 4 main categories, containing education barriers (3 subcategories), implementation barriers (9 subcategories), policy barriers (5 subcategories), and drug availability barriers (2 subcategories). Based on the results, removing the barriers and establishing a strong infrastructure for home-based palliative care services is recommended in the healthcare system by concentrating on 4 essential factors, that is, utilizing a coordinating nurse during the process of patient's hospital discharge, establishment of connecting outpatient palliative care clinics to home healthcare centers, access to palliative care tele-medicine and development of a comprehensive and flexible home-based palliative cancer care model in our context.

Scope of Iranian community health nurses 'services from the viewpoint of the managers and nurses: a content analysis study.

BACKGROUND: Considering the need for nurses specializing in community health and in order to define professional duties for future planning towards creating the position of community health nurses in the primary health care system of Iran, this study aims to explain the range of services which can be provided by community health nurses from the perspective of the mangers and nurses. METHODS: The present qualitative study was conducted with the approach of contract content analysis in Iran in 2020. This study was conducted through in-depth and semi-structured interviews with 22 participants, including community health nursing faculty members, health deputies and managers, community health nurses working in health centers, and the care seekers visiting comprehensive health centers. The samples were selected through purposeful sampling. The interviews continued until data saturation. Data analysis was performed simultaneously with data collection. The interviews were recorded, transcribed, and analyzed through Graneheim & Lundman's content analysis method, and data management was done using MAXQDA software. To achieve data trustworthiness, the criteria presented by Lincoln and Guba were used. RESULTS: The obtained data were classified into the two main categories of service provision settings and service provision domains. The category service provision settings covered 7 subcategories including participation in the family physician plan, activities at the centers for vulnerable groups of the community, establishing private community health clinics, leading health promotion programs in the 3rd generation hospitals, activities in comprehensive health centers, follow-ups and home visits, and activities in schools' health units. Service provision domains consisted of 6 subcategories including participation in health planning, decision-making, and policymaking, research on the health system, health promotion, monitoring and coordination, providing care for the patients with non-communicable diseases and high-risk groups, and eldercare. CONCLUSIONS: From the participants' perspective, important services that can be provided by the community health nurse are health promotion, the management of chronic patients and the elderly, follow-ups, and home visits. Therefore, it is recommended that health policy makers pay attention to the service provision areas and the services providable by the community health nurse in their macro-planning, and to provide primary health care in comprehensive health centers using inter-professional care models, integrating the community health nurse into the care team.

Workload and quality of nursing care: the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion by using structural equations modeling approach.

BACKGROUND: Nursing workload and its effects on the quality of nursing care is a major concern for nurse managers. Factors which mediate the relationship between workload and the quality of nursing care have not been extensively studied. This study aimed to investigate the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion in the relationship between workload and quality of nursing care. METHODS: In this cross-sectional study, 311 nurses from four different hospitals in center of Iran were selected by convenience sampling method. Six self-reported questionnaires were completed by the nurses. The data were analyzed by SPSS version 16. Structural equation modeling was used to determine the relationships between the components using Stata 14 software. RESULTS: Except direct and mutual relationship between workload and quality of nursing care (P ≥ 0.05), the relationship between other variables was statistically significant (P < 0.05). The hypothesized model fitted the empirical data and confirmed the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion in the relationship between workload and the quality of nursing care (TLI, CFI > 0.9 and RMSEA < 0.08 and χ2/df < 3). CONCLUSION: Workload affects the quality of the provided nursing care by affecting implicit rationing of nursing care, job satisfaction and emotional exhaustion. Nurse managers need to acknowledge the importance of quality of nursing care and its related factors. Regular supervision of these factors and provision of best related strategies, will ultimately lead to improve the quality of nursing care.

Developing an integrated model of community-based palliative care into the primary health care (PHC) for terminally ill cancer patients in Iran.

BACKGROUND: Patients with cancer commonly experience pain and suffering at the end of life days. Community-based palliative care can improve the quality of life of terminally-ill cancer patients and provide them with a merciful death. The purpose of this study was to develop an integrated model of community-based palliative care into PHC for terminally ill cancer patients. METHOD: This study is a health system research (HSR) that was conducted in three phases from October 2016 to July 2020. In the first phase, dimensions of community-based palliative care were explored in patients with cancer using qualitative methods and conventional content analysis. In the second phase, a scoping review was carried out to complete the collected data from the qualitative phase of the study. Based on the collected data in the first and second phases of the study, a preliminary draft of community-based palliative care was developed for patients with cancer based on the framework of the World Health Organization. Finally, the developed model was validated using the Delphi technique in the third phase of the study. RESULTS: Data analysis indicated that providing community-based care to patients with cancer is influenced by the context of care. According to the developed model, patients are identified as terminally ill, and then are referred to the local comprehensive health center in a reverse manner. After patients' referral, they can receive appropriate healthcare until death by the home care team in relation to the comprehensive health center based on the framework of primary healthcare. CONCLUSIONS: This model was developed based on the current Iranian healthcare structure and the needs of terminally ill cancer patients. According to the model, healthcare is provided in a reverse manner from the subspecialty centers to patients' homes in order to provide easy access to palliative care. It is suggested to use this model as a pilot at the regional level.

Development and psychometric testing of the career success in Nursing Scale.

AIM: To develop and test the psychometric properties of an instrument assessing career success in nurses. BACKGROUND: Despite the importance of achieving success in nursing, to date, this construct has been measured using unidimensional or generic scales not fully reflecting career success as perceived by nurses. METHODS: This scale development study used a large sample of nurses across 10 hospitals in Tabriz, Iran. Items were generated based on existing literature and previous, research team-led, qualitative study, followed by testing content and face validity of the items. Exploratory factor analysis (N = 530 nurses) then assessed the underlying structure of the scale, and reliability was tested using Cronbach's alpha and a 2-week test-retest correlation. FINDINGS: From the initial 73 items, fourteen rated by experts as 'not relevant' and seven with poor face validity were deleted. Exploratory factor analysis further identified 13 poor items. The final 39-item solution extracted four robust career success factors: expected career progress, providing quality care, effective self-regulation, and person-organization fit. Cronbach's alpha and test-retest correlation showed excellent reliability. CONCLUSION: This multidimensional nursing-specific scale with very good psychometric properties is suitable for individual/group-based decisions. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This instrument can assess current perceptions of career success in nurses, so work resources can be allocated to improve policies, services and training programmes to meet career aspirations of nurses and objectives of the organization. Having a robust scale of career success will enable future research in the field of career success as specific to nursing in a clinical setting.

Perceptions of Spiritual Dryness in Iran During the COVID-19 Pandemic.

This study addresses perceptions of spiritual dryness (a specific form of spiritual struggle) during the COVID-19 pandemic among Iranian Muslims (n = 362), and how these perceptions can be predicted. Spiritual dryness was perceived often to regularly by 27% and occasionally by 35%. Regression models revealed that the best predictors of spiritual dryness (SDS-7) were usage of mood-enhancing medications, loneliness/social isolation and praying as positive predictors, and being restricted in daily life concerns as negative predictor. The pandemic challenges mental stability of people worldwide and may also challenge trust in God. Reliable and humble support of people experiencing these phases is required.

Evaluation of Care Providers' Attitude toward Perinatal Palliative Care and its Challenges in the Selected Teaching Hospitals of Tehran in 2019.

OBJECTIVES: The present study aims to determine the attitudes of care providers including obstetricians, paediatricians and midwives working in perinatal, obstetric and neonatal intensive care unit (NICU) wards of the selected teaching hospitals in Tehran in 2019. In addition, the challenges of providing palliative care from the perspective of these individuals have been examined. MATERIALS AND METHODS: In this descriptive study, the research population was selected through convenience sampling based on the inclusion criteria. To assess care providers' attitude toward the perinatal palliative care and the challenges of its implementation, in addition to the questionnaire of demographic characteristics, a researcher-made questionnaire was also used. RESULTS: Most of the care providers (90.5%) believed that parents should be involved in decision-making to select the treatment type. Most of the care providers (90%) believed that the lack of prepared infrastructures is one of the major challenges in providing these types of care. CONCLUSION: Care providers have almost positive attitudes toward the various dimensions of providing perinatal palliative care, but it has not been properly implemented yet due to the insufficient knowledge of this type of care, the lack of required infrastructures (appropriate conditions in NICUs to provide this type of care, the sufficient number of staff and experts in this field), as well as the health authorities' neglecting this type of care.

Developing a perinatal palliative care service package for women with fetal anomaly diagnosis: protocol for mixed methods study.

BACKGROUND: Diagnosis of perinatal anomalies is a stressful experience that can negatively affect mothers, families, health-care systems, and societies. Perinatal palliative care (PPC) is a new development in maternity services which focuses on emotional, spiritual, social, and symptom management and provides care for women and families with fetal anomaly diagnosis. Therefore, this study aimed to develop a service package for women with fetal anomaly diagnosis in socio-cultural context of Iran. METHODS: This research is an exploratory mixed methods study with the qualitative-quantitative sequencing design that consists of four sequential phases. In the first phase, following a qualitative approach, the researcher will explore the needs and experiences of women with fetal anomaly diagnosis, their families, health care providers and policy-makers. At the second phase, based on the review of the literature, Program, guideline, service package and protocol for care of women and their families after perinatal anomaly diagnosis will be identified in other countries. In the third phase, recommendations from qualitative phase and literature review will be combined, the initial protocol of the palliative care service package for perinatal anomaly diagnosis will be identified and prioritized. In the fourth phase, the opinion of experts about this service package will be collected by using RAND/UCLA Appropriateness Method technique and the applicability of the service package's recommendations in clinical settings will be determined. DISCUSSION: The results of this Mixed Methods study are expected response the needs and experiences of the women with perinatal anomaly diagnosis being met in the socio-cultural context of Iran and a service package for palliative care of these women developed.

The Predictors of Postoperative Pain Among Children Based on the Theory of Unpleasant Symptoms: A Descriptive-Correlational Study.

PURPOSE: Postoperative pain (POP) is a common outcome of surgical interventions among children. Identifying POP contributing factors can help identify children who are at risk for POP and facilitate POP management. The aim of the study was to determine the predictors of POP based on the Theory of Unpleasant Symptoms. DESIGN AND METHODS: This descriptive-correlational study was conducted in 2018-2019 on 153 children purposively recruited. Data were collected using a personal characteristics questionnaire, the Coping Strategies Questionnaire, the Child Pain Anxiety Symptoms Scale, and a Visual Analogue Scale for Pain. The SPSS software (v. 21.0) was used for data analysis. RESULTS: Twelve participants were excluded and final data analysis was done on the data obtained from 141 participants. Most of participants were male (65.2%), underwent abdominal surgery (53.2%), and experienced POP (86.5%). Their age mean was 8.58±2.23. Linear regression analysis revealed that the physiological factors of heart rate, preoperative pain, and surgery duration as well as the psychological factors of anxiety and coping strategies were significant predictors of POP among children. All these factors collectively explained 34% of the total variance of POP. Situational factors (such as age, gender, and ethnicity) had no significant effects on POP. CONCLUSIONS: Heart rate, preoperative pain, surgery duration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies. PRACTICE IMPLICATIONS: The findings provide a better understanding about the predictors of POP and can be used to develop pain management among children.

Development and validation of 'caring ability of family caregivers of patients with cancer scale (CAFCPCS)'.

AIM: Family caregivers have limited abilities that make them vulnerable to the care needs of patients. Therefore, it seems necessary to evaluate their caring ability. The aim of this study was to design an instrument for assessing the caring ability of family caregivers of cancer patients. METHODS: This was a sequential exploratory mixed-method study, carried out in two qualitative and quantitative phases. The concept of caring ability and its dimensions were explained using conventional content analysis in the qualitative phase. The research participants included 41 family caregivers of cancer patients and professional caregivers who were selected using purposeful sampling method until reaching data saturation. The scale items were designed using the results of the qualitative phase of the study, as well as the review of relevant literature. In the quantitative phase, the scale was validated using content and face validity, construct validity, as well as internal consistency and stability. RESULTS: The primary item pool was prepared in 108 items. Content validity was determined using CVR with a cut-off point (0.62), CVI with a cut-off point (0.8) and kappa coefficient (κ) (>0.75). The validity of 72 items was confirmed. Then, the overlapping items were merged and eventually the 45-item scale entered the face validity stage and five items with an impact factor < 1.5 were omitted. Results of KMO = 0.904 and Bartlett = 6184.012 (p < 0.001) justified the need for factor analysis. Scree plot indicates five factors with eigenvalues above 1 and 67.7% of the total variance, including 'Effective role play, Fatigue and Surrender, Trust, Uncertainty, and Caring ignorance'. Reliability of the 31-item instrument indicated a Cronbach's alpha coefficient of 0.93 and ICC of 0.94. CONCLUSIONS: Caring abilities scale (CAI) of family caregivers of patients with cancer is a valid and reliable instrument that can assess caregivers' caring ability.

Human Development Index and its association with staff spiritual care provision: a Middle Eastern oncology study.

BACKGROUND: Although staff spiritual care provision plays a key role in patient-centered care, there is insufficient information on international variance in attitudes toward spiritual care and its actual provision. METHODS: A cross-sectional survey of the attitudes of Middle Eastern oncology physicians and nurses toward eight examples of staff provision of spiritual care: two questionnaire items concerned prayer, while six items related to applied information gathering, such as spiritual history taking, referrals, and encouraging patients in their spirituality. In addition, respondents reported on spiritual care provision for their last three advanced cancer patients. RESULTS: Seven hundred seventy responses were received from 14 countries (25% from countries with very high Human Development Index (HDI), 41% high, 29% medium, 5% low). Over 63% of respondents positively viewed the six applied information gathering items, while significantly more, over 76%, did so among respondents from very high HDI countries (p value range, p < 0.001 to p = 0.01). Even though only 42-45% overall were positively inclined toward praying with patients, respondents in lower HDI countries expressed more positive views (p < 0.001). In interaction analysis, HDI proved to be the single strongest factor associated with five of eight spiritual care examples (p < 0.001 for all). Significantly, the Middle Eastern respondents in our study actually provided actual spiritual care to 47% of their most recent advanced cancer patients, compared to only 27% in a parallel American study, with the key difference identified being HDI. CONCLUSIONS: A country's development level is a key factor influencing attitudes toward spiritual care and its actual provision. Respondents from lower ranking HDI countries proved relatively more likely to provide spiritual care and to have positive attitudes toward praying with patients. In contrast, respondents from countries with higher HDI levels had relatively more positive attitudes toward spiritual care interventions that involved gathering information applicable to patient care.

Correction to: Human Development Index and its association with staff spiritual care provision: a Middle Eastern oncology study.

Incorrect family name of Layth Mula-Hussain.

Training for awareness of one's own spirituality: A key factor in overcoming barriers to the provision of spiritual care to advanced cancer patients by doctors and nurses.

OBJECTIVE: When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist. We aimed to study these barriers in a new cultural context and analyzed a new subgroup with "unrealized potential" for improved spiritual care provision: those who are positively inclined toward spiritual care yet do not themselves provide it. METHOD: We distributed the Religion and Spirituality in Cancer Care Study via the Middle East Cancer Consortium to physicians and nurses caring for advanced cancer patients. Survey items included how often spiritual care should be provided, how often respondents themselves provide it, and perceived barriers to spiritual care provision.ResultWe had 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern countries. The results showed that 82% of respondents think staff should provide spiritual care at least occasionally, but 44% provide spiritual care less often than they think they should. In multivariable analysis of respondents who valued spiritual care yet did not themselves provide it to their most recent patients, predictors included low personal sense of being spiritual (p < 0.001) and not having received training (p = 0.02; only 22% received training). How "developed" a country is negatively predicted spiritual care provision (p < 0.001). Self-perceived barriers were quite similar across cultures.Significance of resultsDespite relatively high levels of spiritual care provision, we see a gap between desirability and actual provision. Seeing oneself as not spiritual or only slightly spiritual is a key factor demonstrably associated with not providing spiritual care. Efforts to increase spiritual care provision should target those in favor of spiritual care provision, promoting training that helps participants consider their own spirituality and the role that it plays in their personal and professional lives.

Prioritizing barriers to implement clinical governance in teaching hospitals of Iran: A mixed method study.

Background: Clinical governance, as a program to improve the quality of health care, was introduced in all hospitals in Iran in 2009. However, implementation assessments revealed that the program was not adopted in many hospitals. This study aimed to determine and prioritize barriers to clinical governance program implementation in hospitals of Shahid Beheshti University of Medical Sciences. Methods: This qualitative study was performed in the first part of this exploratory mixed methods study. A purposive sample of 25 individuals who were involved in the implementation of the program was selected. They participated in semi-structured interviews and the data were analyzed using content analysis. In the second part (quantitative), a questionnaire was prepared based on the first phase of the study, and 74 stakeholders completed the questionnaire, which included all extracted obstacles to the establishment of clinical governance. They rated these obstacles with a 5-point Likert scale. Results: A total of 9 themes were discovered in the qualitative part of the study. These themes were prioritized as follow: (1) weak organizational leadership, (2) insufficient human resources, (3) inappropriate organizational culture, (4) inadequate financial resources, (5) insufficient knowledge of personnel and management, (6) inappropriate monitoring and evaluation, (7) lack of coordination (8) deficiencies in policies and procedures, and (9) incomplete registration system and inadequate documentation. Conclusion: The results of this study showed that significant barriers exist in implementation of the clinical governance program in hospitals. These problems have to be addressed in order for the implementation procedure to be successful.