Exploring fair decision-making rules in nursing: A qualitative study

Abstract

Background:

The decision-making process should be done according to a set of rules and principles so as to be fairly understood.

Objectives:

The aim of this study was to identify the basic principles and rules used by nurses to understand justice in nurse managers’ decision-making processes based on a procedural justice model.

Research design and participants:

This research was a qualitative study based on directed content analysis, which was performed on a group of 15 nurses working in different hospitals in Tehran, Iran. An in-depth semi-structured interview was used as the method of data collection for this study.

Ethical consideration:

This research has been approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences. The respondents were informed about the aim of the study, about voluntary participation, anonymity and confidentiality.

Findings:

The results of this study showed that in order to understand procedural justice, nurses use several rules, including: duties organization, managerial support, consistency, bias-suppression, accuracy, correctability, representativeness, and ethicality.

Conclusion:

Nursing leaders must consider the importance of justice rules as one of many strategies to ensure the nurses’ perception of fairness in decision-making processes.

Keywords

Decision-making justice nurses procedural justice rules

Introduction

Over the past decade, there has been an increasing tendency toward the concept of organizational justice as an essential branch of organizational psychology.¹ Greenberg² believed that studies on organizational justice explain many behavioral consequences in organizations. The understanding of organizational justice by healthcare providers is essential because of their direct relationship with the employees’ well-being, attitudes, performance, and their ability to adapt to stressful and critical situations.³

Organizational justice is one of the strongest determinants of an individual’s decision as to continue or leave the service in a healthcare system.^4,5 In comparison with other health professions, nurses have the lowest level of perceived organizational justice and the highest level of intention to leave employment.^6,7 Studies on organizational justice are valuable and useful in nursing, especially in nursing management because of its potential ability to influence many organizational factors such as psychological empowerment, job satisfaction, organizational commitment, organizational trust, respect, performance, stress, and service abandonment.^8

–11 In addition, one reason for the failure of reengineering projects is that they do not consider the role of organizational justice while deciding about implementing changes.¹² The Canadian Nursing Association’s Code of Ethics considers justice promotion as a nursing value and moral responsibility.¹³ The core of nursing management involves communication between managers and other stakeholders that have different interests. Nurse managers should make decisions and provide responses to the interests of the nurses and the organization, which may sometimes be contradictory. When nurse managers and organizations do not pay attention to the nurses’ voices, do not respond to them, or do not consider them in decision-making, it causes job dissatisfaction, exhaustion, and perception of injustice in the workplace.¹⁴

Nurse managers should use the principles of justice in their decisions, which refers to the way in which the burden of the behaviors and decisions of managers is divided fairly.¹⁵ The results of the literature review showed that most of the studies on decision-making in nursing practice evaluated clinical or ethical decision-making among nurses. There were no models or indices associated with the fair decision-making process in nursing. However, it seems that nurse managers can ensure fairness in decision-making processes by considering procedural justice rules.^16,17

The level of employees’ perceived justice in the decision-making processes is called procedural justice.¹⁵ Procedural justice refers to the fairness of the processes that lead to decisions. Previous studies on justice have shown that perceived procedural fairness positively affects people’s reactions to outcomes they receive from the organization or their supervisor.^16
–18

The procedural justice model is one of the first and most commonly used models in procedural justice. According to his theory, decision-making processes will be perceived as fair when they are based on a set of rules, including: (a) used consistently across time and individuals (consistency); (b) regardless of personal interest, is neutral and based on facts (bias-suppression); (c) based on correct information (accuracy); (d) providing opportunities to correct wrong decisions (correctability); (e) reflecting the concerns of all the groups and people who may be affected by the decision (representativeness); and (f) compatible with ethical values accepted by people (ethicality).¹⁹

Before deciding about the fairness or unfairness of a procedure in the workplace, individuals first evaluate the procedure based on a set of criteria and then perceive the level of fairness of the procedure. These standards are referred to as “justice rules,” and act as a group of cognitive measurement tools, similar to a ruler that helps people measure the level of fairness they have received.²⁰ The individuals apply the justice rules to judge, whether they have been treated fairly or not.^19,21,22 The results of Schweitzer and Gibson’s study demonstrated that when the decisions are not based on rules and standards of fairness, an individual reacts through unethical behaviors in the organization.²³

Previous studies have shown that the role of context is very important in applying the rules of justice, and individuals in different fields may use different rules to perceive justice in decision-making processes.^21,24

In this article, we explored the rules nurses use to judge fairness in decision-making processes.

Qualitative studies, with an approach based on the individuals’ experience, may provide a paradigm that leads to the identification of new rules in justice.²⁰ Qualitative approaches have been useful for exploring justice rules in previous studies.^24
–26

Although the research evidence increasingly points to the importance of perceiving justice by nurses in predicting outcomes, no studies have documented the rules and standards of Fair Decision-Making in nursing yet. It seems that a broader understanding of rules and standards of judgment about fairness in Decision-Making processes by nurses is essential.

Aim and research question

Considering the importance of justice in nurse managers’ decision-making, the goal of this study was to find out whether nurses use the rules of procedural justice to perceive justice in nurse managers’ decision-making processes or they use other rules. This study sought to elucidate these rules for nurses using a directed qualitative content analysis based on their experiences.

What rules do nurses use to perceive justice in decision-making procedures?

Methods

Design

A qualitative study was conducted using a directed content analysis approach to investigate if nurses use previous rules governing the concept of organizational justice to perceive fairness.²⁷ This analysis was performed according to the rules provided for procedural justice. Cropanzano²⁰ emphasized the use of qualitative studies and phenomenological approaches based on the experience of individuals to identify the rules of organizational justice.²⁰

Participants and recruitment

The research population comprised all nurses working at different hospitals in Tehran. In order to achieve a comprehensive and diverse database, purposeful sampling was conducted for this study. The inclusion criteria were as follows: a Bachelor’s degree or higher in nursing, employment in a clinical or healthcare department, and showing an interest in the research topic. The participants included 15 clinical nurses. To maximize the diversity of participants and to achieve a comprehensive and diverse database, nurses of both sexes working in different units (medical, surgical, emergency, and critical care) in different hospitals were used.

Data collection

The data required for this study were collected by conducting in-depth semi-structured individual interviews with the nurses. Each participant was interviewed only once. The interviews started with engagement questions about their managers’ decisions and how they are implemented with regard to them and were continued with some exploratory questions, for example, “Do you see your manager’s decision-making process as fair or not? Please explain your answer.” “Can you give an example?” “Would you say there is a rule that was not respected and that made you think ‘this is unfair!’” These questions were particularly important for identifying the rules that the nurses used to form their fairness judgments.

A few more probing questions were asked during the interview, based on the interviewees’ responses to the listed questions. At the end of the interviews, they were asked to discuss about anything else that they would like about the decision-making processes in their organizations. The background information was also collected from the participants, including age, current job status, level of education, having management experience, and current unit. With the permission of the participants, the interviews were recorded by audio tapes and then transcribed word for word. The face-to-face interviews were conducted in Persian and each interview lasted approximately 30–70 min. The researchers listened to the statements and reviewed the interviews several times to better understand the participants’ feelings and experiences. The interview location was set by the agreement of the participants. Interviews were often conducted at nurses’ rest breaks during the work shift or after the work shift at the hospitals the participants worked in. The analysis of the data took place concurrently with the data collection. This process allowed the researchers to identify data saturation, which was achieved with the 13th participant. To confirm data saturation, two additional participants were interviewed with no new insights generated.

Ethical considerations

This research has been approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences with the code of ethics: IR.USWR.REC.1395.81. The respondents were informed about the aim of the study, about voluntary participation, anonymous responses and confidentiality. Participants who gave consent were informed that they were being recorded during the interview, and it was emphasized that all information would be kept confidential and used solely for the purpose of this study.

Data analysis

Hsieh and Shannon²⁷ identify three types of content analysis that differ in their coding schemes and the origins of codes. In this study, we used directed content analysis, in which theories and relevant existing research are used to inform the codes and themes initially used in this analysis and the findings of the study are hoped to build on this existing knowledge base. This approach is the most appropriate for this study due to the body of literature available on this topic and related topics.^27
–29

Interviews were performed based on the participants’ experience of perceived justice in decision-making by managers and continued until data saturation was reached. After each interview, the audio-recorded data were typed verbatim as soon as possible. The text was read several times to gain a better understanding of it and then was broken into the smallest semantic units (codes) by two researchers. To classify the codes, perceived procedural justice rules were used, and the entire text was read for codification. The sections consistent with the definitions for each of the perceived procedural justice rules were identified and marked. At the next stage, the sections that had been marked were given a code. A new code was given to each section of the text that did not fit into the initial coding. When an extracted code did not fit into any of the rules of the procedural justice theory, a new category and rule were created while taking into account the coordination between the unclassified codes. The two researchers met again to compare their emerged rules and subcategories. With the assistance of a third researcher, any disagreements were discussed in order to reach a consensus on the final set of rules and subcategories.

Rigor

The trustworthiness of this study may be assessed by the concepts of credibility, dependability, and transferability. In order to achieve a comprehensive and diverse database, nurses from both sexes, different hospitals, wards, and work experiences were chosen. A variety of descriptions were provided by participants, strengthening its credibility. The sample size remains small (n = 15). However, the main categories appeared very early, after a few interviews, and were repeated almost in most of the interviews. Data saturation was achieved with the 13th participant. To confirm data saturation, two additional participants were interviewed with no new insights generated. The credibility of the data was also strengthened by conducting member check during the interviews. To address the dependability of the study, two independent researchers were involved in performing data analysis and discussing the findings until a consensus was reached. A third researcher, who was not involved in the data collection and data analysis process, helped validate the findings. The aim of the descriptions of the interviewees and the process was to make it easier for the reader to assess transferability, which is the third aspect of trustworthiness.

Findings

In this section, the results of the directed content analysis based on the interviews with the nurses participating in this research are presented. The participants’ ages ranged from 27 to 38 years (mean = 31 years old), with a job experience of 4–14 years (mean = 8). None of the participants had any management experience.

After the analysis of the interviews, a total of 364 primary codes, 8 categories, and 5 subcategories were extracted. The codes that were obtained from the interviews were categorized into six previous categories (rules) of procedural justice, including consistency, bias-suppression, accuracy, correctability, representativeness, and ethicality, as well as two new categories (rules) of duties organization and managerial support (Table 1). These eight rules formed the basis for the nurses’ perception of fair decision-making in this study. This section describes each of these categories.

Table 1.

Rules and subcategories.

Rules	Subcategories
Duties organization	Job description
	Division of labor
	Workload
Managerial support	Dealing with errors
	Incentives
	Support in crises
Representativeness
Consistency
Correctability
Bias-suppression
Accuracy
Ethicality

Rule 1: duties organization

The nurses are expected to spend their working time building therapeutic relationship with patients and undertaking nursing processes to improve the outcome of patients. To achieve this goal, the managers’ decisions on the distribution of workload and division of labor, and the definition of work based on the job description and the workload of nurses play a vital role.

Subcategory 1: job description

Regarding job description, the experiences of the nurses showed that despite their awareness of the job description, head nurses and physicians did not comply with these job descriptions. The tasks that nurses are expected to perform must be designed for them with a defined legal job description. Duties of other working groups such as doctors or nurse assistants should not be imposed on them by force and pressure. One nurse stated,

Our job description is clear in the ward, but the physicians add some tasks to our duties. Right now, one thing the physicians want us to do is the insertion of the PICC.ⁱ They say nurses must do this, but, it is a very difficult and a highly specialized procedure. You feel guilty as you attempt to do it for a newborn baby who weighs 700 grams. (Participant 3)

Subcategory 2: division of labor

The division of shift work between the staff must be done fairly. Some experienced nurses complained that they were more likely to deal with complicated patients who require a lot of attention and care, since they have more experience and skill and are considered more trustworthy by the managers. The less experienced personnel complained that the senior and experienced staff members worked fewer shifts and had lighter work schedules compared to them:

A nurse with 10 years of work experience deals with just one patient and a newly arrived nurse deals with three or more patients, it’s not fair at all…(Participant 4)

Subcategory 3: workload

The nurses’ workload should allow them to provide patients with appropriate and scientific nursing care, and not just basic care. Regarding this, one of the nurses stated that the pressure of work is so much that they provide care like robots without critical thinking. Moreover, the care process is not done properly and scientifically because of the high workload:

We all know that antibiotics should not be shaken, but when you do not have time to dissolve the medication, you even push the antibiotic. It is all because of the pressure that is on me as a nurse and it will be transferred to the patient. It’s true that we have a work commitment, but for how long? I am supposed to be a father for two children, too. (Participant 1)

What they ask us to do is beyond human capabilities. Today, I had to take care of two patients, and I could only deal with one of the patients from early morning and I couldn’t do anything for the other patient at all. (Participant 13)

Another concern for the nurses was the high level of nursing paperwork and documentation required that prevented them from performing clinical care and attending to their patient.

Rule 2: managerial support

Nurse managers should pay close attention during their work and management processes and support nurses by supportive behaviors. During this study, three subcategories emerged after interviewing with nurses: dealing with errors, incentives, and support in crises.

Subcategory 1: dealing with errors

“Dealing with errors” means that the punishment considered for mistakes made by nurses should be fair and in accordance with the importance of the error; furthermore, it is important that the ward manager informs the nurses about the errors in a private meeting, and not in the presence of colleagues, other employees, or patients. A few nurses expressed that there is always a risk of getting fired even for minor and negligible mistakes. Finally, the nurses expressed that punishments are implemented far faster than recognition or appreciation:

…for just a simple fault, you should not shout on the nurses in front of everyone and say you do not know or you do not pay attention at all…(Participant 2)

Subcategory 2: incentives

The subcategory of incentives means that just as there is a system of punishment for errors and mistakes, there should also be a reward system in times of heavy shift work or outstanding performances, for example, a successful cardiopulmonary resuscitation (CPR), so that the nurses are encouraged to do their job properly:

I’ve been working in this ICUⁱⁱ for two years. I had no case of deceased patient. A major part of it may be luck, but here is a perception; no patient has ever died because of my negligence, I have never been absent, I have never been delayed, and I never had a sick leave but there is no difference between me and others. They don’t even thank me verbally. (Participant 6)

Subcategory 3: support during crises

Regarding the subcategory of support during crises, the nurses complained about the lack of support at the hospital and in the face of problems, believing that they had no support at work and are the weakest members in the system. At the time of a crisis, such as heavy workloads, they are not encouraged nor do they see supportive behaviors such as an increase in the number of staff members. Their work is seen as their duty. The head nurses and nurse managers, who should play a key role in supporting nurses, are silent at the time of crises and in facing criticisms and complaints by physicians, patients, or companions, due to their lack of independence and fear of losing their jobs:

No matter what happens, the pressure is only on nurses. Nurses are safety valves. When patients are angry about being in a 5-bed room, they blame the nurses for everything. It is nurses who always get beaten and insulted. (Participant 8)

No one supports us. We do not have any supporters, except ourselves. If I face a problem, there is no one to support me, neither a colleague nor a head nurse. (Participant 5)

Rule 3: correctability

This principle refers to the ability to modify and change decisions and evaluation results. When people have the opportunity to protest against decisions and evaluations by organizations through a system of complaints or conflict resolution, procedural justice is perceived at a higher level by individuals in the organization.

In this regard, nurses expressed that they had a sense of fear when objecting to the decisions made by the head nurse, matron, or physician. They were also afraid that their manager may take revenge and they were afraid of not being given the opportunity to express themselves:

You know, there is no one to help you. There is no one you can talk to about your problems. If you have a problem with one of the supervisors, the rest of them also turn against you and ignore you, because they have common interests. (Participant 2)

The majority of us had serious problems with our evaluation process and did not accept the results and we refused to sign the assessment sheets. So they had to sign the sheets instead of us. Once when the provincial authorities were coming to visit us, I threatened that I was going to speak up. So, they deliberately changed my work shifts and did not let me speak. (Participant 5)

Rule 4: representativeness

The rule of representativeness characterizes the extent to which the individuals’ interests and concerns are taken into account in the decision-making processes. This rule, which is sometimes considered as the voice of individuals in the organization, has been investigated more than any other rule of procedural justice. Studies have shown that this rule has a significant impact on the perception of procedural justice. In this regard, the nurses pointed out that among other things, the head nurses neither pay attention to their opinion for planning their work schedule nor are their opinions considered in the selection of nurse managers:

You know, nobody likes to work overtime, but now we must do at least 60 hours of overtime. There is a request book in the office to put down your preferred working shift request, but nobody pays attention to it. (Participant 6)

Rule 5: consistency

This principle, as its name suggests, refers to changing the use of different procedures in the organization. In the current research, the nurses in the interviews pointed to lack of consistency and specific guidelines for recognition, punishment, selecting the best nurse of the year, the amount of allowance, and enforcing rules fairly for all employees:

I arrived at the hospital at 7:50 and my head nurse told me that I should request an hourly leave for 50 minutes, as our shift starts at 7.00 and finishes at 13.00, but no one comes at 07.00; everybody comes at 07.30 and leaves at 13.30. But I had to do it because I am a junior nurse. (Participant 9)

Rule 6: bias-suppression

According to this rule, decisions must be neutral and without bias. The perceived procedural justice for individuals will increase when the decision-making processes in the organization are neutral, without bias, and based on facts. In this study, many of the participants stated that the vast majority of evaluations were biased. They felt that their managers were against them:

When I didn’t have a problem with them, any mistakes I made were easily overlooked. But, once you have an argument with them, they look for the smallest mistake you make. (Participant 11)

Furthermore, some nurses stated that the recruitment process was non-scientific and was based on personal issues, rather than their skills and knowledge:

I wanted to be hired. I was turned away by the selection committee. I am sure my clinical skills and performances were ok, but they said I did not comply with the dress code rules and my sleeves were too short, and that was a problem from the Islamic point of view! (Participant 4)

Rule 7: accuracy

This rule refers to the extent to which people believe their managers have evaluated them using all available information. The nurses were concerned about their nurse managers’ lack of knowledge regarding the items of evaluation. For example, a nursing specialist stated that the nurse manager had not considered her research activities in her evaluation because she was not familiar with the research. In some cases, the nurses stated that the head nurse did not care about the quality of their work in the evaluation process and evaluated them with bias or did not ask their colleagues about their opinions and comments:

Our head nurse acts unfairly and selectively. Only what he thinks of other people is important to him and he doesn’t care about the others’ ideas. (Participant 2)

Rule 8: ethicality

Ethicality is the extent to which the working processes and decisions reflect the moral values of the individuals. Studies on the role of ethics and its impact on organizational justice are limited. However, the existing studies show a direct relationship between the decision-makers’ ethicality and level of perceived justice in individuals. The nurses also referred to issues such as being under pressure and the threat to perform tasks that were not their responsibility, being framed, especially in the case of those who voice objections, having heavy workloads, receiving little reward and support from nurse managers, and receiving biased performance evaluations:

I was asked to teach my colleagues and I don’t like it. They gave me the score of two in my evaluation. Others don’t teach either, so why should I teach? Nobody can threaten me with money or these evaluation scores. I don’t have the responsibility to teach. (Participant 8)

Discussion

This study was conducted to extract the rules and standards of perceiving justice in decision-making procedures based on the experience of nurses. In order to extract these rules and standards, the theory of procedural justice was considered as the basic theory.

The results showed that besides the theory of procedural justice rules, nurses use two new rules of duties organization and managerial support to perceive justice during the decision-making process done by managers and organizations. The rule of duties organization has not been addressed in previous studies. According to the participants’ explanations, managers’ decisions on the distribution of workload, task assignment based on nurses’ job description, and the workload of nurses influencing the sense of perceived fairness in the organization. Consistent with our results, the study of Afzali et al.³⁰ showed that unfair work division is one of the main causes of injustice and disruptive behaviors by nurses.³⁰

In addition, the results of the study by LaukKanen et al. (2016) indicated that organization of work by activities, such as arrangement of work tasks, dividing and changing the workload, using an additional workforce, and employee resourcing, can be considered as one of the ethical decision-making activities of nurse managers in solving work-related ethical problems.³¹

In line with the results of this study, it should be noted that governments, managers, and nursing professionals are currently paying more attention to issues such as workload and nurse staffing. Along with the changes in financial and economic systems of healthcare, the importance of patient-based care and shortages of nursing workforce, the importance of understanding how nurses work, and spend their time has grown.³² To improve the level of perceived procedural justice in nurses in the area of duties organization rule, nurses’ work plan should be defined based on their job descriptions. Moreover, the duties of other professions, such as physicians, should not be imposed on nurses and role conflicts should be prevented. The workloads should be planned in such a way that nurses can implement a comprehensive nursing care program.

Another important rule that has not been addressed in previous studies is the rule of managerial support. The study by Laschinger³³ demonstrated that half of the nurses believed that their managers show no sign of care or support for decisions made about them. Gillet et al.³⁴ also showed that procedural justice and organizational support are directly related to job satisfaction, organizational identity, and improvement of patient care among nurses. Establishing a supportive relationship between the nurse managers and clinical nurses during work processes as well as supporting the nurses in crises in a way that they do not feel abandoned is important to promote perceived justice in the nurses. Nurses in magnet hospitals recognized the managers’ support as one of the eight factors of healthy and excellent work environment.³⁵ The results of the study by Chang et al.³⁶ showed that using the Clinical Support Nurse Role leadership style can reduce stress in nurses.

Pinder and Harlos³⁵ believed that organizations that have an institutional culture of injustice develop an atmosphere that dissuades people from commenting on issues and expressing their ideas and opinions. The results of the study by Barclay and Harland³⁷ showed that when a system for the objections and correction of the results of “peer-reviewed” errors is available for nurses, their levels of perceived justice and satisfaction are higher. Regarding the rules of representativeness and correctability, most of the nurses were afraid to make complaints and objections against their managers’ decisions and dreaded their managers’ reaction to such issues. Nurse managers should create a supportive atmosphere and allow nurses to speak and express their point of view on decisions made by them. Giving voice to nurses improves their commitment to their profession and the organization.³⁸

Aitama et al. (2016) quoted from nurse managers saying that when trying to make fair decisions, they face ethical challenges in planning shift work, especially in holidays, rewards, and punishments.¹⁴ In this study, these problems were also referred to in sections “Rule 1: duties organization” and “Rule 2: managerial support.” The nurses complained about the disproportionate level of punishment for errors compared to rewards and recognition.

Bos et al.³⁹ examined the effect of the accuracy rule by intervening in the evaluation procedures of high school students. The results showed that low-accuracy evaluation reduced the level of perceived justice and caused negative consequences in students.³⁹ In addition, the results of De Cremer’s (2004)⁴⁰ study showed that the level of employees’ precision will rise if the evaluation procedures implemented by the leaders are unbiased.²⁰ Nurse managers should make decisions with the utmost care and collect information from all available resources. For example, many nurses complained that the nurse managers just rely on their own findings and opinions in evaluating nurses, and since the head nurse does not work with nurses during night shifts, the evaluation is biased, thus creating a sense of injustice in them.

According to our findings, variation in application of organizational rules across time and individuals in decision-making processes is one of the main sources of perceiving injustice by nurses. In line with this rule, Colquitt⁴¹ examined the extent of control over members of a team and found that when team leaders applied a degree of inconsistent control over employees, the performance and collaboration of the employees decreased compared to the time when they applied consistently high or low level of control over them.

Despite all the above-mentioned issues, previous studies have pointed out that the views of nurse managers and nurses on justice differ.¹⁴ Since the nurse managers have a big role in creating a fair and supportive atmosphere for nurses at work, it is suggested that the experiences of nurse managers in terms of organizational justice should also be addressed for future study. Considering the research population and the limited number of samples, further studies are needed to generalize the results and principles derived from this study.

Conclusion

In this study, we explored the rules nurses use in judgment of fairness in decision-making processes for the first time. Perceiving fairness in these processes is so important because it can influence the reactions and behaviors of nurses to the outcomes they receive.

Nurse managers can create fair working conditions for nurses in accordance with the rules explored in this study. The perception of fairness in decisions can be improved in the following ways: have clear job descriptions for nurses to avoid role conflict, attempt to keep the nurses’ workloads manageable (duties organization), and pay special attention to the perception of organizational support in time of crises and in dealing with errors and providing a reward system for times with outstanding functions (managerial support). Based on this study’s results, nurse managers must listen to the nurses’ opinions and provide them with the opportunity to influence decisions (correctability). They should give nurses the assurance that the procedures and decisions will remain consistent across time and individuals (consistency), with no bias (bias-suppression), based on professional ethics (ethicality) and accurate information (accuracy).

Footnotes

Author’s Note

Asghar Dalvandi is now affiliated with Department of Nursing, Islamic Azad University Tehran Medical Branch, Iran.

Acknowledgements

We would like to thank all the nurses who participated in this study as well as the deputies of Education and Research from the University of Social Welfare and Rehabilitation Sciences for their help and support in carrying out this study. This article is partially based on a thesis submitted to the Graduate School of Social Welfare and Rehabilitation Sciences in partial fulfillment of the requirements for the degree of doctor of philosophy in nursing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Hosein Zahednezhad

Notes

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