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During several years of cooperation with scientific journals in Iran as referee, member of
editorial boards and editor in chief, I have faced with multiple non-ethical behaviors in
publication. These days, I am witnessed to submitting articles to two or more journal
simultaneously. Due to the growing pattern of this illegal action, this editorial will assess its
dimensions and consequences.
The Article 1, Chapter VI of the National guidelines on Ethics of Publishing Medical
Research has clearly stated: "If a manuscript is published or is being considered for publication
in print or electronically, re-publishing in or submitting to other journals is not allowed. This
statement is so important that the editors of the scientific journals have mentioned it in the
author guidelines of the journals. However, what make authors, especially beginners, to submit
their articles to more than one journal are perhaps requirements of the Institutes for defending a
thesis, annual and/or academic ranks promotions.
Republishing articles in scientific journals, especially in the same language, result in
spending cost and taking time of the scientific and executive teams of the Journals and has no
added value. The negative effects of this action are more highlighted when the role of scientific
journals in promoting health care quality through publishing new and valid scientific evidences
and limited spaces of the journals are noticed.

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  A pilot or preliminary study is referred to a small-scale of a complete survey or a pretest for a particular research instrument such as a questionnaire or interview guide (1). Pilot studies could be conducted in qualitative, quantitative, and even mixed methods research (2).

  General application of pilot studies can be summarized in four areas: 1) to find problems and barriers related to participants' recruitment 2) being engaged in research as a qualitative researcher 3) assessing the acceptability of observation or interview protocol and 4) to determine epistemology and methodology of research. Three specific functions of pilot studies in qualitative research are assigned to three main qualitative methodologies including phenomenology, grounded theory, and ethnography. It allows exercising epoch within the phenomenological research, increasing theoretical sensitivity in grounded theory, and familiarity with fieldwork in ethnography (3-5).

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  Nurses’ turnover phenomenon is a major concern in healthcare systems of many countries. In recent years, nursing shortages in Iran has become a major challenge for healthcare system managers. Based on the definition, “turnover” is a process in which employees leave an organization or transfer to other departments or units of the organization. However, in this definition it has not been specified whether members’ turnover is voluntarily or involuntarily (1). Also, nurses are vital components of healthcare systems, so that as the largest group, they constitute about 56% of the hospital staff (2). Lack of knowledge about nurses’ turnover makes it hard for managers of healthcare systems to recognize its effect and it complicates the efforts to fill nurses’ vacancies (3). This complex issue has been affected by several factors. Turnover and relocation of nursing employees have affected medical expenses through impact on patients’ resultants.

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  Self-care is a series of learned actions and goal-directed activities done by individuals in order to provide, maintain, and promote health. Self-care activities involve health promotion, disease prevention, treatment of diseases and injuries, and treatment of chronic diseases. Although the impact of the self-care on improvement of health outcomes and reduction of costs are proven in numerous studies, implementation of self-care programs requires systematic educational and supportive interventions provided by health care providers including nurses to overcome health problems.
Many health professionals in Iran emphasize on negative aspects of unhealthy behaviors to persuade people to do preventive and healthy behaviors. For example, in drug abuse preventive programs, disadvantages of drug abuse as well as the increasing rate of drug abuse and other addictive behaviors, and the economic costs resulting from drug abuse are presented to youth.
Although the emphasis on negative aspects and side effects of unhealthy behaviors is worthy, especially when negotiating the budget with the competent organizations and key supplier, it is not always the best way of proposing behavior change to individuals. For example, showing the pictures of amputated parts of body, and/or blindness to patients with diabetes who are mostly depressed and seek treatment in the diabetes clinics does not seem to be an appropriate approach. Is not there any other positive ways to announce messages to people?
To answer this question, let's take a look at the concept of commercial marketing. Do successful companies highlight negative content of their products and services? The answer is: not often. In commercial marketing, products are presented in a positive way. In fact, everything from cars to clothing, from food products to furniture is offered positively in the market. Car reminds success, health and welfare; cloths helps people to seem younger and more fit; food products help people to feel refreshed, healthy and happy; even furniture is for a modern and convenient life. In commercial marketing, foot blisters of a walking individual are never shown to make people to buy cars.
 

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  The results of several studies show the relationship between the ratio of nurses/patients with quality of care and patient outcomes (1-3). This means that less the ratio, more expected adverse outcomes for patients. These findings have led some institutions to establish mandated nurse-patient ratios (4). Establishing standard ratios could potentially improve patients' outcomes such as patients' safety (5, 6), decrease length of stay (3) and readmission rates (7), and improve recruitment and retention of nurses in the system and reduce their burnouts (8).

  According to Mohammad Aqajani, Deputy of the Iran Ministry of Health and Medical Education (MOHME), the country is facing a serious nursing shortage as about 80 thousand nurses serve 80 thousand beds in public hospitals, i.e. one nurse per hospital bed. However, the national standards suggest at least two nurses per bed. Now each year there are nine thousand graduates of nursing baccalaureate program thus, even if no nurse is retired or leave the system and all graduates could be recruited to work in the nursing field, still at least nine years will be needed to provide adequate nurses. In fact, a significant number of nurses leave their job due to retirement, early retirement, turnover and migration so achieving the standard of nursing staffing in a ten-year timeframe seems impossible. ...

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  Caring is the most central concept in nursing. This concept distinguishes nursing from other health professions. However, according to some experts’ opinions, caring is not an only-nursing concept it is defined as the heart of all health professions. Caring is entered in the philosophy, vision and mission of several health organizations (1) and is introduced as the essence of nursing and the fourth complementary concepts of nursing Meta paradigm (2). Caring, as a central concept in nursing, has led to developing various caring theories. The most popular ones involve the cultural care theory of Leninger and the human care theory of Watson that were presented in the 1970s. In addition, the theory of Roach was developed in the 1980s. Another theory was presented by Boykin and Schoenhofer in the 1990s. These theories can be compared in some aspects including origin, domain, and definition of caring, description of nursing and other key components (3).

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Ethnography is a qualitative research method in which researchers study various values, beliefs and cultural meanings in a group of people or society. Critical ethnography puts more emphasis on social groups and individuals' power, prestige, authority and status (1). In ethnographic studies, researchers employing inductive logic focus on interactions between people to discover the meaning embedded in culture. Critical approach attracts researchers’ attention towards individuals who play a minor role in social interactions (2). Madison quoting Thomas contends that critical ethnography is a classic ethnography with a political aim. The ethnographer not only explains the meanings of interaction in a specific context, but also strives to know how these meanings are described against the broad structure of power (3). Thus, critical ethnography involves all the fields in which interactions are influenced by power relations. Critical ethnography plays an essential role in health research and nursing, in particular. Most of the nurses are female and power relations are one of many factors that affect the complex doctor-nurse and nurse-patient interactions (4).

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The essence of nursing is protecting the public and nursing profession believes that receiving high quality and safe services, is the community’s right. During the past decades nursing has been considered as a significant profession with characteristics such as autonomy, professional commitment, expertise and responsiveness (1). The body of contemporary nursing is consisted of knowledge and skills, value system, academic education and professional socialization. Autonomy has been defined as nurse’s capacity for determining their action through independent choosing in all the fields of nursing practice and self-regulatory in nursing practice is necessary for achieving professional freedom of action (2).

Professional self-regulatory is the decision-making power for determining the inclusion criteria for the members to enter the profession and start their activity in that profession. It will determine who, with what specialties and how much knowledge and skills have the inclusion criteria for the profession (3). During the mid-19^th century, combination of knowledge and skills, emphasis on commitment to duty against seeking personal interests and also independence from external interferences in professional matters (autonomy) were mentioned as the most important features of self-regulated professions. From the early 20^th century, the motivations for professionalization got in line with professional self-regulatory (2). According to the Donabedian Model, a “social contract” exists between the society and the profession and under this contract the society will accept profession’s independence in exchange for their services and will give independence to that profession so that they could manage their own matters. In return for this privilege, the profession would act responsively to maintain the public interests (4).

Professional self-regulation would be granted to a profession as a privilege when the public would be able to receive the best possible services after that professions’ self-regulation (4). In fact, professional self-regulatory would guarantee the quality of services (2,5,6). During the past two decades, World Health Organization (WHO), to educate and employ competent and skilled nursing workforce, has recommended the governments to strengthen their professional self-regulatory frameworks. International Council of Nurses (ICN) in cooperation with the WHO has published a statement of their perspective of professional self-regulatory. This statement has mentioned that safe and high quality care, creating a monitoring system for licensing, professional policy making and applying the professional laws and rules could be reached by creating and improving the infrastructures of professional self-regulatory systems. ICN stated that professional self-regulatory is a method for applying discipline, stability and control over the profession and its performance (7, 8). National and international studies have shown that would improve educational and clinical standards which in turn would increase the power of the profession in managing its own matters.

Since professional self-regulatory would lead to the activity of qualified and competent individuals in a profession, it would increase people’s trust in professional services providers as capable and honest individuals and would provide the public interests (1). In professional self-regulatory, by firing professionally unqualified and uncommitted to the ethical codes individuals from the profession, the interests of the profession would be provided (4).

In the main, there are two ways a profession can be regulated: by the profession itself (professional self-regulatory) or directly by government. If the government would take the responsibility of managing the profession, the members of the profession would be forced to accept the laws and rules of the profession; while the approved laws by the self-regulated profession are flexible and would be accepted voluntarily (9).

Self-regulatory professions have two separate bodies for their activities: 1- the monitoring body and 2- the supporting body. The monitoring body maintains the interests of the profession through creating the inclusion criteria for the profession, licensing, certifying and disciplinary actions; while the supporting body would perform toward promoting the economic and professional benefits of the profession’s members. The goal of the supporting body is to develop the profession to assist the members and advance the profession; but the monitoring body will develop the profession to support the public interests. Most of the times, the public interests are not in conflict with the profession’s interest, but in case of such conflicts, professional self-regulatory should act toward achieving the public interest (10).

The condition of professional self-regulatory in Iranian nursing

Iranian nursing has had significant advancements during the recent years which development of academic education, formation of Iranian Nursing Organization (INO), establishment of Scientific Association of Iranian Nursing, establishment of research centers and publishing numerous research-scientific journals in different fields of nursing are some of them (11). However, the profession of nursing in Iran still has many shortcomings. Evaluating the laws of the Nursing Organization of the Islamic Republic of Iran, which is the greatest non-governmental nursing organization in Iran, although the goals of the organization are in line with the self-regulatory goals of the profession, but in most of the self-regulation requirements, no independent role has been defined for the organization, in a way that, in the definition of 6 duties out of 8 defined duties for the INO cooperation with or helping other organizations has been used and only in the third duty, “trying for improvement of the quality, skills and knowledge of nursing graduates” and the seventh duty, “determining standards for issuing, extending or cancelling membership cards”, the legislator has appointed an independent role for the organization. Maybe for this reason, and many other reasons that are not in the scope of this article, the INO has not considered professional self-regulation performances sufficiently. Other nursing associations in Iran, due to lack of regulatory mechanism and also the low number of members from the nursing profession, could not have an effective role in professional self-regulatory. In Iran, regulating the rules and managing the matters of nursing have always been a responsibility of the government (6,12). On the other hand, during the recent years, we have witnessed the establishment of the nursing deputy in the Ministry of Health and Medical Education (MOHME) which indicates the efforts for governmental management of this profession.

The authorities’ approach toward the nursing profession during the recent years for encountering various challenges is one of the examples of governmental management and lack of professional self-regulatory. For example, the nursing shortage could be mentioned which is a global problem. To resolve this problem, the MOHME has increased the capacity of training nursing students and the number of nursing schools. These measures have led to educating students at schools with no infrastructures and no competent educational board which is in conflict with the quality of services (public interests). In return, the next measure to compensate for the shortage in nursing workforce is educating practical nurses by the MOHME. Most of the experts have suggested this solution for the problem of shortage in nursing workforce, but it has been perceived as compulsory by the members of the profession and they disagree with it (13).

Considering that finding an appropriate self-regulatory mechanism for the profession requires the involvement of all the beneficiaries, especially the members of the profession, it is recommended that all of the active organizations in the field of nursing would start determining the characteristics and features of an appropriate self-regulatory organization for the nursing profession of Iran through conversations and then would make their best efforts for its establishment.

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The essence of nursing is protecting the public and nursing profession believes that receiving high quality and safe services, is the community’s right. During the past decades nursing has been considered as a significant profession with characteristics such as autonomy, professional commitment, expertise and responsiveness (1). The body of contemporary nursing is consisted of knowledge and skills, value system, academic education and professional socialization. Autonomy has been defined as nurse’s capacity for determining their action through independent choosing in all the fields of nursing practice and self-regulatory in nursing practice is necessary for achieving professional freedom of action (2).
Professional self-regulatory is the decision-making power for determining the inclusion criteria for the members to enter the profession and start their activity in that profession. It will determine who, with what specialties and how much knowledge and skills have the inclusion criteria for the profession (3). During the mid-19^th century, combination of knowledge and skills, emphasis on commitment to duty against seeking personal interests and also independence from external interferences in professional matters (autonomy) were mentioned as the most important features of self-regulated professions. From the early 20^th century, the motivations for professionalization got in line with professional self-regulatory (2). According to the Donabedian Model, a “social contract” exists between the society and the profession and under this contract the society will accept profession’s independence in exchange for their services and will give independence to that profession so that they could manage their own matters. In return for this privilege, the profession would act responsively to maintain the public interests (4).
Professional self-regulation would be granted to a profession as a privilege when the public would be able to receive the best possible services after that professions’ self-regulation (4). In fact, professional self-regulatory would guarantee the quality of services (2,5,6). During the past two decades, World Health Organization (WHO), to educate and employ competent and skilled nursing workforce, has recommended the governments to strengthen their professional self-regulatory frameworks. International Council of Nurses (ICN) in cooperation with the WHO has published a statement of their perspective of professional self-regulatory. This statement has mentioned that safe and high quality care, creating a monitoring system for licensing, professional policy making and applying the professional laws and rules could be reached by creating and improving the infrastructures of professional self-regulatory systems. ICN stated that professional self-regulatory is a method for applying discipline, stability and control over the profession and its performance (7, 8). National and international studies have shown that would improve educational and clinical standards which in turn would increase the power of the profession in managing its own matters.
Since professional self-regulatory would lead to the activity of qualified and competent individuals in a profession, it would increase people’s trust in professional services providers as capable and honest individuals and would provide the public interests (1). In professional self-regulatory, by firing professionally unqualified and uncommitted to the ethical codes individuals from the profession, the interests of the profession would be provided (4).
In the main, there are two ways a profession can be regulated: by the profession itself (professional self-regulatory) or directly by government. If the government would take the responsibility of managing the profession, the members of the profession would be forced to accept the laws and rules of the profession; while the approved laws by the self-regulated profession are flexible and would be accepted voluntarily (9).
Self-regulatory professions have two separate bodies for their activities: 1- the monitoring body and 2- the supporting body. The monitoring body maintains the interests of the profession through creating the inclusion criteria for the profession, licensing, certifying and disciplinary actions; while the supporting body would perform toward promoting the economic and professional benefits of the profession’s members. The goal of the supporting body is to develop the profession to assist the members and advance the profession; but the monitoring body will develop the profession to support the public interests. Most of the times, the public interests are not in conflict with the profession’s interest, but in case of such conflicts, professional self-regulatory should act toward achieving the public interest (10).
The condition of professional self-regulatory in Iranian nursing
Iranian nursing has had significant advancements during the recent years which development of academic education, formation of Iranian Nursing Organization (INO), establishment of Scientific Association of Iranian Nursing, establishment of research centers and publishing numerous research-scientific journals in different fields of nursing are some of them (11). However, the profession of nursing in Iran still has many shortcomings. Evaluating the laws of the Nursing Organization of the Islamic Republic of Iran, which is the greatest non-governmental nursing organization in Iran, although the goals of the organization are in line with the self-regulatory goals of the profession, but in most of the self-regulation requirements, no independent role has been defined for the organization, in a way that, in the definition of 6 duties out of 8 defined duties for the INO cooperation with or helping other organizations has been used and only in the third duty, “trying for improvement of the quality, skills and knowledge of nursing graduates” and the seventh duty, “determining standards for issuing, extending or cancelling membership cards”, the legislator has appointed an independent role for the organization. Maybe for this reason, and many other reasons that are not in the scope of this article, the INO has not considered professional self-regulation performances sufficiently. Other nursing associations in Iran, due to lack of regulatory mechanism and also the low number of members from the nursing profession, could not have an effective role in professional self-regulatory. In Iran, regulating the rules and managing the matters of nursing have always been a responsibility of the government (6,12). On the other hand, during the recent years, we have witnessed the establishment of the nursing deputy in the Ministry of Health and Medical Education (MOHME) which indicates the efforts for governmental management of this profession.
The authorities’ approach toward the nursing profession during the recent years for encountering various challenges is one of the examples of governmental management and lack of professional self-regulatory. For example, the nursing shortage could be mentioned which is a global problem. To resolve this problem, the MOHME has increased the capacity of training nursing students and the number of nursing schools. These measures have led to educating students at schools with no infrastructures and no competent educational board which is in conflict with the quality of services (public interests). In return, the next measure to compensate for the shortage in nursing workforce is educating practical nurses by the MOHME. Most of the experts have suggested this solution for the problem of shortage in nursing workforce, but it has been perceived as compulsory by the members of the profession and they disagree with it (13).
Considering that finding an appropriate self-regulatory mechanism for the profession requires the involvement of all the beneficiaries, especially the members of the profession, it is recommended that all of the active organizations in the field of nursing would start determining the characteristics and features of an appropriate self-regulatory organization for the nursing profession of Iran through conversations and then would make their best efforts for its establishment.
 

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Statistics show that brain death constitutes 1-4% of hospital deaths and 10% of the deaths occurred at the intensive care units (1). In the United States, brain death accounts for less than 1% of all deaths (about 15000 to 20000) (2). According to Iranian statistics, more than 15000 brain deaths occur every year in Iran, and driving accidents are one of its main causes (3-6). Then, these patients are taken to the ICUs to be cared for by nurses (7).

Considering the great number of brain deaths in Iran, and also the great number of patients needing transplant who die due to lack of obtaining an appropriate transplant organ, the Ministry of Health has notified to the universities of medical sciences the regulation number 54/100 dated 23.01.1394. In the 4^th clause of this regulation, accurate and specialized medical care in accordance with the instructions, preserving the vital organs of brain death patient (maintaining electrolytes, kidneys, liver, heart, lungs, and stabilizing vital signs) are emphasized which shows the necessity and importance of accurate training for all staffs specially nurses involved in caring for the brain death patients.

Given the high rate of brain death, most patients that ICU nurses face are the brain death patients (8). The caring process of brain death patients has different challenging and undiscovered dimensions due to its difficult and complicated nature which has attracted attention of researchers from all over the world to study its different dimensions. Some of the most important challenges which ICU nurses referred to in the caring process of brain death patients in studies are as follows: understanding the concept of brain death by the ICU nurses is one of the most challenging dimensions of this process (9). Although the meaning of brain death and caring for these patients is one of the vital components of nursing practice at the ICUs (10), understanding the concept of brain death is very difficult for most nurses and challenges all their previous beliefs about death and dying (11) because the concepts and implications for understanding brain death are beyond the understanding of the normal death of a person. This phrase is translated as actual death which means there is no hope for improvement, while the physical appearance of brain death patients, the presence of family members and nurses’ caring activities at the bedside of patients give the impression that they are alive, and all of these contribute to this ambiguity. But this conflict is naturally emotional and experimental for nurses (12). Ronayne in their study found that despite the knowledge about the physiology of brain death, its experience is stressful for nurses even long after facing these patients (8).

One of the other challenges is the announcement of brain death to the patient’s family. Although this is one of the physician’s responsibilities, nurses are also involved in because of their constant presence at the hospital and easy access of patients’ family members to them. This announcement is very stressful and challenging for nurses and is one of the most important parts of caring process (13) because nursing care is not only limited to the patient but also includes facing the specific needs of patient’s family members who are in crisis and experiencing an acute, complex and stressful clinical situation (14). Other nurses’ challenges in the caring process of brain death patients are ethical and legal aspects especially in the field of brain death and organ donation (4). Studies in Iran show that only half of physicians and medical staffs have sufficient awareness about organ donation and its laws, but they do not attempt to encourage organ donation for the fear of increasing mental pressure on patient’s family members (4). However, training is considered an effective factor in facilitating organ donation process (15).

Caring for a brain death patient and possible potential members to donate is another nurses’ challenge in caring process. Caring for a brain dead patient has been always a big challenge for the ICU nurses (14). According to different studies, most nurses believe that they are not ready enough to care for a patient who is a candidate for organ donation (16). So, one of the most difficult responsibilities of ICU nurses is caring for a brain dead patient who is a candidate for organ donation after her/his family’s consent (12). Studies showed that nurses feel hopelessness, inadequacy and depression after caring for a brain dead patient. These feelings may interfere in the quality of patient care and lead the nurse to be burnout (17). Ronayne found that because of the stress of caring for the brain dead patients, some nurses experience cognitive dissonance (8). One of the most important and controversial aspects of caring process is to give the request form of organ donation to the patient’s family. Given that caring process at the ICU involves both the patient and her/his whole family (18), the attitude of staffs especially nurses towards organ donation is very important since their positive attitude leads them to try more to prepare families for organ donation consent (13).

Some research has shown that providing opportunities for training nurses in this area, promotes organ donation and transplant rates since potential donors are timely identified and introduced to the organ bank (19). Nurses found that they need training and support on all aspects of caring for a brain death patient, organ donation and supporting her/his family (15). So, accurate and comprehensive understanding of the caring process of brain death patients especially from the nurses’ perspectives is very important for high quality and comprehensive caring. Due to the shortage of organ donation and the importance of organ health for transplantation, accurate and high quality caring for patient is necessary to make sure that organs remain healthy. Therefore, it is necessary to consider the caring process of the brain dead patient in order to develop an appropriate caring program for these patients.

Thus, considering that nurses are responsible for one of the most stressful caring processes including both caring for a brain dead patient and facing her/his family members (who may not be able to accept their patient’s brain death), and given the necessity of increasing the organ donation rate, and as well as the lack of targeted education on caring for the brain dead patients and insufficient nurses’ knowledge in this area, there is a need for accurate training on this caring process more than before.

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Nurses are a major part of the health system workforce. Also, this group of healthcare workers has an important role in providing direct care to the patients. Therefore, nurses are considered an important pillar in any health system (1). However, during recent years, the shortage of nursing staff and high rate of job leaving have become a serious concern in many countries (2). To properly and timely deal with this challenge, it is necessary to have accurate information about all its relative factors such as number, age status, years of service, employment of nursing graduates, the number of active beds, their geographical distribution and the prediction of the number of nursing graduates in the next years.
While some studies have recently emphasized the issue that Iran, similar to many other countries, is facing nursing staff shortage (3), no clear picture is available of the current and future needs for nursing workforce due to the poor infrastructures of health information system in our country. Nejatian has stated that “there is still no accurate statistics on the shortage of nursing staff and the required nursing workforce” (4). However, some health ministry officials have suggested that there is a shortage of 200 thousand nursing staff (5).
Currently, if we accept that the country is facing the challenge of nursing shortage, it will be necessary to comprehensively consider all the factors related to supply and demand. One of the efforts made in recent years was to increase the capacity of nursing schools and establish new nursing schools for training a higher number of nurses. But some believe that a number of graduated nurses are not interested in working in the nursing field (6). For example, according to a governmental report, in 2013, about 1.6 million licensed nurses in the United States did not work in nursing (7). Therefore, further workforce training will not necessarily resolve the shortage of staff and it is necessary to consider other important factors influencing the recruitment and retention of nursing workforce. Among these factors, job satisfaction has a great role in the nurses’ intention to leave their profession (8) or decrease their working hours (9). Occupational burnout, social support (10) and the salaries and bonuses system (11) are other important factors that should be considered for resolving the problem of nursing shortage.
Considering the current situation, if the current shortage is caused by the lack of interest in working in nursing field or leaving nursing career, as Florence Nightingale proved that caring for the injured soldiers is less costly for the British army than letting them die and recruiting new soldiers (12), increasing the capacity for training nurses is not a cost-effective approach for resolving the problem of nursing shortage.
Despite what was mentioned above, the policy makers’ main strategy is still to increase the number of graduated nurses. In this regard, there are various experiences about developing and implementing nursing education programs in the world that could be an appropriate choice for resolving the problem of nursing staff shortage. One of these programs is “Accelerated Nursing Program” which has been developed for the graduates of non-nursing bachelor’s degree to be trained as a nurse. The first Accelerated Nursing Programs was developed in the early 1970s which gradually grew over the next years (13). These accelerated programs are based on the previous experiences of the students and provide an opportunity for individuals with a bachelor’s degree in other disciplines to enter the field of nursing (14). Accelerated nursing programs would provide the fastest way for issuing a nursing license to non-nursing graduates and last from 12 to 18 months (15). These programs are intense with courses offered full-time and there is no break between the courses; the students would pass the same hours of clinical internship as their counterparts in traditional nursing programs. Nursing staff value to the graduates of accelerated nursing programs because they would bring a great amount of skill and education to the workplace; they claim that these graduates are more mature and have stronger clinical skills and also are quick in learning the necessities of the job (14). Results of the study by Ouellet showed that accelerated programs would train qualified nurses who could be successfully prepared for clinical activities (16). Results of a retrospective study by Raines revealed that most graduates of accelerated nursing programs were working in nursing field and a great percentage of them were either studying or a higher degree graduates in nursing (15). Studies on the evaluation of accelerated nursing programs revealed positive results and outcomes in implementing these programs (17, 18).
Iran has high rates of unemployment among university graduates in many fields (19). Considering this important issue and our country’s priority in creating employment for them, it seems that applying the accelerated nursing programs rather than untested programs such as nurse training plan using the capacity of hospital, which has no clear structure, process and results, can be appropriate for the current situation in the country. Therefore, in order to find an answer to this challenge, it is recommended that nursing shortage area should be determined and these programs be launched in those areas. In such a framework, the required nursing staff can be provided in a shorter duration of time and with less cost.
 

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World’s health systems have entered a critical period of human resource shortage. The shortage of qualified nurses has been suggested as one of the most important barriers to achieve effective healthcare systems (1). According to the WHO (2014), there is currently a shortage of 7.2 million health care providers at the international level. This shortage is estimated to reach 12.9 million by 2035 (2). In other words, in order to develop healthcare systems, achieve positive outcomes and ensure patient’s safety, recruiting well-qualified nurses is a global concern (3). Nursing shortage in Iran has also become a concern for managers and a major challenge to the healthcare system. The nursing deputy of the Iran Ministry of Health and Medical Education reported that the number of nurses working in health care settings is estimated to be 140,000, but there is a need for 2,60,000 nurses to deliver ideal levels of health care (4). While, qualified nurses adequacy is one of the essential components of the nursing professional practice environment (5). Poor nursing work environment, inadequate resources, imbalanced workload, disproportionate nurse-patient ratio, high bureaucracy (5), lack of supportive management, low salaries, and reduction in employment are major challenges that have caused Iran’s healthcare system to face a serious crisis of nursing shortage despite a large number of young nursing graduates (6). Evidence suggests that the nursing practice environment has a significant role in the retention of expert nurses, the quality of care and, safety of patients (7). Poor nursing work environments are related to adverse patient outcomes, including an increase in mortality rate, patient falls, and medication errors (8, 9). In addition, unhealthy workplaces are important causes of turnover, efficient nurses’ intention to leave, early retirement, job dissatisfaction and burnout (10, 11). Therefore, efforts to create environments that attract and retain nurses are worthwhile. Different strategies have been proposed to improve the nurses’ work environment. In this regard, making workplace attractive is a basis for increasing the quality of nursing practice environment (12).
Today, there are hospitals called "Magnet Hospital" that are renowned for attracting and retaining expert nurses. The Magnet hospital was first used in the United States. In the early 1980s, concurrent with nursing shortage crisis in the United States, extensive studies were begun to examine the organizational structures of Magnet hospitals. In a study, the American Academy of Nursing (AAN) identified 41 hospitals that were known to attract and retain qualified nurses, and used the term "Magnet" as a gold standard for nursing practice in these hospitals (13). Magnet hospitals are evaluated in terms of achieving goals in five areas including transformational leadership, structural empowerment, new knowledge, innovation, and empirical outcomes and development (14). Magnet hospitals with a more different organizational structure than non-Magnet ones play an important role in nurses’ job satisfaction and retention (15). One of the main reasons for the attractiveness of these hospitals is the existence of work environments focusing on decentralized decision-making, autonomy, control over practice, resource adequacy, supportive management, effective inter-professional communication, and career development (16). In other words, the organizational attributes of Magnet hospitals lead to the nurses’ empowerment by increasing autonomy and authority, and subsequently improving job satisfaction. These hospitals have designed a set of work environment standards to support professional nursing practice (17). Many studies have shown that Magnet hospitals provide a healthier environment with higher job satisfaction for nurses and better outcomes for patients, compared to non-Magnet ones (18, 19). In recent years, the development of Magnet hospitals has rapidly grown in various countries. Considering the complexity of nursing shortage phenomenon, paying attention to the factors influencing the nurses’ attraction, retention and productivity is important to overcome the challenge of nursing shortage (20).
Conclusion
The nurses’ dissatisfaction with the work environment and consequently, the shortage of competent and educated nurses, is a major challenge to Iran’s health system. Therefore, solving this crisis is vital to prevent adverse health consequences. In this regard, nursing managers and health policy-makers can create a quality work environment using the features of Magnet hospitals to increase the attraction and retention of health care professionals, especially nurses. This will not only result in the nurses’ job satisfaction but will also increase the quality of care and ensure the patients’ safety.
 

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Health (hygienic) literacy is a cognitive skill and an important and effective issue in the healthcare system that was first proposed in 1974 in an educational panel about health education. Since then, this concept has been discussed by the researchers in various fields of literacy and health, and many definitions have been presented for it. Usually, health literacy is defined as a wide range of knowledge and skills in accessing, appraising, understanding and applying health information (1).
The importance of health literacy impact on the health outcomes of the patients has been well recognized and it has an important role in individual’s decision-making regarding their health needs (2). Health literacy as a social and cognitive skill has various aspects including accessing, appraising, understanding and applying. The ability to understand the educational content, as one of its aspects, has a significant importance in the patients (3-6). In recent years, health literacy has been recognized as an important skill that patients require for making an appropriate health decisions in difficult situations they encounter. Improving patients’ health literacy would cause outcomes such as increasing the patients’ potential to make informed decisions, decreasing health-threatening risks, increasing prevention of the diseases, improving patient safety, and improving quality of life and patient care (7-9).
To educate people, usually their general literacy would be considered, not their health literacy; while there is a significant difference between general literacy and health literacy. General literacy means having the ability to read and write and having basic skills. In contrast, health literacy is defined as a cognitive and social skill determining the individuals’ ability to access, understand, and apply information in order to promote health (10). Studies have shown that limited health literacy is associated with various complications in different aspects of health including lack of access to appropriate health services, less willingness to follow up treatments, less compliance with medication, increased number of visits to the emergency ward, increased duration of hospitalization, and increased mortality rate, and it has a significant effect on using healthcare services (3-6).
Furthermore, the negative economic effect of low health literacy on the patients and healthcare system could not be ignored. These issues would indicate the need for paying more attention to individuals’ health literacy.
According to a study conducted by Montazeri et al in Iran, it has been revealed that half of the Iranian population has a limited health literacy and this limitation is more common in the vulnerable groups such as the elderly, housewives, unemployed people and those with lower education levels; this would put them at more health risks (2). Also, results of various studies have shown that some health information is not appropriate for the audience and would not address their needs; whereas the effect of limited health literacy could be improved using appropriate health information. So, the challenging issue regarding these individuals is how to train them (regarding understanding health information); there are various strategies for resolving this issue such as limiting the information provided at each patient’s visit, avoiding technical terms, speaking slowly, finding educational content tailored to individuals’ ability to read, using pictures for explaining important concepts, encouraging people for asking more questions and assessing individuals’ understanding of the education provided using teach back and show me methods (11).
In this regard, in 2011, Centers for Disease Control and Prevention (CDC) designed the Health Literacy Index as a tool for providing appropriate educational content based on people’s health literacy. This comprehensive checklist comprises 63 items organized into 10 criteria; its criteria and items are shown in table 1. According to this checklist and based on its ten criteria, the educational process (content, procedure and evidence) would completely be evaluated to limit the effect of health literacy on the understanding of information provided to individuals (12).
 
Table 1. The criteria of the health literacy index

Criterion	Items	Evaluated subject
Plain language	8	Writing style (short and easily readable sentences) Terms (avoiding technical terms) numbers and data (ease in understanding the content)
Clear purpose	8	Precision, summaries and reviews Number of key points purpose of material (purposiveness) Using visual elements in the educational content
Supporting Graphic	6	Explanatory labels Graphic and images of the educational content in relation with the text to help the understanding of the abstract concepts
User involvement	7	Interactive strategies (the level of attention received by the audience and the extent of their active participation through the column of counseling, answer and question, games or competitions and storytelling narrations) Audience response
Skill-based learning	3	Focus on behavioral skills (modifying a health behavior and providing examples related to this modification)
Audience appropriateness	6	Match between audience and material (cultural and social appropriateness to the audience in terms of their experiences, values and beliefs) Audience identified
Instructions	6	User instructions Instructions for using the educational content regarding its technicality, applicability and comprehensiveness
Development details	3	Authors’ contact information Recent review of the studies
Evaluation methods	13	Process, formative and outcome evaluations
Strength of evidence	3	Evaluation findings

 
Andrade and colleagues studied the impact of using this index in providing educational materials for falling in the elderly. The results of this study showed that all the educational information is not suitable for audience and does not meet their needs. However, with the help of Health Literacy Index, it is possible to provide educational materials that are fit for the level of health literacy of elderly (7).
Due to the Low health literacy is very common particularly in the elders, it is crucial to provide educational materials that are consistent with the level of health literacy in target groups. Regarding the small number of studies have been conducted on the impacts of using health literacy index, It is imperative that the researchers in the related fields provide empirical evidence for its efficiency and effectiveness.
 
 
 

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The World Health Organization (WHO) has introduced palliative care as a way to improve the quality of life of patients with incurable diseases and their families. This care begins with the diagnosis of the disease, and continues throughout the illness (1). Palliative care improves the quality of life of patients with life-threatening diseases and their families. Its purpose is to relieve suffering through the identification, evaluation, and relief of pain and other physical, psychosocial and spiritual problems (2).
Palliative care is required for many diseases. According to reports, every year about 40 million people in the world need palliative care, but only 14% of them receive it, of whom 78% live in low-income or middle-income countries. According to the World Health Organization, patients who require palliative care services, suffer from cardiovascular diseases (38.5%), cancer (34%), chronic pulmonary diseases (10.3%), AIDS (5.7%), and diabetes (4.6%). Other patients with diseases, such as dementia, kidney failure, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological diseases, congenital anomalies, and resistant tuberculosis may also need palliative care services (1). Palliative care can be offered to patients through various models, including hospital-based palliative care, hospice-based palliative care and home-based palliative care (3). Studies have shown that home-based palliative care has a very beneficial effect on the physical, mental, psychological, social and economic dimensions of patient’s life, and reduces the cost of health system, shortens the length of hospitalization, reduces hospital complications and prevents hospital readmission (4-6). This type of care also facilitates the continuity of post-discharge care and helps patient to easily benefit from the facilities of different centers (7). On the other hand, most people prefer to receive care at their homes with their families (8). Studies have shown that home-based palliative care is clinically and economically effective and leads to the satisfaction of patients and their families. Also, the World Health Organization in 2014 has introduced home-based palliative care as one of the main elements of the health systems all around the world (1). However, reports indicate that many countries in the world do not have palliative care programs in their health care system (7), and the lack of government support for palliative care services, lack of prepared professional staff to provide palliative services, limitation in access to narcotic analgesics, resource constraints, lack of policy-makers’ familiarity with palliative medicine, the negative attitude of society towards palliative care and socio-cultural issues have been mentioned as barriers to palliative care in the world (1, 9,10).
Iran’s health system is faced with increasing number of chronic patients and shortages of manpower and ICU beds in health centers. Most patients with life-threatening diseases in Iran are frequently admitted to hospital during the last days of their lives. Despite the shortage of hospital beds, especially in the critical care units, these patients occupy these beds and receive specialized medications until the end of their lives and eventually many of these patients die on ICU beds in hospital (11). While in many cases, hospitalization of incurable patients in critical care units does not have any positive effects on patients’ recovery, and is considered a futile care (12), which increases the costs of health system, poses financial burden on patient’s family, and leads to dissatisfaction and work burnout in healthcare staff (13). On the other hand, many of these patients prefer to spend the last days of their lives at home with their family and be in close contact with their relatives. Evidence suggests that palliative care in Iran is only offered in isolated and limited centers. Most patients are deprived of this kind of care, and home-based palliative care does not have any place in Iran’s health system (14). Patients with incurable conditions who require palliative care services are lost in the system, and in most cases do not receive proper and timely services they need (15). Also, the traditional attitude of healthcare staff towards the management of incurable conditions, the lack of transparency in the protection of healthcare staff against discontinuation of unnecessary treatments or unreasonable expectations of patients and their families, as well as social and cultural differences are barriers to the promotion of palliative care in Iranian society. Another problem in providing home-based palliative care services is the defect in the payment process and insurance coverage of end-of-life patients (16,17). Therefore, given the high prevalence of chronic and incurable illnesses, the increasing number of elderly population, limited critical care beds, shortages of human resources, limited financial resources and equipment in health centers, and taking into account the benefits of home-based palliative care, healthcare system authorities should consider this care method to be one of the important priorities of the health system so that patients can maintain their quality of life and also experience peace during the last days of their lives. Considering the limited research in this field, further research is required on the management of various dimensions of home-based palliative care in order to provide suitable models for the provision of home-based palliative care services in Iran.