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   Table of Contents      
ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 5  |  Page : 363-370

The meaning of managerial competency of ICU head nurses in Iran: A phenomenological study


1 Department of Nursing, School of Nursing and Midwifery Amol, Mazandaran University of Medical Sciences, Sari, Iran
2 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
3 Department of Biostatstics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran

Date of Web Publication20-Aug-2018

Correspondence Address:
Dr. Zohreh Vanaki
Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_132_17

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  Abstract 


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

Keywords: Critical care nursing, intensive care units, Iran, nursing, professional role


How to cite this article:
Nazari R, Vanaki Z, Kermanshahi SM, Hajizadeh E. The meaning of managerial competency of ICU head nurses in Iran: A phenomenological study. Iranian J Nursing Midwifery Res 2018;23:363-70

How to cite this URL:
Nazari R, Vanaki Z, Kermanshahi SM, Hajizadeh E. The meaning of managerial competency of ICU head nurses in Iran: A phenomenological study. Iranian J Nursing Midwifery Res [serial online] 2018 [cited 2019 May 24];23:363-70. Available from: http://www.ijnmrjournal.net/text.asp?2018/23/5/363/239238




  Introduction Top


Nursing and other healthcare professions are currently faced with challenges in responding to the changing needs of the people and the changing nature of the society.[1] Head nurses of hospital wards face many challenges in their managerial role alongside the burden of increased workloads.[2] Because head nurses are the key to professional communication between the top management and the clinical personnel, their role is highly important in the success of healthcare organizations and they require certain skills and competences; identifying these competences is very important.[3] Although researchers consider the managerial competence of head nurses intrinsic to their professional role,[4] very few studies have been conducted in Iran and across the world on nursing management and leadership in intensive care units (ICUs) and the meaning of this competence remains unclarified. This lack of clarity is important because efforts to improve the nursing management of ICUs will be in vain without knowing the meaning of managerial competence. Moreover, attempts to find a universal definition of competence for each individual health profession might be futile because professional performance does not merely depend on the tasks that have to be carried out but also on the needs, healthcare resources, healthcare system structure, as well as the social, political, and economic conditions of the society.[5] The question raised in this study asks about the meaning of managerial competence in ICU head nurses in Iran. To answer this question, the present study was designed and conducted with a phenomenological approach to explore the meaning of managerial competence in ICU head nurses in Iran.


  Materials and Methods Top


This study used Van Manen's phenomenological qualitative approach (1990) to obtain a unique understanding of the experiences of ICU head nurses in Iran. Choosing the phenomenological approach is important for three reasons. First, no qualitative reports were found to have directly explained the particular experiences of head nurses regarding the meaning of managerial competence in ICUs with a descriptive or exploratory approach. Phenomenology, however, can explore what ICU head nurses do as a group that is mainly responsible for a competent healthcare and that works in the real world to offer patients a successful care experience. Second, the existing qualitative studies tend to focus on the experiences of nurses, but given the recent changes in the national health system of Iran, exploring the daily experiences of head nurses in the country can expand knowledge on this subject beyond the existing assumptions. Third, phenomenology turns the attention from a positivist cause and effect to human mentality and the discovery of the meaning of practices.[6]

Purposive sampling was used to access participants' experiences. As a result, ten Iranian ICU head nurses with at least 2 years of head nursing experience who were willing to share their experiences participated in the study. Sampling started in May 2014 and continued till February 2015 until data saturation. Attempts were made to select participants with an adequate diversity, and 6 women and 4 men in the 35–52-year age range were selected with a mean head nursing work experience of 2.5 years and a mean ICU work experience of 6.8 years. Nine participants had bachelor degrees and one had a master degree. Two participants had been head nurses in other wards before becoming an ICU head nurse.

Data were collected and produced through unstructured, in-depth, individual interviews. The interviews began with a general and broad question about participants' lived and day-to-day experiences, such as “What comes to mind when you hear the phrase 'competent head nurse'?,” “What does the managerial competence of ICU head nurses mean?,” and “Please give as much detail as you can about your experience.” Further exploratory questions were posed during the interviews, such as “Please elaborate on this,” and “Can you give an example of this feeling so I can better understand how you've felt?” The interviews were recorded using a digital recorder and transcribed and typed for use in data analysis. All interviews were conducted with the consent of the participants in the hospital. Mean time of each interview was 45 min.

Six stages Van Manen, hermeneutic phenomenology guided this research and data analysis. Van Manen, hermeneutic phenomenology is not a constant succession of stages but a dynamic contrast between six stages as follows – turning to the nature of lived experience, obtaining descriptions of lived experience from the participants, phenomenological interpretation and thematic analysis, description of the phenomenon through the art of writing, the establishment and maintenance of a strong and informed relation to the phenomenon, and creating consistency by considering parts and the whole.[7] Therefore, data were analyzed using holistic and detailed analysis. In the holistic approach, the transcription of each interview was reviewed several times and a general understanding of it was briefly written in one or a few paragraphs. In the detailed approach, the transcription of each interview was first carefully reviewed line-by-line for several times, and the key words and statements derived from the lived experiences of each participant related to the meaning of “managerial competence” were identified and isolated. This process was carried out for all the interviews, and main themes and subthemes were formed according to their common aspects. To maintain contact with the phenomenon, attempts were made to use a combination of holistic and detailed approaches to maintain constant flow from the whole to the parts and the parts to the whole. For instance, the secondary theme “unique insight” was obtained in the holistic approach from all the interviews. The initial themes were arranged according to their meaning in such a manner to obtain this secondary theme. No software was used to analyze the data. Data were analyzed manually on a thematic basis and were classified in categories based on the similarity and the meaning concept.

Lincoln and Guba's evaluative criteria were used to confirm the rigor and trustworthiness of the data.[8] To increase data validity, member check and peer check were used, and the results of the holistic analysis and the initial themes and the transcribed interview of each participant was sent to the same participant who was asked to review and confirm the content. All the participants agreed with their transcribed interviews. The researcher also reviewed the emergence of the initial, secondary, main themes, and subthemes with the other team members and reached a consensus about them. Data stability was ensured through member check and peer check. To ensure the consistency of the categories with participants' statements, the data were reviewed by two experts using a qualitative approach. External observers were employed for confirming data validity. For confirmability, attempts were made to fully describe all the stages of the research, including data collection and analysis and the formation of themes to enable inspection by others. To evaluate the transferability of the data, the collected data were shared with two head nurses who had similar positions as the target population and in most cases the results were similar to their experiences.

Ethical considerations

The participants were briefed on the study objectives and methods, ensured of their right to withdraw from the study at any point, and of the confidentiality of their information and the private storage of the research documents and evidence in a safe place. They were then asked to sign an informed consent form. All the names were turned into codes during the transcription of the interviews and were referred to with the same codes during data anlysis and presentation of the results.


  Results Top


A total of 442 initial themes were obtained from the thematic analysis conducted using a detailed approach. The expansion and clustering of these themes led to the emergence of 35 secondary themes, nine subthemes, and three main themes. Managerial competence theme included “self-excellence,” “ward excellence,” and “intensive care excellence.” [Table 1] presents the main and subthemes, and [Figure 1] demonstrates the relationship between the themes.
Table 1: The themes extracted from the experiences of the ICU head nurses about the meaning of managerial competence

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Figure 1: The mutual interaction between the components of managerial competence in ICU head nurses

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Managerial competence means: Self-excellence

The themes comprising this main theme suggest that a competent ICU head nurse should not only possess excellent personal and nursing characteristics and a holistic knowledge but also not be satisfied with such possessions and be committed to further learning and self-improvement to excel. The subthemes of this theme include:

Unique nursing attributes

According to the lived experiences of the participants, feeling committed to the families of ICU patients, being a model ICU nurse, being capable of acceptance by other personnel and the authorities, professional attachment to the ICU, and a history of intensive care nursing are competences that make an ICU head nurse an excellent nurse. Although due to the enclosed nature of ICUs, the nurses and head nurses of these wards have little contact with the patients' families, the experiences of the participants in this study revealed their commitment to the patients' families, especially with regard to training and notifying the family members. “I asked Mr. Q to come with me to the front door and see from the eye of a family member what signs are missing and where, and that is how so many signposts were put up.” P5.

The holistic approach of data analysis led to the finding that all participants considered being a competent nurse a requirement for becoming a “competent head nurse,” and to be a role-model in this field, the nurse should have an active presence in clinical care and possess ICU nursing skills. For example: “I rub alcohol on my hands and change my gloves on every patient's bedside, to make others understand that what I ask of you, I do myself too.” P1.

In participants' experiences, an ideal ICU head nurse should have nursing characteristics that are accepted by other nurses and doctors and can also gain the trust of the authorities. Participant 2 discussed the ability to be accepted by nurses and said: “Many tasks are not properly performed when you are not accepted in the mind of the nurses.” P2.

The important point in this theme is the interest of ICU head nurses in working in these wards, so that, in addition to benefiting the patients and performing their duties. They may gain some sort of delight from it. Participant 1 commented on this issue: “The ICU gives me such a wonderful feeling that I always want to continue working in this unit.” P1.

Unique personal attributes

Unique personal attributes include having a confident appearance, the physical and mental ability to work under difficult conditions, administrative discipline, forbearance, and a religious and spiritual role-model. “I have a 9-month-old baby. Seeing the critical traumatic kids, I am seriously upset.” P9.

Administrative discipline in the form of coming and going on time and having no personal engagements during work hours was another issue viewed essential for a competent ICU head nurse by all the participants. One participant remarked: “I don't leave CCU for personal matters. I do not take time off. I am the first person to arrive in the department in the morning, and I expect the same from others.” P10

Another unique personal characteristic was forbearance, which was described by the participants as being gentle, open to criticism, and articulate. Participant 4 said: “A night shift personnel argued with the person in charge about the division of work. When we were done with hand-over, I asked them to stay a little longer if they weren't in a hurry. I took them to the room one by one and shut the door to see what they each had to say. Then I took both of them in a room and talked to them together to clear the misunderstanding.” P4.

Having a holistic knowledge

Based on their own experiences, the participating head nurses argued that one of the competences required of an ICU head nurse was the possession of a holistic knowledge encompassing professional legal knowledge, managerial literacy, knowledge about the use of information technology, and basic and specialized knowledge about ICU nursing care. “Once a patient with a head trauma arrived in the ward and underwent a CT scan, which showed extensive epidural bleeding. So, I rang the doctor. Since he trusted my word, he asked me to shave the patient's head and send him to the operating room until he got here.”P5

Commitment to learning and self-improvement

Participants' experiences suggested that ICU head nurses are committed to learning and self-improvement to accomplish professional excellence. ICU head nurses are very enthusiastic about learning because of constantly evaluation of their strengths and weaknesses; due to this enthusiasm, they follow the most recent scientific findings and make an effort to use their own and other people's experiences. Participant 7 discussed nurses' interest in learning and studying and said: “The CCU is too technical both for the nurses and the head nurses (requires specialized knowledge). Since the patients may die in the blink of an eye. I've studied a lot, and still do, and hold scientific discussions with heart surgeons. This makes me learn a lot.” P7

Managerial competence means: Ward excellence

The participants considered ward excellence in subjective, physical, and workforce dimensions as one of the main meanings of managerial competence. The subthemes of this theme include:

The ability to smartly facilitate effective interpersonal and inter-professional communication

This ability is indicative of the head nurse's competence in creating an ICU with an excellent subjective dimension. The participants argued that the competence of an ICU head nurse with regards to this theme means an ability to establish effective interpersonal and interprofessional relationships, wisely facilitating interpersonal and inter-professional interactions, having motivating feedbacks for their personnel's conduct, and facilitating a peaceful and spiritual work environment.

The participating head nurses had valuable experience about the need for their own communication ability as well as highly valuable experience about the need to wisely facilitate other people's interpersonal and interprofessional interactions. They described this competence effective in the prevention of stress, informed conflict evaluation and resolution, and facilitating communication between people.

Once, one of our good nurses rang the doctor at 1 o'clock at night and reported that a patient's condition had worsened, and the doctor got angry for being phoned at that hour of the night and spoke unkindly to that nurse. I talked to him and reminded him that he was on-call and had patients here and that it was his duty to be available for the patients and he had no right to insult any of the nurses.” P3.

The participants argued that to improve performances people need to receive appropriate feedback at the right time and in the right place with no reservations. For this, they should have an autonomous mind, and through the intelligent management of relationships, be careful not be influenced by gossips and redundant talk and remain firm in dealing with errors and negligence committed by the personnel. It is in this case that their feedback will be motivating. Participant 5 discussed motivating feedbacks and said: “After two years in the ICU, this nurse still does not know proper Hemovac drain care for a patient with hematoma drainage. I told her that since she had done this mistake a few times this month, I will take half a mark off from her internship score, because it is crucial to the patients' survival.”P3.

Smart optimization of the ward

The head nurse's capability to smartly optimize the ward is indicative of her competence in making the physical dimension of the ICU excellent. The capability of the head nurse to smartly engineer the process of work and her efforts to physically optimize the ward indicate her competence in this dimension. Participant 5 explained:

Because the ward is huge and we had to walk a lot, all the nurses had developed backache and foot pain. If they wanted to write a report or just sit down for a moment, they had to come to the station. I made a request to have proper chairs for them on the patients' bedside. They can now sit down and be with their patients at the same time.”P5.

Commitment to the ongoing professional improvement of nurses

The head nurse's commitment to the ongoing professional improvement of nurses is indicative of her competence in excelling in the human resource dimension of the ICU, which can be achieved through the active participation of new nurses in empowerment programs and the commitment to train nurses in an empowering manner. “I always train our new personnel properly … And when I become certain that the new nurse is capable of carrying out her duties, then I send her to work with an experienced nurse to support her.” P3.

To reinforce this competence, the nurses sometimes tried to create proper learning opportunities for nurses. For example: “… There was a patient who had a fever a few times in the morning at hand-over. Now this was the perfect opportunity for me to teach the nurses what to do with a patient who has a fever.” P8.

Managerial competence means: Intensive care excellence

Considering participants' experiences, excelling in intensive care was the main goal and ideal of the nurses. The subthemes of this theme include:

Ability for smart planning and organization of nurses

One of the key competences of ICU head nurses that was emphasized by all the participants was the smart planning and organization of human resources, which can be achieved through knowledge of the factors affecting the planning and organization of human resources, flexible monthly planning based on patients' care requirements, and nurses' personal capacities. “This particular male personnel of ours isn't very competent despite his extensive work experience, so, I try to schedule him with a stronger second person. I try not to schedule people who don't get along well on the same shift.”P1.

Some of the statements made by the participants about the importance of proper organization of human resources based on the level of care needed and the nurse's capabilities are presented below: “We had a patient with preeclampsia in bed 1 today, and a DKA patient in bed 3. So, I assigned these two to a stronger nurse.”P7.

The ability to provide intensive care with an insight

As stated, the goal of the participants was to provide intensive care for patients with specific needs. They stated that to achieve this competence it does not suffice to have a complete dominance over the ward and the patient treatment and care program, but a special insight is also required. This insight makes their “perspective on the ICU” and the patients admitted to this ward different from those in the other wards, which reveals the need for conscientiousness and empathy. Participant 1 discussed this issue and said: “You can talk to the patients in the other wards, but not here. You have to sense what the patient needs and take care of it without him having to verbalize these needs or call you.”P1.

They also considered themselves committed to providing scientific and safe care to patients with special diseases and carefully and smartly monitoring the scientific performance of the nurses and other personnel. “How should a nurse assistant know, for instance, how important the head position of a patient with head trauma is when bathing him? The head nurse should actively participate in every task related to an intensive care patient.”P8.


  Discussion Top


This study described the lived experiences of ICU head nurses in Iran with regards to the meaning of managerial competence. In the present study, the managerial competence of ICU head nurses meant excelling in three dimensions, including oneself, the ward, and intensive care. Mitchell and Boack (2009) categorized competence in three levels, namely personal, organizational, and strategic levels.[9] These categories are different from those obtained in the present study because the present study specifically deals with managerial competence whereas the other focuses on individual's competence in a profession.

The first dimension of managerial competence in the present study was “self-excellence.” A competent head nurse possesses outstanding personal and nursing characteristics, benefits from a holistic knowledge, and is committed to ongoing professional improvement. In one study, Luo (2016) considers improving competences in routine nursing tasks the first phase in the making of a nursing manager.[2] Ham (2011), however, argued that assuming a managerial position requires different responsibilities from routine tasks,[10] such as efforts for self-improvement and obtaining a broad and holistic knowledge, which have also been emphasized in the present study. Other studies also consider being knowledgeable in various areas necessary for a head nurse.[4],[5],[11] The American Organization of Nurse Executives (2008) consider knowledge as one of the main dimensions of competence in a nursing manager, although a great part of this scientific knowledge pertains to the science of management and business.[12] The present study found management science and the knowledge of care and treatment to be more important than the knowledge of business management. In a study conducted by Pazargadi (2005), the most important criterion considered in the evaluation of personal management in head nurses was managerial knowledge.[13] Nazari et al. (2016) also considered managerial knowledge to be the most important element for head nurses' success.[14] Other studies, however, have proposed adequate knowledge regarding health promotion as the key element in the competence of all nurses.[15],[16],[17] This disparity of findings on the most pertinent field of knowledge to competence in nursing might be the type of duties assigned to head nurses in Iran and the recent changes in the health system management. For instance, because Iranian head nurses are given little duties in terms of financial management of their ward, this dimension of knowledge was quite unimportant in the present study, and given the recent changes in hospital management systems based on clinical governance and accreditation, head nurses have developed a need for knowledge in newer areas because of their involvement in these new areas. Nonetheless, the important point in this dimension is the commitment to self-improvement, which makes the ICU head nurse make greater efforts for achieving competence. These efforts include self-learning, participation in training courses, and the use of own and other people's experiences. The head nurse aims to become competent by these efforts. This definition somehow encompasses competence-based pedagogy, which is regarded as the philosophy of nursing education by many experts in nursing education; that is, there is a need to explain the concept and dimensions of competence for diverse nursing roles and the education and training of nurses based on the defined competences,[15],[16],[17],[18],[19],[20],[21] and the applied objectives of the present study also seek to respond to this need.

In the present study, the need for possessing a series of personal attributes was part of the self-excellence dimension. Nasami (2008) also considered attributes such as enthusiasm, talent, experience, and personality traits the prerequisites of competence.[22] In addition to the various skills required by efficient managers, Koontz (2010) also regarded certain personality traits important, such as enthusiasm for management, the ability to connect to people with empathy, righteousness and honesty, and past managerial performance.[23] Chase (2010) also viewed certain attributes essential for a competent nursing manager, including good nursing care planning, clinical skills, the use of technology, respecting the standards of nursing care, and a good humor and optimism.[11] Nazari et al. (2016) also considers having a broad knowledge of healthcare and respecting professional ethics the requirements of a competent nursing manager.[14] Although the present findings are slightly different from other studies, the entire body of research on this subject generally agrees on the necessity of personal attributes and professional knowledge and skills for the intended job.

Ward excellence in its subjective, physical, and human resource dimensions was the second dimension of the definition of managerial competence in this study. The important point in this dimension is the particular attention given to the competence of ICU head nurses in the management of communications and the establishment of efficient and smart relations. In the model of consolidation of leadership in healthcare, Stefl (2012) reports the management of communications and the establishment of contact as the first common dimension of competence for all health system managers.[24] In line with these findings, nursing researchers have also considered competence in establishing communication a key competence of nursing managers.[2],[11],[12],[13] Proper communication is clearly an important factor in professionalizing occupations, and because nursing is considered a profession, having communication skills is a professional necessity of this field,[12] which is precisely the reason why this skill is integral to having competence.[16],[17]

In the present study, attention to optimizing human resources, especially nurses, was considered an attribute of ICU head nurses that helps the ward have an excellent human dimension. Other study have also considered the issue of personnel training.[11] Palmer (2009) emphasized the key role of head nurses as trainers in the ongoing education of nurses and considered them a more effective kind of teacher than others in the past.[25] This finding is justified by noting that nursing managers of all levels have to facilitate the professional development of nurses.[26]

The third dimension of managerial competence in ICU head nurses was intensive care excellence. In ICUs, critical patients are expected to be treated and cared for by the most skilled and competent nursing and medical personnel under the best conditions and with the latest equipment available.[27] It is, therefore, crucial for the head nurses of these wards to smartly organize their human resources according to their physical, mental, scientific and practical capabilities, and their type of interpersonal communication, so that they can provide smart and insightful care to the patients. According to the present findings, a competent head nurse requires special insight in addition to full dominance over the ward and the patient care and treatment plans to achieve this aim. This insight makes her “view the ICU” and the patients admitted to this unit different than in the other wards and reveals the need for greater conscientiousness and empathy. Because the patients in these wards are very vulnerable and are often unable to carry out their most basic human tasks, they require adequate and excellent treatment and have the right to receive this treatment in an outstanding manner with kindness and compassion.[28] Wilkin and Slevin (2004) also found similar results and considered care a fundamental part of ICU nursing through which the nurse will be able to personalize the common interventions according to the patient's needs.[29] Morton (2017) argued that ICU nurses should provide care through a humanistic perspective on the patient.[30] The results of these studies confirm the present findings regarding the need for competence in providing safe and scientifically-based care (and also treatment) with a special insight or particularism (i.e., compassion, empathy, and a humanistic view on patients made possible through proper care). Even though the cited studies have examined the perspective of ICU head nurses, this finding is justified by noting that, according to the results of the present study, the first prerequisite for being a competent ICU head nurse is to be a competent ICU nurse; this competence is what distinguishes ICU head nurses from the head nurses of other wards. Because ICU head nurses work in a different environment in terms of the technology and care required[31] and because they should not allow the dominance of technology in these wards to restrict the care they provide[29] and deprive it of its humane, empathetic, and compassionate aspects, the present study advocates this insight for ensuring the competence of ICU head nurses.

The main limitation of this study is low number of participants that threatens all phenomenological studies. Of course, the researcher has tried to deal with this challenge by choosing participants with maximum variability.


  Conclusion Top


The “managerial competence of ICU head nurses” is a dynamic concept that reflects the psychological and functional capability of head nurses in contributing towards excellence in their own critical care practice as well as that of the ward. A competent head nurse has outstanding personal and nursing attributes and a holistic knowledge and is also committed to the ongoing professional improvement of him/herself. Using their ability to facilitate interpersonal and interprofessional communication effectively, a head nurse seeks the psychological, physical, and human optimization of the ward in which he/she works. Therefore, the goal of providing insightful critical care through the smart organization and planning of nurses and other personnel can be achieved. Based on these findings, an instrument is recommended to be developed for assessing the managerial competence of head nurses to be used in the recruitment, promotion, and training of ICU head nurses.

Acknowledgments

We thank all the head nurses who participated in the study and shared their thoughts and experiences. This project was approved by the Ethics Committee of Tarbiat Modarres School of Medical Sciences (number: 7043/52D, 1392/12/10).

Financial support and sponsorship

Medical School of Tarbiat Modares University.

Conflicts of interest

Nothing to declare.



 
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