Iranian Journal of Medical Ethics and History of Medicine

The white coat ceremonies are a recent phenomenon in medical education at the first steps of their education, that use as a symbol to impress upon medical students the importance of professionalism in medicine. This ceremony is known as one of the primary preparations for entrance of medical students to clinical courses. This study aims to investigate the effect of white coat ceremonies on professional ethics and student familiarity with their professional tasks in clinical departments. The present study is a qualitative study on the students' viewpoints regarding white coat ceremony and based on goal-based sampling. The statistical population included 4th-year medical students of Shiraz University of Medical Sciences in 1394. Data collection was done by a mixed method which one part of it was the half structural interview and another part by answering the open questions. Data collection continued to the saturation phase, furthermore; the data were analyzed by content analysis method according to the instructions. Most of the participants in this study considered holding a ceremony before entering the hospital as an important event for the readiness of students to go through a clinical course. The most important positive effects of white coat ceremony were increased students' commitment and accountability, improved interactions with patients, increased motivation and self-confidence, and familiarity with some of the basic principles of professional ethics. A white coat celebration can enhance the students' familiarity with their professional duties and motivations. More studies are needed to better understand the strengths, weaknesses, and shortcomings of this ritual.
 

The most important factor in interpersonal relationships is trust. Trust in the physician-patient relationship is key and essential. Understanding the factors that affect trust is a prerequisite for trust. These factors vary in different societies. So we need to identify these factors and provide a single criterion for measuring them. Therefore, because we need a tool to measure these different factors in the context of culture and society, the purpose of this study is to determine the factors that influence public confidence in physicians to provide the necessary evidence for making appropriate instruments in Iran. The first step was to investigate the factors affecting patients' confidence in physicians during a library study. Then, during interviews and numerous discussion sessions, nineteen factors influencing public confidence in physicians were provided. Then, to determine the content validity, twenty experts evaluated the transparency, relevance and importance of the factors. Content validity ratio (CVR) and content validity index (CVI) were measured. CVR value for each of nineteen factors was 0.42, therefore content validity of the tool was significant with P.value 0.05. CVI value was 0.944 and content validity of the tool was confirmed. Factors affecting public confidence in physicians in Iran include 19 factors extracted during this study and can be used as factors for assessment of public confidence in physicians. Factors affecting public confidence in physicians in Iran include 19 factors extracted during this study.

Nursing ethics is one of the most basic aspects of nursing profession, which nurses are required to follow the principles receiving nursing care with confidence by patients. This study was conducted to determine the level of moral development of nurses and its contributing factors. This descriptive, analytic study was performed in 2017, study samples were 310 nurses working in educational hospitals of Ardabil University of Medical Sciences. Samples were selected by convenience method. The data was collected using a Kohlberg’s nursing dilemma test. The questionnaire included six scenarios: newborn with anomalies, forcing medication, adult's request to die, new nurse's orientation, medication error, and uninformed terminally ill adult. The data was analyzed by IBM SPSS 18 using descriptive and analytic tests. In this study, 51 nurses (16.45%) were in the pre-conventional level, 101 nurses (32.58%) in the conventional level, 132 nurses (42.58%) at the post-normal level and 26 nurses (8.38%) at the level of clinical considerations. Moral thinking mean score was 42.58 ± 5.6 and the mean score of the clinical considerations was 21.53 ± 4.3. The present study showed that the majority of nurses are in the post conventional and conventional level; but this is less than 50% of all nurses, which shows that the level of moral development of nurses is in the moderate level. It requires further investigation of the causes and related factors and more efforts for improving it.
 

The concept of Islamic medicine, which differs from traditional medicine and even Muslims’ medicine, has become more and more popular in recent years in Iran, especially in religious cities. In the present article, we have addressed the extremist approach of the claimants of Islamic medicine (which considers itself a competitor of modern medicine and traditional medicine).Our theoretical basis for the ethical criticism of this approach has been the principlism of "Beauchamp and Childers". Thereby, we have attempted to challenge the clinical position and medical performances of extremists in the Islamic medicine on the basis of four principles of "justice, autonomy, beneficence, and non-maleficence". Then, we have concluded that the claim of the Islamic medicine cannot, in the present circumstances, satisfy the principle of distributive justice. It also violates patients' autonomy by making unfair judgments and fears about modern medicine. It is very prone to harm clients by refusing scientific evaluation of medicines and therapies and lacking a valid certification system.  Accordingly, we  particularly challenged the attribution of this process to Islam.  This attribution may cause serious damage to the religious beliefs of the clients.

Physician- patient communication is essential for good medical practice and leads to patient satisfaction and subsequent following of prescribed therapeutics and health promotion. There is limited study on this subject in Iran. The purpose of this study was to evaluate patients' satisfaction of the physician-patient communication and factors influencing it to provide useful information for decision-makers within the health services. This research was an applied field cross-sectional study among hospitals in Tehran. Satisfaction was assessed by 22 questions after obtaining consent from the patients. The level of patient's satisfaction with physician's communication among 1200 patients in order of priority was: medium 63.4%, high 15.1%, low 14.4%, very high 4.7%, and very low 2.5%. Mean patients’ satisfaction was 76.35±13.99, maximum and minimum satisfaction was 110 and 30, respectively. There was a significant relationship between patient satisfaction and patients’ gender, age, marital status, occupation, physicians’ age, sex and timely presence of the physician in the clinic and good deal of communication between patient and physician’s receptionist. Overall patient satisfaction with the patient -physician communication is medium that is not desirable. Factors such as gender, age, material status, and occupation of patients and age and sex of physician, timely presence of the physician in the clinic and a good deal of communication between patient and physician receptionist had a positive correlation with patient's satisfaction. According to important role of communications’ skills in patients’ satisfaction, it is necessary to put more emphasis on training and assessment of communication skills of physicians and health care personnel.
 

One of the most common ethical issues in nursing profession is moral distress which causes discomfort and impedes nurses proper moral performance, despite having sufficient knowledge. Moral distress disturbs the relationship between nurse and patient which leads to the decreased quality of care. Caring behaviors greatly contribute to improving the quality of care and patient safety. The present study aimed to determine the correlation between moral distress and caring behaviors of nurses in intensive care units of Bandar Abbas hospitals in 2018. This was a descriptive correlational study that was performed on 173 nurses working in ICU and NICU departments of Bandar Abbas hospitals. The data collection tools were demographic information questionnaire, the moral distress scale of nurses of intensive care units, and nursing Caring Behaviors Inventory. Data were analyzed using IBM SPSS 20. Moral distress in nurses in the intensive care unit was in the middle range (1.75 ± 0.81 of 4 score). Also, the mean score of nurses' caring behavior was 5.28 ± 0.48 of 6 score which was considered as an acceptable level. There was a significant negative correlation between moral distress and caring behavior (r = -0.150, P = 0.049). Regarding the importance of moral distress, as well as the role of caring behaviors in improving the quality of care of nurses and satisfaction of patients, it seems necessary that nurses get more familiarized with this concept and attempts to provide solutions for coping and reducing moral distress and improving nurses' caring behaviors.
 

Communication with patients is an important issue in nursing meaning that to realize the truth from their viewpoints. This study was performed to compare levels of nurses’ empathy with patients at drug abuse treatment centers (DATCs) and the internal ward of hospital. The present research was a cross-sectional and descriptive-analytic study conducted at two environments of the internal ward and DATCs. A total of 60 subjects comprised research participants and were listed in the study through census method. A two-part scale was used including personal information and Jefferson scale of empathy with verified validity and reliability. Data were analyzed using SPSS16 software. The scores of nurses' empathy with patients recorded in the internal ward and at DATCs were 67.84±6.32 and 79.73±9.21 (out of 100), respectively (P=0.001). Male nurses (76.80±9.88), married nurses (75.93±9.98), ages of >40 years (79.1±11.12), masters’ degrees (75.5±3.78), job experiences of >10 years (83.53±8.53) and overtime hours of <50 h (80.61±9.9) attained the highest empathy scores with significant differences (P<0.05). The scores of nurses’ empathy with drug-dependent patients at DATCs were higher than those of internal wards indicating that the care of addicted patients in a specialized ward leads to increased empathy. Considering the relationship between empathic communication, educational levels and occupational experience of nurses, it is essential to consider training empathy skills to nursing students from the first semester and to provide in-service training to nurses working at hospitals and centers by nurses of higher educational qualifications and experiences.

Adherence to professional ethics based on spiritual intelligence is conducive to patient welfare and satisfaction. The purpose of this study was to determine the relationship between professional ethics and spiritual intelligence of Kerman University of Medical Sciences' students. In this descriptive co relational study, 150 undergraduate medical students were enrolled in the census. The tools used were spiritual intelligence and professional ethics questionnaires. Data were analyzed by SPSS version 22 using independent t-test, one-way ANOVA, and Pearson correlation coefficient. The mean and standard deviation of professional ethics score was 57.72±6.2 and the spiritual intelligence of students was 73.97±12 12.3. The lowest score of professional ethics was in the area of ​​responsibility and the most in sympathy with others. There was also a significant positive relationship between professional ethics scores and students' spiritual intelligence (P = 0.001). This means that by educating and enhancing students 'spiritual intelligence during their studies, one can expect to increase students' professional ethics during clinical work and professional communication with the patient. To this end, teachers' emphasis on aspects of ethical applied education, especially during clinical education, as well as honoring spiritual patterns as the foundation of ethical education during college education seems necessary.

Medical error is one of the most important ethical and legal issues that sometimes occur when a variety of health care practices are provided by healthcare professionals. Due to the necessity of medical error disclosure and lack of adequate personal and organizational support in this field, this study investigates strategies for facilitating error disclosure as well as increasing the variety of supportive measures from the perspective of residents. This was a descriptive cross-sectional study with statistical population including all residents of Shiraz University of Medical Sciences. The sample size was obtained using Morgan table as 248 participants. Data were collected using a researcher-made questionnaire (with descriptive and valid reliability) and analyzed by SPSS software using descriptive and inferential statistics. In this study, increasing support facilities for medical error disclosure (mean 4.38) was the most important factor, and increasing the lawfulness and transparency of activities in the medical setting (mean 4.32) was the second factor affecting the promotion of medical error disclosure. Also, medical liability insurance (mean 4.80) was the most important supportive measure. The fear of legal and judicial consequences was reported as the most effective factors on the error concealment and having experienced lawyers and cultivation effects of mass media declared as the way out. In the present study, although most residents agreed with medical error disclosure, but due to the wide range of risk management problems that affect error disclosure, they found it necessary to establish a support system. Given the teamwork in health-care delivery, support should be given to all members of the treatment team.

Patient safety is one of the basic principles of health care and its evaluation and promotion are one of the main goals of the health system development plan in Iran. Therefore, the present study was designed to determine the status of patient safety culture in nursing staff of three hospitals, A and B, Shahrekord and C Borojen hospitals. This was a descriptive-analytical study performed from September to February 2018 and 359 eligible nurses were evaluated based on a multi-stage sampling method based on Patient Safety Culture Questionnaire. The collected data were analyzed by descriptive and inferential statistics using SPSS 20 software. The mean age of participants was 23.33 ± 7.79 years. The overall score of patient safety culture was 123.23 ± 16.15 for nurses, with the lowest score being 8.40 ± 1.86 for communication channels as well as feedback and informing others about errors 8.72±2.23 reported. Also, there was no statistically significant difference between different dimensions of patient safety culture and overall score in three hospitals (p> 0.05). Leadership is a key element in prioritizing patient safety. How to respond to mistakes determines the hospital safety culture. To promote a good hospital safety culture, the fear of being blamed for mistakes must be eliminated and the atmosphere of open communication and continuous learning must be implemented in the hospital.

Imamate jurisprudents, consider Damie as a little rupture in the flesh while Motalaheme is a deep one. Hence, the place of the two injuries is the same but the depth of the rupture in Motalaheme makes the difference. This difference has been identified in Clause “b” and “p” of article 709 of the Islamic Punishment law. Furthermore, their historical understanding of the anatomy of this injury led to the concept of rapture in the flesh because they believe in order for the bleeding which is constituent of Damie, rupture in the flesh is necessary. However, contemporary anatomy explains that rupture in the flesh is not necessary for bleeding. Bleeding can occur through derma and hypoderm of the skin. This analysis adds on the hypothesis of the historicity of their definitions of the two injuries. With a descriptive-analytic approach and library study, we prove this hypothesis and make modification of their definitions on Damie and Motalaheme.
 

Nurses are always exposed to job burnout due to high workload. This research was performed to investigate relationship between need for drama and work context with job burnout in nurses. The study was a descriptive survey. The whole nurses Ardabil city, comprised the statistical population of this research. From this population, 247 nurses were selected by convenience sampling method. For data collection  the following questionnaires were used: job burnout questionnaire (Cronbach's alpha coefficient0.76), work context questionnaire (Cronbach's alpha coefficient 0.83) and need for drama scale (Cronbach's alpha coefficient 0.81). For data analysis, descriptive statistics and statistics from Pearson correlation coefficient and multiple regression were used. Results showed that between work context and job burnout (p<0.01) there is a significant negative relationship and between need for drama and job burnout (p<0.01) there is a significant positive relationship. The results showed that the relationship between need for drama and work context are two factors that affect the job burnout, which more attention to these indicators can reduce burnout in nurses.

Medical errors in pediatrics if different from adults. This study aimed to investigate type and frequency of medical errors and the related contributing factors from pediatric residents' point of view. This descriptive and cross sectional study was done in 2016. After determining validity (face and content) and reliability the final questionnaire with 17 questions categorized in six parts was used for data collection. Data were analyzed descriptively using SPSS v.22. ''Errors of diagnosis or delay in diagnosis' (8.6)', ''choosing appropriate dose (8.3) and medication (8.2)'' had the highest average weights. Fellows of pediatrics (12.6) and pediatrics’ professors (12.1) with the highest average weights had the most dominant role in diagnosis and prevention of errors. The most and the least average weights of the errors was reported for urban general physicians and pediatrics’ professors, respectively. Errors could occur at 2-8 AM more likely. Junior residents were the ones with the most chance of doing errors. Medical errors were mostly reported to occur in the group of children (70.6%) than neonates (29.4%). Reconstruction and strengthening educational and supervision role of pediatric fellowships and attending with the aim of in time diagnosis and then prevention of medical errors could be considered as a must in teaching hospitals. Holding purposeful educational courses and control of contributing factors like workload, exhaustion, inexperience, etc. are among duties of educational and executive managers.
 

According to the important role of family factors in people quality of work and the importance of correct emotional relationship of medical staff in patients' satisfaction and spirits, the aim of the present study was to investigate the relationship between perceived intimacy from the main family and work-family conflict with empathy and addiction to work in the medical staff. This study was a description of correlation type. The statistical population of this study included all the medical staff of medical centers in Bojnourd city in the 2018-19 year. Among them 250 person were selected by available sampling method. For data collection we used main family health Questionnaire, work-family conflict questionnaire, Lamonica empathy scale, and work addiction questionnaire. To analyze the data of this study, Pearson correlation coefficient and regression analysis were used. In order to analyze the data, SPSS software (version 25) was used. The results of Pearson correlation showed that perceived intimacy from the main family had a positive and significant correlation with empathy and negative correlation with addiction to work. Also, the results indicated that there is a significant correlation between work-family conflicts with empathy, but there was not a significant correlation between work-family conflicts and addiction to work. The results of the present study indicate the role of family system and its internal conflicts on empathy with patients and work addiction in hospital staff, which emphasizes the need to pay more attention to the improvement of quality of family life of health care staff.

One of the main methods of improving patient safety is use of reporting systems and providing facilities for analyzing and preventing mistakes. The aim of this study was to determine the attitude of nursing managers of hospitals affiliated to Kurdistan University of Medical Sciences towards the voluntary reporting system of medical errors in 2015. In this descriptive-analytic study, all managers of selected hospitals in Kurdistan province were enrolled in this study. The data was collected through a valid questionnaire for attitude towards the voluntary reporting system of medical errors. Data were analyzed by SPSS software version 20, independent t-test, chi - square and ANOVA. According to the results of the study, 87.9% (80 participants) of the managers encountered reporting of errors in their workplace. 68.1% (62 participants) of the managers had a positive attitude toward the voluntary system of medical errors and 16.15 % (15 participants) had a negative attitude and 15.38% (14 participants) were indifferent. According to the results of the research, more than 68.1 % of managers have a positive attitude towards the voluntary reporting of medical errors and with the necessary measures a suitable platform for launching the voluntary reporting system of medical errors in the treatment centers can be provided.

The mutual trust in a social relationship is essential to adjusting that relationship under ethics and law. The functionality of legal and ethical rules can be trusted to create a good, orderly and just relationship when the parties can trust each other under the protection of such rules. The first legal documents in Iran required the practitioner to obtain the respect and trust of the society in himself and his colleagues, and then made clear his obligation under it. In subsequent reforms, such obligation stood as they were, but the values of “trust” and “respect” were not mentioned. It seems that “trust” and “respect” of physicians in a society is the good will of these professionals which supports the efficiency of the treatment on one hand, and the conscious cooperation of the patient on the other. This matter is dependent on the physician’s effort in respecting the patient’s boundary and staying true to the physicians own technical and professional obligations. This article emphasizes the necessity this inseparable relationship, and the analysis of legal obligation in the light of such higher ethical values.
 

Over the past years in the literature of medical ethics about the doctor-patient relationship, patient's rights have been greatly considered, but the other side of this relationship is not concerned, and the physician’s obligations have been highlighted. The two meanings are understood from the concept of   physicians’ rights; their rights in conflict with the patient rights’ and the right to self improvement. We want to review the causes of this neglect and its complications. The reasons for not paying attention to the physician’s rights include: traditional beliefs about the power imbalance in doctor-patient relationship, lack of emphasis in the four principles of medical ethics, lack of supportive structures, customer-orientation in medicine, and hyper medical professionalism. Continuing this neglect creates complications that include: physicians’ work-life imbalance, symbolic violence in their society, burnout of physicians, forgetting the principle of gratitude and ultimately, the lack of respect for patients' rights. Consequently, the discourse of medical ethics fails to achieve its primary goals.

To consider ourselves as "lesser evil" and to consider ourselves "holier" are two different categories in evaluating moral action, that its motivation and success rate vary in each other. After reviewing the justification mechanisms in four real situations involving altruistic act, the present study seeks to examine the validity of the current models of the temporality of justification for moral disengagement in terms of inclusion. In addition to verify the common models for categorizing justifications in two situations as "less evil" and as "holier", this examination aims to clarify the moral behaviors of the moral actor and facilitate ethical judgment in a more analytical space. The participants of the study were 71 undergraduate and postgraduate students at Shiraz University selected in convenience method. In order to evaluate how respondents respond to situations which require altruistic action, four realistic situations of altruistic action were designed. The responses and justifications presented by those who didn’t cooperate with the altruistic plan were subjected to direct content analysis. In the face of the altruistic plans of those who refuse, their justifications were in accordance with some of the mechanisms mentioned in the background. However, there were two categories of justification that were not understandable with the categories in the literature. These two categories are named according to their core themes, self-oriented justification, and other-oriented justification. The results implied confirmation of Klein and Epleis’s distinction of motivation toward lesser evil and holier.
 

Obtaining informed consent is for protection of patients' rights. The aim of informed consent is not decreasing physicians' responsibility.Informed consent assists the patient in making a decision concerning their care, improve their satisfaction, and decrease legal litigations. This study examined patients' attitude toward the quality of informed consent and its challenges in educational -clinical settings. Current qualitative research was simple content analysis. Semi-structured interviews were conducted with 15 hospitalized patients who were selected by purposeful sampling method considering type and severity of the disease, gender, age, and satisfaction or dissatisfaction from the management. The data was analyzed using MAXQDA 2007 software. Primary codes and categories were extracted then the findings were presented based on the main. Five themes were extracted from the data: "meaning, importance and status of consent in medicine", "consequences of obtaining consent", "the role of patient and therapist in the process of informed consent", "challenges of making informed consents" and "facilitators in the process of informed consent"; all could define and compile the main theme “doctor, patient, and procedural elements, three pillars of informed consent”. Inadequate explanation to the patient, signing the form prior to read it, lack of trust to the practitioner, disregarding patients' psychologic needs and stress and obtaining the consent by someone other than the physician was among the main reported challenges of informed consent. Correction and standardization of obtaining informed consent's culture requires knowledge about current situation followed by training, enforcement, supervision, encouragement, and punishment.  Collaboration of health care team needs comprehension of necessity and importance of this issue and its consequences.