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One of man's fundamental needs is communication. Nurses within their specialty sense this need in their relationship with their patients, even though in some cases with physical impediments e.g. the placing of bypass tubes, this relationship is endangered. This study is a quasi experimental research, whose main aim is to compare the effects of two types of communication methods on anxiety and satisfaction in patients after cardiac and bypass surgery having intubation, warded at chosen hospitals affiliated to the Tehran University of Medical Sciences. According to the specific criteria, 90 patients were randomly selected by divided into two groups (experimental and control). The researchers met all patients the day before the surgery explained the reason and use of the picture chart for the experimental group and the routine communication methods for the control group. Therefore on the day of surgery communication was established with both groups with their own particular method. Data collection was done through a questionnaire consisting of: 1) demographic specification and clinical history, 2) Spielburger's questionnaire for obvious anxiety and 3) visual analogue scale (10cm) for patient satisfaction evaluation which is undertaken the day after surgery and after extubation. The results of the χ² test and the Fisher's exact test showed significant statistical differences between the two groups concerning the level of the patient's anxiety and satisfaction. The use of the picture chart for the experimental group, decreased patient's anxiety resulting from speech disability and increased their satisfaction with their communication with nurses as compared to the control group. Considering the beneficial results from using picture charts in establishing communication with patients, nurses with the help of devices, must try to create better relationships with intubated patients in the post-surgery period and provide them with more desirable services.

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Background & Aim: Decreasing mechanical ventilation and early extubation after cardiac surgery are the important scientific subjects that their clinical and financial benefits had been demonstrated. There are some variables that are associated with extubation time so, determination of them will help nurses to plan appropriate care aimed at doing an early and safe extubation.

Methods & Materials: The purpose of this descriptive-analytic study was to determine whether any preoperative variable had a significant effect on extubation time after CABG. The research was conducted in one of hospitals in Tehran city. In this retrospective study, data were collected by reviewing of files of eligible patients who were undergoing CABG from December 2003 to March 2005. 93 files reviewed by convenience sampling method. Collecting data tool was a checklist consists of three parts: 1) demographic characteristics 2) health and disease history 3) physiologic status. Samples divided into two groups: early and delayed extubation (>6h). Data analysis was performed by descriptive methods, chi square, fisher exact test and regression analysis.

Results: Mean and standard deviation of duration time of intubation was 7.19±3.00 with range of 3-18.25 hours in all samples. Totally 43% of subjects extubated in ≤6h and 57% of them in >6h. Age was the only preoperative variable that was found to be statistically significant to extubation time (p=0.01).

Conclusion: According to our findings age is associated with postoperative intubation time after CABG. It means older patients need to be under long mechanical ventilation. So, nurses should make a decision on extubation in older patients, carefully.

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Background & Aim: Achieving to desire patients quality of life can result to programming for make use of strategies for prevention and control chronic complications of diabetes and promote quality of life.

Methods & Materials: This research is a descriptive and cross-sectional study. The purpose of this study was to assess the quality of life among 310 diabetic patients with chronic complications. The data were collected through interview. The tool of data collection was the questionnaire that consisted of two parts, demographic and disease charactristics, and questions about dimentions of Quality of life. Score were analyzed by descriptive and infrerntial methods (Chi square, Fisher exact test, and Pearson correlation coefficient).

Results: The findings of research showed that quality of life in majority of the subjects (71%) was moderate. The most percent of the health perception (68.3%), mental health (67.7%), Physical functioning (56.1%), and social/ role functioning (54.8%) of the quality of life were moderate. Also there was no relationship between the number of complications and Quality of life. Also there was a significant relationship between demographic variables [age (p=0.028), sex (p<0.001), BMI (p=0.024), grade (p<0.001)] and Quality of life.

Conclusion: According to the results of this study, quality of life in majority of patients with chronic complications of diabetes was moderate.

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Background & Aim: Modification of unhealthy life style is a preventive method in cardiovascular diseases. It seems that education which results in enhancing knowledge would improve the life style. For developing effective educational plans, it is required to evaluate the knowledge and performance of the patients. So, this study aimed to determine the relationship between the teachers&apos preventive behaviors and their knowledge on cardiovascular risk factors.  

Methods & Materials: This cross-sectional study was conducted in five zones of Ministry of Education in Tehran. Seven hundred and three teachers participated in the study. Multi-stage sampling was used to gather data using a self-report questionnaire consisted of demographic characteristics, risk factors of CAD, and related modifiable behaviors. Data were analyzed using Pearson coefficient test to determine correlations.

Results: The results showed that the majority of participants (67%) had good knowledge on cardiovascular risk factors with the mean scores of 15.20±2.63 out of 20. Stress was found to be the most recognized risk factor (95.3%). Knowledge about diabetes (61.2%) and gender (17.6%) were in the lowest level. Regarding prevention, just 27.7% of the participants reported healthy nutrition. Some of the patients (35.6%) exercised regularly and majority of them (77.7%) were not active or passive smokers. Pearson coefficient did not find any significant relationship between knowledge level and preventive behaviors among teachers.

Conclusion: According to our findings, teachers&apos knowledge level on cardiovascular risk factors was good but it did not result in healthy practice. Therefore, providing effective educational programs about healthy life style can improve their daily life practices, as well as it can affect the knowledge and practice of their students about prevention of CAD.

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Background & Aim: Self-care activity is a key factor in managing Rheumatoid Arthritis (RA) in order to reduce disability caused by the disease. Predisposing factors including knowledge, attitude, and self-efficacy are introduced as determinants of self-care behaviors in the forth phase of PRECEDE model, i.e., ecological and educational assessment. This study aimed to assess the relationship between the predisposing factors and self-care behaviors in patients with RA in Yazd, Iran.

Methods & Materials: In this cross-sectional study, a convenience sampling was used to recruit 181 outpatients with RA referred to a rheumatology clinic in Yazd, Iran. Data were collected by conducting interviews with the participants using a survey questionnaire included knowledge, attitude, and self-efficacy, as predisposing factors and self-care behaviors items. Reliability and validity of the instruments were examined and approved. The statistical tests included bivariate correlations, Mann-Whitney U test, and linear regression.

Results: Knowledge, attitude, and self-efficacy scores were 71.7%, 66.9%, and 47.5%, respectively. The total predisposing factors score was 62.3%. There was a significant positive correlation between the self-care behaviors with attitude and self-efficacy. However, there was no significant correlation between the patients&apos knowledge and self-care behaviors. Totally, the measures explained 39.3% of total self-care behaviors variance within which the self-efficacy was the strongest predictor (β=0.41).

Conclusion: Regarding the high power of predisposing factors, especially self-efficacy, in predicting self-care behaviors and the low scores of self-efficacy, health promotion planners should pay more attention to predisposing factors of self-care behaviors especially the self-efficacy in designing health promotion programs.

 

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Background & Aim: Postoperative nausea is a common problem after general anesthesia, especially in ambulatory surgery. In ocular surgeries including strabismus surgery, intraocular pressure increase may lead to eye damage. Drug therapy has various side effects. The purpose of this study was to evaluate acupressure on nausea in patients undergoing strabismus surgery.

Methods & Materials: In this double-blinded clinical trial, 60 patients undergoing strabismus surgery were allocated into intervention and control groups. In the intervention group, a sea-band was placed on the P6 point of patients&apos wrists 30 minutes before induction of anesthesia. In the control group, the sea-band was placed in the opposite position of the patients&apos wrists. Data were collected during six hours after surgery in the recovery room. Data were analyzed using Chi square, t-test, and Mann-Whitney tests.

Results: There were no differences in demographic and surgical characteristics between the two groups at baseline. The intensity of nausea in the recovery room (P=0.002) and six hours after surgery (P<0.001) were significantly less in the intervention group than the control group.

Conclusion: Based on the findings of this study, acupressure decreases post operative nausea. Acupressure is a simple, noninvasive and cost- effective intervention which can be applied by nurses to prevent post operative nausea.

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Background & Objective: Hospitalization of patients in the intensive care unit of open heart surgery (ICUOH) is often stressful for patients&apos family carers. This study aimed to investigate the effectiveness of the informational support on anxiety among families of patients undergone open heart surgery.

Methods & Materials: In this double-group randomized clinical trial, 64 family carers of patients undergone open heart surgery were selected using convenience sampling method and were randomly allocated into two intervention or control groups. The informational support consistedof  holding the ICU orientation tours and educational sessions, and providing educational pamphlets and booklets. The members of the control group received routin information. The anxiety of the family carers was measured using the trait Spielberger anxiety questionnaire before surgery and in the day of discharge from the ICU. Independent and paired t-tests were used to analyze the data.

Results: According to the findings, there were no significant difference between the two groups regarding demographic charachteristics. At the baseline, the mean of anxiety scores were 47.9±11.5 and 49.2±11.5 in the control and intervetion groups, respectively. The anxiety scores diminished in both groups after the surgery, however, the difference was not statistically significant between the two groups (P=0.18).

Conclusion: For effective control of anxiety among family members of patients, both informational support and other supportive techniques such as psychological support and meeting other family needs should be considered.

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  Background & Aim: The ultimate goal of self-care behavior is patients' empowerment. There are limited studies on perspectives of patients with Parkinson's disease on self-care. This study aimed to explore for the process of self-care in patients with Parkinson’s disease during 2011 to 2013 .

  Methods & Materials: This exploratory qualitative study was carried out using grounded theory method. Data were collected via semi-structured in-depth interviews and field notes. We interviewed with 12 patients with Parkinson 's disease and four family caregivers . Participants were selected from two neurology clinics. Interviews were conducted at participants' homes or nursing homes. Data were analyzed using the Corbin and Strauss (2008) approach . 

  Results: Concepts of study were identified using a micro and general analysis. The 'fear of becoming crippled' was identified as a main concern. Strategies used in response to context included 'independency', 'spiritual care', 'informed self-care' and ‘seeking treatment’. 'Striving for taking independent self-care' was the most important process. Demographic, familial and social factors had important roles in self-care processes of patients with Parkinson's disease .

  Conclusion: The process of self-care in patients with Parkinson’s disease depends on the context and severity of the signs and symptoms. Health care providers especially nurses can support patients with Parkinson's disease in achieving maintain independence in self-care. In addition, attention to self-care behaviors with focus on person as self-care agent can considerably increase control and management of life .

  

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  Background & Aim: The central venous pressure measurement is a common and important care provided by nurses in intensive units. The measurement should be according to the pre-defined standards. The purpose of this study was to evaluate the effect of using a checklist in measuring central venous pressure by nurses .

  Methods & Materials: This was a nonequivalent group design on 70 nurses working in ICUs. T he quality of measurement of central venous pressure by recruited nurses were measured via direct observation in the control (n=35) and experiment (n=35) groups. The intervention group nurses were recommended to use a performance checklist in each measurement of central venous pressure for one month. At the end of the intervention, the performances of both groups were evaluated through observation. Collected data were analyzed using the Chi-squared test, paired and independent test in the SPSS-17 . 

  Results: At b aseline, the mean scores in both groups were not statistically significant (P=0.7) The mean performance score of the control group at the beginning and one month later were 7.64±2.33 and 7.65±2.28, respectively (P=0.6). In the experiment group, the mean performance score was 7.85±2.29 before the intervention and 9.28±3.16 after the intervention (P=0.001). T he difference between the scores before and after the intervention were significant (P=0.001) in the intervention group .

  Conclusion: Using checklist by critical care nurses could enhance their performances in measurement of central venous pressure. This method can be used as an accessible, inexpensive, and simple method to improve quality of nursing practices .

  

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  Background & Aim: Virtual education can be delivered via different routes. The purpose of this study was to investigate the effectiveness of interactive and non-interactive virtual educations about brain death and organ transplantation on knowledge and satisfaction of education among intensive care nurses .

  Methods & Materials: This quasi-experimental study was conducted on intensive care nurses of hospitals affiliated to Tehran University of Medical Sciences in 2014 . Participants were selected through a convenient sampling method and were assigned into two groups with 32 participants in each. The first group participated in an interactive electronic education while the second group received a non-interactive education about brain death and organ transplantation . Knowledge of both groups was measured before and after the education. The satisfaction of participants with the course was measured using a questionnaire. The scores were compared within and between groups using the paired and independent t-test, respectively . 

  Results: The knowledge of both groups increased significantly after the intervention (P<0.001) however, there was no significant difference between the mean scores of the two groups after the education (P<0.05). The s atisfaction with the course was significantly higher in the interactive education group (P=0.04) .

  Conclusion: B oth interactive and non-interactive electronic educations increased the knowledge of nurses. The nurses were more satisfied with the interactive education. Further studies are recommended .

  

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Background & Aim: The physiological and psychological changes in pregnancy, can affect the lives of couples. The present study aimed to determine the effect of sex education on the marital relationship quality of pregnant women.

Methods & Materials: This study is a quasi-experimental. In this study, 100 pregnant women referred to health centers in Zahedan in 2015, were selected and assigned into two groups of intervention and control (50 in each group). Data collection tool was the perceived marital relationship quality components questionnaire. Questionnaires were completed by the both groups before and six weeks after the sex education sessions. Data were analyzed using descriptive and inferential statistics through SPSS software version 20.

Results: There was no statistically significant difference between the two groups (P<0.05) in terms of age, the duration of marriage, gestational age and gravidity. In post-test measurement, the mean of the total score of marital relationship quality and components such as satisfaction, sexual excitement, love, commitment, intimacy, and trust, were significantly higher in the intervention group than in the control group. Analysis of covariance also showed that the total score mean for the marital relationship and its components had significant difference in the pregnant women in two groups, after sex education (P<0.001).

Conclusion: Given the effectiveness of sex education in the improvement of marital relationship quality in pregnant women, this educational intervention is recommended to be integrated into the education program and prenatal care of pregnant women in order to improve the couple’s relationship quality in pregnancy.

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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.

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Background & Aim: Restless leg syndrome (RLS) is one of the common complications in patients under treatment with hemodialysis. Progressive muscle relaxation is a method which has been designed for reducing patients’ stress, pain and anxiety. The present study aimed to determine the effect of progressive muscle relaxation on the severity of RLS in hemodialysis patients.

Methods & Materials: In this quasi-experimental study (IRCT2015102824769N1), 74 hemodialysis patients were selected by convenience sampling method and divided into intervention and control groups based on records numbers. The intervention group was trained in progressive muscle relaxation technique in two half-hour sessions and they were asked to practice it twice a day for one month. RLS severity was measured using the standardized RLS questionnaire. Data were analyzed by descriptive and inferential statistical tests (independent and paired t-test, analysis of co-variance) using SPSS software version 23.

Results: There was no significant difference in the distribution of variables in the intervention and control group before intervention (P>0.05). Before the intervention, RLS severity score was 28.24±7.33 in the intervention group and 25.57±9.85 in the control group (P=0.189). After the intervention, the score for the intervention group was reduced to 10.67±5.66 (P>0.001) while there was no significant change in the control group after the intervention (26.16±9.69). Also, a significant difference was observed between the two groups in the mean score of RLS severity after removing the effect of RLS severity on pretest (P>0.0001).

Conclusion: The use of progressive muscle relaxation technique reduces RLS severity in patients under treatment with hemodialysis. Therefore, this technique is recommended to be used as one of the non-pharmacological methods to improve RLS in these patients.

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Background & Aim: Promoting hope in hemodialysis patients is very important. Various methods have been suggested in order to raise hope in patients with chronic diseases. The aim of this study was to investigate the effect of an illness perception-based intervention on hope in patients with hemodialysis.
Methods & Materials: This is a randomized clinical trial (IRCT2016103130609N1) on 120 hemodialysis patients admitted in the dialysis department of Bou Ali Sina hospital in Qazvin from December to February 2016. The samples were randomly assigned into control and intervention groups. Before the intervention, questionnaires including demographic information, the Herth hope scale and a summarized form of illness perception were completed. The intervention group received the illness perception-based intervention in three sessions of 30 minutes each, prior to hemodialysis. Four weeks later, the Herth hope scale and illness perception questionnaire were re-completed by the both groups. Data were analyzed by descriptive statistics, t-test and ANCOVA using the SPSS software version 23.
Results: Results showed no statistically significant differences in hope scores between the two groups (P=0.5589) but after the intervention, hope scores significantly increased in the experimental group (36.54±2.98) compared to the control group (33.88±3.76) (P<0.001).
Conclusion: The result of the present study indicated the illness perception-based intervention was effective in enhancing hope in the patients underwent hemodialysis. Therefore, this intervention is recommended for hemodialysis patients.
 

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Background & Aim: Breast cancer is one of the most prevalent cancers in women and is regarded as a chronic disease with various psychological complications including death anxiety. This study aimed to examine the effect of Benson’s relaxation technique on death anxiety among women with breast cancer.
Methods & Materials: In this randomized clinical trial, 100 patients with breast cancer referred to Velayat Hospital in Qazvin in 2017 were selected using the consecutive sampling and randomly assigned into groups of experimental and control. A questionnaire on demographic information and the Templer Death Anxiety Scale were used. Benson’s relaxation technique was taught to the patients in the experimental group. Afterward, they were asked to perform the technique for three months and were monthly followed up using checklists. The Templer Death Anxiety Scale was completed again by both groups. Data were analyzed via the SPSS software version 23 using descriptive and analytical statistics.
Results: There was no significant difference in demographic variables between the two groups (P>0.05). Before the intervention, no statistically significant difference was observed between the mean scores of death anxiety in the patients of the experimental group (46.4±10.3) and the control group (49.6±10.07) (P>0.05). However, after the intervention, a statistically significant difference was observed between the mean scores of death anxiety in the experimental group (44.5±10.2) and the control group (48.9±11.2) (P<0.05).
Conclusion: According to the results of the study, it can be concluded that Benson’s relaxation technique is effective in reducing death anxiety among patients with breast cancer.
Clinical trial registry: IRCT20170610034435N8
 

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Background & Aim: Anxiety and hemodynamic changes are common complications of surgeries. The aim of this study is to investigate the effect of foot reflexology massage on overt anxiety and physiological parameters of patients undergoing tibia plaque surgery.
Methods & Materials: In this clinical trial study, 96 eligible patients who were candidates for Tibia plaque surgery, referred to Imam Ali (AS) Teaching Hospital in Bojnourd in the spring of 2016, were selected by the convenience sampling method. Then, they were randomly divided into two groups of 48 people: experiment and control. For the experiment group, one hour before the operation, the foot reflexology massage was performed for 10 minutes. For the control group, the foot was touched for 2 minutes. Patients’ anxiety was measured using the Spielberger Manifest Anxiety Questionnaire before and one hour after the intervention, and patients’ physiological parameters were measured before and after the intervention and at 2, 4, 6, 12 and 24 hours after the surgery. To compare and analyze the data, chi-square tests for qualitative variables and t-test, Mann-Whitney test and Repeated Measure ANOVA for quantitative variables were used on the SPSS software version 21.
Results: This study showed that the average score of anxiety after the intervention was significantly different in both the control and experiment groups (P=0.038). Also, Foot reflexology massage significantly reduced systolic blood pressure after the intervention (P=0.039) and 4 hours after the surgery (P=0.007), and also reduced diastolic blood pressure immediately after the intervention (P=0.001). Heart rate decreased significantly at all measured times after the intervention (P<0.05).
Conclusion: Foot reflexology massage can reduce overt anxiety and improve physiological parameters of patients undergoing tibia plaque surgery. Therefore, this method can be used for reducing anxiety in the patients candidate for orthopedic surgery.
Clinical trial registry: IRCT20200502047265N1

 

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Background & Aim: The Covid‐19 pandemic has posed numerous ethical challenges to nurses and has exacerbated moral distress in clinical settings. Hence, due to the important role of nurses in pandemics, this study was conducted to investigate the severity and frequency of moral distress among nurses working in clinical settings at Maragheh teaching hospitals during the outbreak of COVID-19.
Methods & Materials: This was a cross-sectional study conducted on 174 nurses working in surgical-medical, intensive care, pediatric and emergency wards of Maragheh hospitals in 2020-2021. Data were collected using a demographic form and the Corley’s Moral Distress Scale.
Results: The median (Interquartile Range (IQR) = Q3 − Q1) of the severity and frequency of moral distress experienced were 54 (44-59) and 52 (43-58), respectively. The median of moral distress experienced in the intensive care and emergency wards were 56 (51-59) and 46 (43-51), which was more severe than that of in other wards. The median of frequency and severity of moral distress in men were 48 (41-59) and in women 50 (43-59), respectively, which was significantly higher than that of in women (P<0.001). The severity and frequency of moral distress had a statistically significant relationship with age, and work experience (P>0.05) so that with increasing age and work experience, the severity and frequency of moral distress decreased.
Conclusion: Given the high frequency of moral distress among nurses during the COVID-19 pandemic in specific clinical settings, the use of management strategies in order to improve working conditions and create a positive setting can be helpful. It seems that holding courses on coping with moral distress in nurses in the context of the COVID-19 pandemic is an appropriate practical solution.

 

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Background & Aim: Nurses, due to the demands of their profession, are frequently exposed to high-stress clinical situations, such as the COVID-19 pandemic, which can lead to moral distress and affect their resilience, ultimately contributing to job burnout. This study aims to investigate the relationship between moral distress, resilience, and burnout among nurses.
Methods & Materials: In this descriptive, cross-sectional study, 188 nurses working in hospitals affiliated with the Birjand University of Medical Sciences during the years 2021-2022 were selected through simple random sampling. The data collection tools included demographic information, the Moral Distress Scale, the Davidson Resilience Scale, and the Maslach Burnout Inventory. Data were analyzed using descriptive and inferential statistics in SPSS software version 21.
Results: The results indicated that the nurses experienced low moral distress (30.28±12.59), high resilience (63.70±13.44), and high levels of burnout (54.98±12.30). A direct and significant relationship was found between moral distress and burnout, while a weak and significant inverse relationship was observed between moral distress and resilience (P<0.001).
Conclusion: Given the significant relationship between moral distress, resilience, and burnout, it is recommended that policymakers develop strategies to enhance resilience, which could lead to a reduction in moral distress and burnout among nurses.