---

Background & Objective: Poor physical and psychological health status in chemical warfare victims could result in decreasing quality of sleep. This study was conducted in order to evaluate the effect of using Continuous Care Model on sleep quality in chemical warfare victims with bronchiolitis obliterans.

Methods & Materials: A total of 62 chemical warfare victims with bronchiolitis obliterans were recruited to the study. The participants were randomly allocated to experimental and control groups. The Continuous Care Model was used to experimental group for a period of two months. The quality of sleep was measured using Pittsburgh Sleep Quality Index (PSQI) before and after the intervention in both study groups. Data were analyzed using independent sample t-test, and paired t-test in the SPSS-version 15.

Results: There were significant differences between experimental and control groups in the means of Subjective Sleep Quality, Sleep Disturbances, Use of Medications, and global scores after the intervention (P<0.05).

Conclusion: Using Continuous Care Model had positive effect on sleep quality in chemical warfare victims suffering from bronchiolitis obliterans.

---

Background & Aim: Motivated faculty promotes nursing students&apos educational level which leads to community health promotion. Attempts should be made to recognize and analyze motivating factors including expectations. This qualitative study attempted to clarify expectations of faculty of Tehran nursing schools on management system.

Methods & Materials: This was a qualitative study. The participants were 14 nursing faculty members of Tehran, Shahid Beheshti, Artesh, Shahed, and Baghiatallah Universities located in Tehran. Purposive sampling was used to recruit the participants. Data were collected using semi-structured interviews with the participants. Qualitative content analysis was used to analyze the data.

Results: Expectations of nursing faculty were explained in eight categories: empowerment of the faculty, organizational support, fairness, appropriate performance evaluation, providing appropriate working conditions, applying appropriate management strategies, attention to welfare and financial problems and promoting quality of education and research.

Conclusion: Understanding the expectations of the nursing faculty and trying to meet them can improve performance of the faculty. Meeting these expectations can enhance motivation and job satisfaction among the faculty.

---

  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.

---

Background & Aim: Increasing understanding of death anxiety among different cultures and patient populations is critical to provide quality patient care. Researchers who investigate death anxiety, are looking for a reliable and valid instrument compatible with culture in order to achieve this goal. The aim of the study was to evaluate the psychometric properties of the Templer’s Death Anxiety Scale-Extended (TDAS-E) among a sample of chemical veterans of Iran–Iraq warfare.

Methods & Materials: In this methodological study, 300 veterans completed the Persian version of the 51-item TDAS-E in 2015. The face, content and construct validity (convergent and discriminant validity) of the TDAS-E were assessed. Also, its reliability was measured using Cronbach’s alpha coefficient, construct reliability and intra correlation coefficient.

Results: Results of exploratory and confirmatory factor analyses extracted four stable distinct factors including fear of the hereafter, fear of facing death, fear of the shortness of life, fear of dying following an incident and mishap. The fitness of the four-factor model of the Templer’s death anxiety construct was approved based on standard indices (c²/df=2.832, GFI=.915, AGFI=.873, PCFI=.657, PNFI=.612, RMSEA=.078). Discriminant and convergent validity of all factors were acceptable. Also, scale reliability was confirmed using Cronbach’s alpha coefficient (0.88), construct reliability (higher than 0.70) and intra correlation coefficient (0.87).

Conclusion: The results of the current study revealed that the four-factor construct of TDAS-E had suitable validity and reliability among Iranian chemical warfare veterans. Given the proper psychometric properties, this scale can be used in future research to evaluate death anxiety in this population.

Background & Aim: Increasing understanding of death anxiety among different cultures and illness populations is critical to provide quality patient care. Researchers who investigate death anxiety, are looking for a reliable and valid instrument compatible with culture in order to achieve this goal. The aim of the study was to evaluate the psychometric properties of the Templer’s Death Anxiety Scale-Extended (TDAS-E) among a sample of chemical veterans of Iran–Iraq warfare.

Methods & Materials: In this methodological study, 300 veterans completed the Persian version of the 51-item TDAS-E in 2015. The face, content and construct validity (convergent and discriminant validity) of the TDAS-E were assessed. Also, its reliability was measured using Cronbach’s alpha coefficient, construct reliability and intra correlation coefficient.

Results: Results of exploratory and confirmatory factor analyses extracted four stable distinct factors including fear of the hereafter, fear of facing death, fear of the shortness of life, fear of dying following an incident and mishap. The fitness of the four-factor model of the Templer’s death anxiety construct was approved based on standard indices (c²/df=2.832, GFI=.915, AGFI=.873, PCFI=.657, PNFI=.612, RMSEA=.078). Discriminant and convergent validity of all factors were acceptable. Also, scale reliability was confirmed using Cronbach’s alpha coefficient (0.88), construct reliability (higher than 0.70) and intra correlation coefficient (0.87).

Conclusion: The results of the current study revealed that the four-factor construct of TDAS-E had suitable validity and reliability among Iranian chemical warfare veterans. Given the proper psychometric properties, this scale can be used in future research to evaluate death anxiety in this population.

---

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.
 

---

Economic evaluation is an invaluable and important tool in healthcare decision- and policy-making. The volume-based paradigm has been a prominent tool to evaluate healthcare economy for consecutive decades. In this approach, the main focus is on volume of treated patients alongside to reduce healthcare costs. Despite this view and during recent years, there was a dramatic rising in healthcare costs without attaining excellence in quality and health outcomes. This status is escalating to the point at which governmental budgets, service providers, and patients are unwilling or unable to afford its related costs (1). There is a similar situation in high-income countries that spend several times more money on health than middle-income and low-income countries (2).
The experts believed that one of the most important and underlying causes of this situation is ineffective healthcare service models that resulted in fragmentation, lack of coordination, reduced quality of care, and finally increased health costs (3). It is assumed that the health service delivery models can seriously affect health costs. Accordingly, health economics does not only refer to health costs but also it includes quality improvement, access to, and equity of health services (4).
For the first time in 2006, “value-based care” was developed to evaluate healthcare economy (5). This paradigm which is also considered a kind of healthcare delivery model, is based on patient outcomes payment as an alternative for the fee-for-service model of payment. Based on this approach, healthcare providers such as physicians and nurses will be rewarded when their services improve the health of patients, reduce the complications, and help to make a healthier life for patients (6); while the population transition to old age and an increase in noncommunicable diseases which require behavioural approches for modifying risk factors in addition to acute care only, are also fueling the mandate for change. Therefore, 30% of healthcare payments in the US by the end of 2016 and 50% of payments by the end of 2018 were tied to the value-based care approach. Based on that, new institutions such as Accountability Care Organizations (ACOs), Advanced Primary Care and Integrated Care models were launched (7). The focus of these institutions is on effective care pathways which, along with the reduction in health care costs, lead to prevention and primary care (7). The principals of new payment model are greater teamwork and integration, more effective coordination of health providers across settings, greater attention to population-based healthcare, and providing information system to improve care for patients (7).
A report in 2011 entitled “The future of nursing: leading change, advancing health” asserted that despite the financial concerns, nursing service can on the one hand address the increasing demand for safer and high-quality healthcare and on the other hand, create equitable and affordable access to health services for societies (8).
The report believed that nursing practice covers a broad continium from health promotion, to disease prevention, to coordination of care, to cure-when possible-and to palliative care-when cure is not possible. Therefore, nurses have a direct and indirect effect on patient care. They can provide assessments and care in hospitals, nursing homes, clinics, schools, ambulatory settings, and workplaces and accordingly they can contribute to the provision of accessible, equitable, and high quality care in healthcare system.
From value-based model perspective, quality, access, and value are key indicators that are specific and sensitive to health service effects on health economics (1). Evidence reveals that nursing services can suprisingly affect these three indicators. However, there are few studies showing that the development of nursing services results in lower costs, along with increased service quality. Of course the evidence in favor of such a conclusion is growing. The current evidence on these indicators are as follows:
Nursing and health service quality
Although causation is difficult to prove, an emerging body of literature has revealed that the quality of care depends, in a large degree, on nurses.  The association between nursing care and quality of hospital care such as patient outcomes, including lenghts of stay, mortality, pressure ulcer, deep vein thrombosis, and hospital-acquired infections has been published in several studies (9-11). Studies have shown the role of nurses in improving the quality and efficacy of hospital (12,13). However, the extent to which nursing care has an impact on health and life or death issues is still ambiguous (8) Also, the patient-centered nursing care has recently been disscussed as a cause of patient satisfaction which is an indicator of the delivered service quality in all over the world (14,15).
Nursing and access to health services
Evidence suggests that access to quality care can greatly be expanded by developing the use of nurses in primary, chronic, and transitional care from hospital to home. For example, If nurses are involved in special roles such as care coordinators or primary healthcare providers, that increase the level of access to services, the hospitalization and rehospitalization rates of patients will be reduced. A 52% reduction in emergency department (ED) visits with a cost per admission of at least $800 has been mentioned as a result of nursing postoperative visits and telephone follow-ups (16). In the coordination of transitional care from hospital, nursing visits during a three-month transition period in patients with heart failure showed the average savings of $4,845 per patient with a significant increase in survival and fewer readmissions (17). Also, performed activities such as self medication management and referral care coordination by nurses in community-based or ambulatory care settings can save $686 per patient in a 12-month period (18).
Nursing and value of health services
The value in healthcare is expressed as the physical health and sense of well-being achieved relative to the cost. There is little evidence at the macro level indicating that the development of nursing services results in cost savings to society while promoting outcomes and ensuring quality (19).  For example, managing nursing work hours is dramatically associated with 1.5 million fewer hospital days, nearly 60,000 fewer inpatient complications, and 0.5 percent reduction in costs (20). 
Overall, it seems that we need to conduct precise studies at macro-level to assess the net economic effects resulting from nursing care delivery models in order to seriously integrate them into health policy. Also, undrestanding the impact of nursing care on the health system requires the data to enable nurses have more effects on healthcare transformation.   
 

---

Background & Aim: Self-control is the capacity to organize cognitive and emotional responses in order to provide continuous and adaptive behavior with ideal standards for long-term goals. Due to the high levels of care burden of patients with chronic disease, this study aims to explain the concept of self-control in the family caregivers of patients with chronic disease based on the family-centered empowerment model.
Methods & Materials: Data were collected through in-depth, semi-structured interviews with 26 participants (19 caregivers, four nurses and three patients with chronic disease) from June 2016 to August 2017 in southwestern of Iran. Data were analyzed using the directed content analysis approach. The documents recording, accurate description of details, member checking, peer checking, and maximum variation of participants, were considered for ensuring the trustworthiness of the data.
Results: “Transcendental self-control” of family caregiver was explained by four conceptual categories: “caregiver insight", "value prioritization in care", "acceptance of care responsibilities" and "committed care". By predicting the potential risks of playing the care role and deeply understanding the conditions of care while paying attention to the value prioritization outcome-centered and virtue-based care, the family caregiver accepts the care burden through positive thinking and expediency and modestly offers "committed care" while having competent care experiences.
Conclusion: The explanation of self-control concept based on family-centered empowerment model in the real field creates a clear understanding of this concept and leads to "commitment care" by family caregivers of patients with chronic diseases and in turn provides a basis for reducing workload in the clinical setting.
 

---

Background & Aim: Pre-hospital emergency staff, as the first responder group at the scene of emergencies and disasters, should be able to cope with, and maintain their physical and mental health. The aim of this study was to investigate the relationship between resilience and self-efficacy of pre-hospital emergency staff with their professional quality of life.
Methods & Materials: The present study is a cross-sectional, descriptive study that was conducted in 2019. A total of 200 pre-hospital emergency operational staff from Alborz province participated in the study using proportional and convenience sampling. Data collection tools were a demographic form and three standardized questionnaires including the emergency medical services resilience scale, the Schwartz and Jerusalem self-efficacy scale, and the Stamm professional quality of life scale. Data were analyzed through the SPSS software version 20 using descriptive statistics (mean and standard deviation) and analytical statistics (Spearman correlation, one-way ANOVA and linear regression) at the significance level of P less than 0.05.
Results: The mean and standard deviation of self-efficacy (29.67±5.82), resilience (123.14±17.07), compassion satisfaction (39.81±8.09), burnout (12.06±4.76), and secondary traumatic stress (23.61±7.27). There was a significant correlation between self-efficacy and three components of professional quality of life (P<0.05). Self-efficacy was positively related to compassion satisfaction and negatively related to burnout and secondary traumatic stress. Self-efficacy and resilience were also predictors of compassion satisfaction and burnout (P<0.05). The effect of self-efficacy and resilience on compassion satisfaction was positive. The results of stepwise multiple linear regression analysis showed that five components of resilience including self-management, stress outcomes, communication challenges, maintaining peace of mind and job motivation had an effect on compassion satisfaction (P<0.05). The effect of all resilience components on compassion satisfaction was positive.
Conclusion: Alborz pre-hospital emergency operational staff were at an acceptable level in terms of resilience, self-efficacy and professional quality of life.