Integrating the social determinants of health into curriculum: AMEE Guide No. 162.

The World Health Organization (WHO) defines the Social Determinants of Health (SDOH) as the non-medical factors influencing health outcomes. SDOH is associated with conditions in which people are born, grow, work, and live. Medical schools and licensing bodies are increasingly recognizing the need for doctors and healthcare professionals to be aware of their patient's social context and how it impacts their states of health and disease. However, there is considerable variation in the approaches of different institutions and countries to incorporating SDOH into their curricula. In order to allow clinicians to adopt a holistic approach to patient health, equipping them with extensive knowledge of SDOH would give learners the confidence, skills, knowledge, and attitudes needed to effectively engage with patients and their families. This approach aids health professionals with knowledge of the influence of the social context and cultural factors that affect patients' behaviors in relation to health. Incorporating the SDOH in medical and health professional school curricula would contribute towards adequately preparing future healthcare practitioners to provide effective, comprehensive, and equitable care, especially to marginalized and underserved populations. The Guide will take an evidence-based approach grounded in the available contemporary literature and case studies. The focus will be on integrating SDOH into undergraduate and postgraduate medical curricula to promote an understanding of the social factors that influence patients' and communities' health. Ultimately, this guide seeks to contribute to the reduction of inequalities in health.

Integrating the social determinants of health into graduate medical education training: a scoping review.

BACKGROUND: The social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs. METHODS: A systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded. RESULTS: The initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum. CONCLUSION: Applying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force.

Effect of the knee replacement surgery on activity level based on ActivPAL: a systematic review and meta-analysis study.

BACKGROUND: The knee replacement (KR) surgery aims to restore the activity level and reduce the risk of experiencing disabilities. The outcomes of this surgery are evaluated mainly with subjective tools or low validity objective tools. However, the effect of the surgery on activity level using high validity objective accelerometer is still in question. METHODS: A systematic review and meta-analysis were conducted to evaluate the benefit of KR surgery alone to enhance physical activity recommendations based on high validity accelerometer. Two independent reviewers evaluated five electronic databases (Cochrane-Central-Register-of-Controlled Trials, EMBASE, PubMed, Web of Science, and Scopus) to find relative studies between January 2000 and October 2021. The quality assessments and risk of bias assessments were examined. RESULTS: Three articles were included with 202 participants (86 males, 116 females), with an average age of 64 years and an average 32 kg/m2 body mass index. The results found that the number of steps was significantly improved up to 36.35 and 45.5% after 6-months and 1-year of the surgery, respectively. However, these changes did not meet the recommended activity level guideline and could be related to the patients' health status and their activity level before the surgery. No significant changes were seen in sedentary time, standing time, and upright time after 6-months and 1-year follow-ups. Heterogeneity among studies was low to moderate (0-63%). CONCLUSION: Knee replacement surgery is an effective treatment for improving patients' quality of life with severe knee injuries. However, various factors impact the success of surgical and achieving maximum benefit of the surgery. One factor, sedentary time, can be reduced by implementing pre-and post-surgery exercise or physical activity recommendations. Further studies are needed to understand the benefit of surgery with or without rehabilitation assessed using high validity monitors.

Monkeypox viral disease outbreak in non-endemic countries in 2022: What clinicians and healthcare professionals need to know.

An outbreak of monkeypox Viral Disease in non-endemic countries in May 2022 is increasingly spreading. Clinicians and other healthcare professionals need to understand the aetiology and characteristics of the monkeypox pathogen and illness. By familializing themselves with these characteristics, they can map out the outbreak and roll out necessary public health mitigation measures to curb the spread. This short communication presents a summarized message regarding the aetiology, mode of transmission, clinical features, risk factors, diagnosis, treatment, and prevention of monkeypox viral disease. Considerations for surveillance and reporting have also been highlighted.

Effect of using knee valgus brace on pain and activity level over different time intervals among patients with medial knee OA: systematic review.

BACKGROUND: The Knee valgus brace is one of the accepted conservative interventions for patients with medial compartment knee osteoarthritis to correct the knee varus and increase functional activity level. Nevertheless, comprehensive overview of the effects of using this brace on self-reported pain activity level over time is not available. Thus, this study aimed to systematically review the effect of using this brace on pain and activity levels in the last 20 years in patients with medial compartment knee osteoarthritis. METHODS: Five databases were searched to find articles from the year 2000 to the end of November 2020: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PubMed, Web of Science, and Scopus. Two reviewers independently evaluated the available articles for eligibility and assessed quality. The risk of bias in each study was assessed by two reviewers independently according to the Strengthening the Reporting of Observational Studies in Epidemiology tool (STROBE) for the non-randomized controlled studies and the Cochrane risk-of-bias tool for the randomized controlled studies. RESULTS: Seven randomized controlled studies and 17 cohort studies (in total 579 participants) were included in the systematic review. Most of these studies found using a knee valgus brace effective in reducing pain and improving activity level over different time intervals. The majority of the included studies (14 studies) evaluated the impact of the brace for a considerably short-term (less than 6 months). Thus, limited evidence is available on the long-term use of the knee valgus brace and its associated complications. CONCLUSION: The knee valgus brace is an effective conservative intervention to improve the quality of life and reduce pain during daily activities for some patients. However, the long term of using this brace is still not very convenient, and the patients who benefit most from using the brace should be identified with high methodological quality studies.

Assessing the prevalence of self-medication among healthcare workers before and during the 2019 SARS-CoV-2 (COVID-19) pandemic in Kenya.

BACKGROUND: Self-medication plays a key role in public health as it influences both negatively and positively on the health of individuals and the existing healthcare systems. This is especially the case during public health emergencies like the 2019 SARS-CoV-2 disease. OBJECTIVES: The study aimed at assessing the prevalence of self-medication before and during the outbreak of COVID-19 pandemic among healthcare workers and its associated factors. METHODS: Stratified sampling was used to select 379 study respondents. The authors developed an online questionnaire, pretested and submitted to various online professional groups of different cadres of healthcare workers. Collected data was analysed using descriptive and inferential statistics. The data was presented in tables, graphs, percentages, and cross-tabulation with different variables. Multivariable logistic regression was used to ascertain factors that influence an individual's desire to self-medicate and associations were considered significant at p < 0.05. RESULTS: The overall prevalence of self-medication increased from 36.2% (n = 137) before the pandemic to 60.4% (n = 229) during the pandemic. The respondents' gender, level of education, age, marital status, participation in physical activity, and drug reaction events, were significantly associated with self-medication before and during the outbreak (P < 0.05). Multivariable logistic regression analyses showed that participants engaging in physical activities, working during the day and being healthy were less likely to self-medicate (p < 0.01). CONCLUSION: Self-medication is an important health issue, especially during the COVID-19 pandemic. Continuous awareness creation and sensitization could help in reducing self-medication practices among healthcare workers.

The Burden of Communicable Diseases in Lebanon: Trends in the Past Decade.

The present study aims to review the main communicable diseases that experienced an upsurge in the past decade in Lebanon and to highlight the reasons behind this increase. Data of reported communicable diseases from 2010 till 2019 were obtained from the Lebanese Ministry of Public Health (LMOPH) epidemiological surveillance database. Tuberculosis, measles, mumps, leishmaniasis, and hepatitis A were the main communicable diseases that showed a sharp increase in the past 10 y. Measles outbreaks occurred in 2013 and 2018, leishmaniasis outbreak in 2013, and mumps and hepatitis A outbreaks in 2014. The highest percentages of reported diseases were from Beqaa and North governorates. The massive influx of Syrian refugees to Lebanon, together with the poor water management system, poor sanitation, deprived living conditions, and limited health-care access in rural areas might have contributed to the upsurge of communicable diseases. Although the LMOPH succeeded in containing the outbreaks, further efforts are needed to improve the identified gaps to avoid future outbreaks.

Assessing Patient Experience and Attitude: BSC-PATIENT Development, Translation, and Psychometric Evaluation-A Cross-Sectional Study.

Health care organizations (HCO) did not consider engaging patients in balanced scorecard (BSC) implementations to evaluate their performance. This paper aims to develop an instrument to engage patients in assessing BSC perspectives (BSC-PATIENT) and customize it for Palestinian hospitals. Two panels of experts participated in the item generation of BSC-PATIENT. Translation was performed based on guidelines. Pretesting was performed for 30 patients at one hospital. Then, 1000 patients were recruited at 14 hospitals between January and October 2021. Construct validity was tested through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Additionally, the composite reliability (CR), interitem correlation (IIC), and corrected item total correlation (CITC) were assessed to find redundant and low correlated items. As a result, the scales had a highly adequate model fit in the EFA and CFA. The final best fit model in CFA comprised ten constructs with 36 items. In conclusion, BSC-PATIENT is the first self-administered questionnaire specifically developed to engage patients in BSC and will allow future researchers to evaluate the impact of patient experience on attitudes toward BSC perspectives, as well as to compare the differences based on patient and hospital characteristics.

Nurses' burnout and quality of life: A systematic review and critical analysis of measures used.

BACKGROUND: Nurses' burnout might affect their quality of life, productivity and nursing care services. AIM: The aim of this systematic review was to systemically review the relationship between nurses' burnout and quality of life and to introduce practical recommendations to reduce nurses' BO and improve their QOL. METHODS: In April 2021, MeSH terms (("Nurses"[Mesh]) AND "Burnout, Professional"[Mesh]) AND "Quality of Life"[Majr] were used to search five electronic databases: CINAHL, PubMed, Medline, Psychology and Behavioral Sciences Collection and Google Scholar. RESULTS: The search produced 21 studies exploring nurses' burnout and their quality of life within the last ten years (2009-2021). Most of these studies found significant relationships between the burnout dimension(s) and quality of life dimension(s) among the nurses. CONCLUSION: Nurses have moderate to high levels of burnout and were negatively associated with poor quality of life. Interventional programs are needed to decrease nurses' burnout and improve their quality of life.

Correction: Amer et al. Assessing Patient Experience and Attitude: BSC-PATIENT Development, Translation, and Psychometric Evaluation-A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 7149.

The authors wish to make the following corrections to this paper [...].

An empirical assessment of the factors influencing acceptance of COVID-19 vaccine uptake between Kenyan and Hungarian residing populations: A cross-sectional study.

The development of effective, safe, and acceptable vaccines is a long process. COVID-19 vaccine hesitancy continues to elicit mixed reactions among different quarters despite numerous evidence of their effectiveness. This study aimed to determine the availability and acceptance rates of SARS-CoV-2 vaccines, among Kenyan and Hungarian residing populations and the underlying reasons contributing to the hesitancy of uptake. A non-probability, snowball sampling design was employed, and a survey questionnaire tool link was expeditiously disseminated. Data were carefully analyzed descriptively. Demographic variables, COVID-19 awareness, possible exposure, reasons associated with hesitancy in taking up a vaccine, choice of a vaccine, and availability of vaccines among other important variables were tested to explore their associations with vaccine acceptance rates between the two distinct countries. A total of 1960 participants were successfully enrolled in the research study, while 67 participants were excluded based on the inclusion criterion set. There was, however, no significant difference in COVID-19 public awareness between the Kenyan and Hungarian-residing participants, p = 0.300. Of the respondents, 62.4% were willing and ready to receive vaccines against COVID-19 disease. There was a significant difference (p = 0.014) between the Kenyan and Hungarian-residing respondents concerning vaccine uptake and acceptance rates. The vaccine acceptance rates in Hungary were higher than in Kenya, with mean = 0.27, SD = 0.446, S. E = 0.045 for the Hungarian population sample and mean = 0.40, SD = 0.492, S. E = 0.026, for the Kenyan sample respectively. Concerning gender and vaccine acceptance, there was a notable significant difference between males and females, p = 0.001, where the mean for males and females were 0.29 and 0.46 respectively. Acceptance rates among males were higher than among females. The functions of One-Way ANOVA and Chi-square were used to establish any significant differences and associations between means and variables respectively. Concerns regarding the safety, efficacy, and accuracy of information about the developed vaccines are significant factors that must be promptly addressed, to arrest crises revolving around COVID-19 vaccine hesitancy, especially in Kenya and among females in both populations, where acceptance rates were lower. Expansion of the screening program to incorporate antibody (serology) tests, is also highly recommended in the present circumstance. Equitable distribution of vaccines globally should be encouraged and promoted to adequately cover low- and middle-income countries. To enhance effective combat on vaccination hesitancy and apprehension in different countries, mitigation techniques unique to those countries must be adopted.

Prenatal fear of childbirth among pregnant women and their spouses in Kenya.

OBJECTIVE: The study sought to explore the prenatal fear of childbirth and its contributing factors among pregnant women and their spouses in Kenya. METHODS: 254 pregnant women and their spouses participated in this cross-sectional analytical study. A researcher-developed questionnaire was used alongside the Fear of Birth Scale (FOBS) for data collection. RESULTS: 58.6% of pregnant women and 45.7% of their spouses reported high fear of childbirth with primiparous spouses having high fear of childbirth compared to multiparous spouses. Also, the findings revealed a significant relationship between fear of childbirth among pregnant women and variables such as level of education (p = 0.022), parity (p < 0.001), previous mode of childbirth (p < 0.001), going for a routine prenatal check-up (p < 0.001), and having a positive feeling about the expected delivery (p < 0.001). For the spouses, the level of education (p < 0.001), the previous childbirth experience (p < 0.001), and feelings about the forthcoming childbirth (p < 0.001), were significantly associated with prenatal fear of childbirth. Spearman's correlation test results indicated a significant positive correlation between prenatal fear of childbirth among pregnant women and their spouses (r = 0.182, p < 0.001). CONCLUSION: The study found a significant positive correlation between the fear of childbirth among pregnant women and their spouses. There is a need to address the fear of childbirth not only among pregnant women but also their spouses. This might help to reduce the fear of childbirth, considering the significant role men play in supporting their spouses in the family as well as agents of change.

Health-seeking behaviour among pregnant women during the COVID-19 pandemic: A qualitative study.

BACKGROUND: The novel coronavirus pandemic has killed millions of people globally while significantly destroying the social, economic, and political wellbeing of people. The global pandemic has negatively impacted pregnant women's access to prenatal care. The current study sought to understand the health-seeking behaviour of women who were pregnant during the onset of the COVID-19 pandemic in Kenya. METHODS: The "Three Delay" model theoretical framework was applied to piece together the pregnant women's health-seeking behaviour during the early stages of the pandemic through focus group discussions. The collected qualitative data was analysed using thematic analysis. RESULTS: The delays in deciding to seek care, delays in reaching healthcare facilities and delays in receiving quality healthcare services at the healthcare facility were a result of the fear of contracting the virus. These delays were occasioned by participants' personal experiences and uncertainties about COVID-19 pandemic, compulsory quarantines, national cessation of movements, compulsory lockdowns, loss of income to many households and the influence of traditional birth attendants (TBAs). CONCLUSION: The current study found that fear of COVID-19 was a major factor that hindered access to maternal healthcare services. In this regard, there is a need to upscale awareness creation on the significance of seeking maternal health services during the pandemic to reduce the possibility of obliterating the gains made in reducing poor health-seeking behaviours among pregnant women.

Does institutional maternity services contribute to the fear of childbirth? A focus group interview study.

BACKGROUND: The quality of institutional maternity services offered significantly determine the health outcomes of pregnant women and their infants. OBJECTIVES: The study aimed at understanding perceptions and experiences of new mothers diagnosed with the fear of childbirth in Kenya; regarding the institutional maternity services offered and if they contribute to the fear of childbirth (FOC). METHODS: This was a qualitative descriptive study. A total of 29 women who had given birth recently in a maternity institution, and had been screened with the fear of childbirth at 32 weeks' gestation period participated in focus group interviews. The Framework for Assessing the Quality of Care of institutional maternity services (FAQC) developed by the University of Southampton was adopted in this study. Thematic analyses were used. RESULTS: It was reported that institutional maternity services contributed directly and indirectly to FOC. The direct contribution included the performance of unintended caesarian sections, severe and prolonged labour pains and negative attitude of healthcare providers. The indirect contribution was in form of challenges in the provision of care and the experience of care in the maternity institutions. In the provision of care; human and physical resources, inadequate referral systems, and inadequate management of emergencies were reported. In the experience of care; lack of cognition, respect, dignity, equity and inadequacies in emotional support were reported. CONCLUSION: The study identified systemic challenges related to both the provision and the experience of care. Therefore, there is need to astutely analyze all critical steps identified in the FAQC, as this will greatly improve the uptake of institutional maternity services.

Translation and validation of the Swahili version of the Wijma Delivery Expectancy/Experience Questionnaire version A (W-DEQ-A).

BACKGROUND: Prenatal fear of childbirth is a common health concern that negatively affects the emotional wellbeing of women during pregnancy. Wijma Delivery Expectancy/Experience Questionnaire version A (W-DEQ-A) is used extensively to measure fear of childbirth during pregnancy. Nevertheless, previous studies have not evaluated its psychometric characteristics among the Swahili-speaking pregnant women. Therefore, the aim was to translate and test the validity and reliability of the questionnaire into Swahili as the popular language in Kenya. METHODS: In the current descriptive cross-sectional study, the W-DEQ-A, together with the Edinburgh Postnatal Depression Scale (EPDS) and Beck Anxiety Inventory (BAI) were administered to a group of 628 pregnant women to explore the dimensionality of W-DEQ-A using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), respectively. RESULTS: EFA and CFA of the Swahili version of W-DEQ-A identified five-factor loadings: lack of self-efficacy, fear, negative emotions, negative appraisal, and social isolation. However, this model failed to support the unidimensional structure of the original W-DEQ-A. The Swahili version of the W-DEQ-A correlated well with EPDS and BAI at acceptable levels. The Cronbach alpha values of the subscales ranged from 0.867 to 0.967, an indication of an excellent internal consistency of the instrument. CONCLUSION: The current study findings provide support for the Swahili version of the W-DEQ-A to be considered as a valid and reliable measuring tool for the fear of childbirth among Swahili-speaking pregnant women in Kenya, and the entire East and Central African region. Also, due to its multidimensional structure, the original W-DEQ-A should not be used in its original form.

Exploring fear of childbirth in Kenya through evaluation of the readability of Wijma Delivery Expectancy/Experience Questionnaire Version A (W-DEQ-A).

BACKGROUND: Several tools measuring fear of childbirth (FOC) have been developed in the last three decades, however concerns about their readability have been raised. AIM: To explore the fear of childbirth in a sample of women of reproductive age by evaluating the readability of Wijma Delivery Expectancy/Experience Questionnaire version A (W-DEQ-A). METHODS: The Flesch Reading Ease Formula, the Flesch-Kincaid Grade Level, the FOG Scale, the SMOG Index, the Coleman-Liau Index, the Automated Readability Index, and the Linsear Write Formula were used to evaluate the readability of the W-DEQ-A. Also, focus group discussions were held to validate the findings of the readability scales mentioned above. FINDINGS: The SMOG Index (score = 7.6), Coleman-Liau Index (score = 7.6), and the Linsear Write Formula (score = 9.4) were easily readable by women of reproductive age who had at least secondary school education (grade 12). Concerns were raised over some terms used such as desolate and deserted, which were rarely used in day to day English language conversations. CONCLUSIONS: In this study, participants observed that W-DEQ- A was readable if administered to expectant women with a basic secondary school certificate; but there is a need to simplify some words. It was emphasized that societal dynamics play an important role in the fear of childbirth and therefore the questionnaire should address all aspects contributing to fear of childbirth and not merely the feelings and thoughts women may have at the prospect of labor and delivery.

Assessing the usability of a Willingness to Quit smoking questionnaire in a sample of active tobacco smokers: A qualitative study.

Background and objectives: Tobacco products are conceivably the most accessible addictive substances. Its use contributes to numerous negative health outcomes both in the developed and developing world. The objective of the study was to assess the usability of a Willingness to Quit smoking questionnaire; a concise questionnaire used to assess the readiness of active tobacco smokers to stop smoking, and also guiding in constructive conversations between healthcare workers and clients regarding stopping smoking.Methods: In this study, 25 active tobacco smokers and four healthcare workers of different cadres were interviewed. Participants were given the Willingness to Quit smoking questionnaire and asked to fill and comment on its usability, ease of comprehension and plausibility in the healthcare system settings.Results: All the 25 active tobacco smokers demonstrated their readiness to stop smoking. It was reported that the Willingness to Quit smoking questionnaire triggered the intention to stop smoking and effectively guided the interviews between the healthcare workers and clients who had expressed the intention of stopping smoking.Conclusion: The Willingness to Quit smoking questionnaire is a valuable tool in clinical practice as it can be used to prompt tobacco cessation dialogues between healthcare workers and clients attempting to stop smoking.

Anxiety and depression due to 2019 SARS-CoV-2 among frontier healthcare workers in Kenya.

BACKGROUND: The novel coronavirus disease continues to spread across the globe, causing anxiety and depression among healthcare workers. OBJECTIVES: The current study aimed to determine the levels of anxiety and depression due to the coronavirus pandemic among healthcare workers in Kenya. METHODS: A total sample of 476 respondents participated. The 7-item Generalized Anxiety Disorder Scale (GAD-7) and Patient-Health Questionnaire (PHQ-9), together with a socio-demographic questionnaire, were applied. Stratified sampling was used. Data was analysed using the Statistical Package Programme for Social Science Version 23.0.0. Kruskal Wallis test and Mann-Whitney U test were employed to establish the differences in levels of anxiety and depression across socio-demographic characteristics. Ordinal logistic regression analysis was used to establish the predictors of levels of anxiety and depression, and associations were considered significant at p < 0.05. RESULTS: A total of 35.1% (n = 167) of the participants had mild anxiety, and 13.4% (n = 64) severe anxiety. Approximately 53.6% (n = 255) had mild depression while 9.2% (n = 44) had severe depression. The univariate analysis illustrated a statistical difference in anxiety levels in gender (p > 0.027), years of work experience (p = 0.005), and the cadre of respondents (p = 0.0028). Gender was statistically significant with the level of depression (p = 0.045). About 62.6% (n = 298) of healthcare workers had been trained, and only 9% (n = 43) were confident in managing COVID-19 cases. A large proportion, 98% (n = 458) had concerns about the availability of personal protective equipment. CONCLUSION: The study findings indicated that the majority of healthcare workers had mild anxiety and depression. Female healthcare workers were more likely to experience severe anxiety and depression. Also, levels of anxiety and depression differed across different cadres of healthcare workers.

The relationships between paediatric nurses' social support, job satisfaction and patient adverse events.

AIMS: To explore the relationships of family, co-worker and manager support with paediatric nurses' satisfaction and their perception of adverse events. Furthermore, this study aimed to assess the job satisfaction, social support and the perceived patient adverse events. DESIGN: This study used a cross-sectional correlational design. METHODS: A convenient sample of 225 paediatric nurses was selected from nine hospitals in Jordan. Both the Pearson correlations and multiple regression tests were used in the analysis. The study was prepared and is reported according to the STROBE checklist. RESULTS: Significant and positive correlations were found between paediatric nurses' job satisfaction and the social support they receive. Significant negative correlations were also found between adverse events and both family and manager support. The multiple regression results showed that manager support is a significant negative predictor of both pressure ulcers and patient falls, and family support significantly predicted paediatric nurses' job satisfaction.