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Investigating the Effects of Spiritual Care on Death Anxiety: A Systematic Review
Mohammad Hossein Khani, Zahra Abdollahi, Marzieh Barahooei Noori , Mohammad Hossein Taklif, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Death anxiety, characterized by persistent fear of death, is a significant psychological burden. Spiritual care, encompassing compassionate listening, fostering trust, and addressing spiritual and existential concerns, has the potential to alleviate this anxiety. This systematic review aimed to investigate the impact of spiritual care interventions on death anxiety in various patient populations. A comprehensive literature search was conducted using keywords such as "spiritual care," "death anxiety," "spirituality," and "patients" in major databases, including Web of Science Core Collection, PubMed/Medline, Scopus, Irandoc, SID, Magiran, and Google Scholar. The search included publications in English and Persian with no time limitations. After screening and removing duplicates, eight studies met the inclusion criteria. Ethical considerations, including minimizing bias in the selection, extraction, and analysis of evidence, were adhered to throughout the review process. The review followed the PRISMA guidelines for reporting systematic reviews. The findings suggest a potential positive impact of spiritual care on reducing death anxiety. Studies conducted among patients with chronic kidney disease, multiple sclerosis, and stroke demonstrated that spiritual care interventions, including individual counseling and group support, can effectively alleviate death anxiety and improve overall well-being. However, some studies, particularly those involving patients with cardiac problems and gastrointestinal cancer, did not show a significant reduction in death anxiety. Furthermore, research conducted during the COVID-19 pandemic highlighted the potential effectiveness of tele-nursing interventions for providing spiritual care and alleviating death anxiety in older adults. This review provides evidence suggesting that spiritual care interventions may be effective in reducing death anxiety in certain patient populations. Further research is warranted to investigate the effectiveness of different spiritual care modalities across diverse patient groups, including those with chronic illnesses, terminal diseases, and those facing end-of-life care.

Educational Strategies to Enhance Moral Sensitivity in Nursing Students: A Systematic Review
Pooriya Samadzadehshahri, Reza Mohammadpourhodki, Zahra Delir,
Volume 17, Issue 0 (12-2024)
Abstract
Nursing students, as future healthcare professionals, must develop not only clinical competencies but also ethical competencies to deliver appropriate and professional care. Moral sensitivity is a critical aspect of professional competence, enabling nurses to recognize and respond sensitively to ethical situations as patient advocates. Consequently, fostering moral sensitivity should be prioritized from the beginning of nursing education to ensure quality care. This study aimed to examine the characteristics and effectiveness of educational interventions designed to improve the moral sensitivity of nursing students. In this systematic review, articles were retrieved using Persian and English keywords from international databases, including PubMed, Web of Science, and Scopus, as well as Persian databases such as SID and Magiran, from inception until October 2024. Keywords used in the search included "moral sensitivity," "ethical sensitivity," "nursing students," "ethics," and "moral sensitivity in nursing students." A total of 2,321 articles were identified in the initial search. References for each study were also manually reviewed. Based on inclusion criteria, experimental and quasi-experimental studies published in Persian and English focusing on effective interventions to improve the moral sensitivity of undergraduate nursing students were selected for analysis. Ultimately, six articles met the criteria for thorough review, and relevant data were extracted. Two researchers independently extracted the data and assessed the quality of the studies using the Joanna Briggs Institute (JBI) checklist. A total of 190 nursing students from six selected studies participated in the research, with 60% in intervention groups. The six educational interventions identified included:
  1. Two studies on nursing ethics workshops.
  2. A nursing ethics workshop conducted through a seminar.
  3. A motivational ethical education program.
  4. A virtual narrative ethics workshop.
  5. Problem-based learning.
However, the nursing ethics workshop conducted through a seminar was not effective in improving the moral sensitivity of nursing students. Evidence suggests that while the positive effects of educational interventions on the moral sensitivity of nursing students are limited, they are nonetheless encouraging. This review highlights various approaches to ethics education and moral sensitivity development. The findings can be utilized to enhance students' preparedness and ability to navigate ethically challenging work situations. However, further research is necessary to confirm the effectiveness of these interventions in fostering moral sensitivity among nursing students.

COVID-19: An Opportunity to Restore Lost Trust? A Narrative Review of Trust Trends Before and After the Pandemic
Hanieh Karimi, Ali Farahmand Asil, Saeedeh Saeedi Tehrani,
Volume 17, Issue 0 (12-2024)
Abstract
Trust between doctors and patients is a cornerstone of improved health outcomes and quality medical care. However, this trust has eroded in recent decades due to various factors. The global crisis of the COVID-19 pandemic presents a unique opportunity to examine and analyze changes in public trust towards the healthcare system. This narrative review explores the state of public trust in healthcare before and after the COVID-19 pandemic, analyzing the factors influencing this trust and proposing strategies for its maintenance and rebuilding. A narrative review was conducted, with information gathered from searches in reputable national and international scientific databases like PubMed, ScienceDirect, Springer, and Scopus. Relevant articles from Iranian databases such as Magiran and IranMedex were also included. The review focused on the components of trust, factors affecting it, and challenges faced by the healthcare system during the pandemic. The review revealed significant changes in the components of trust in doctor-patient relationships due to the COVID-19 pandemic. Prior to the pandemic, public trust in physicians had been declining due to factors such as perceived inequities in treatment, medical errors, and unprofessional behavior by some healthcare professionals. For example, surveys indicate a decline in public trust in healthcare professionals in the United States, dropping from 73% in 1966 to 34% in 2012. The COVID-19 pandemic significantly exacerbated this decline, with many people distrusting governmental institutions, pharmaceutical companies, and media outlets perceived to be providing misleading information. A study in Poland found that 31% of respondents viewed the pandemic as an exaggerated threat, while 3% considered it entirely fictional. However, the dedicated service and transparent communication of some institutions and healthcare personnel during the COVID-19 crisis partially restored public trust. This led to the emergence of a concept known as "dual trust," where people not only trust individual physicians but also pay closer attention to the overall performance of the healthcare system and governments. Dual trust has implications not only for the quality of healthcare services but also for the success of prevention and treatment programs. The COVID-19 crisis has had a profound impact on public trust in the healthcare system. To maintain and rebuild this trust, effective measures are essential. These measures should focus on enhancing service quality, fostering scientifically informed citizens, ensuring transparent communication, and promoting positive interactions between doctors and patients.

Cutting the Financial Relationship Between Doctor and Patient: A Key Solution to Health Ethics Challenges
Mohsen Rezaei Adaryani,
Volume 17, Issue 0 (12-2024)
Abstract
The relationship between healthcare providers and patients is often marred by financial issues, which present significant ethical challenges. These financial interactions can be categorized into direct and indirect communications, both of which give rise to various ethical dilemmas. In direct financial communication, issues such as under-the-table payments, fee splitting, self-referral, inappropriate referrals, induced demand, and unnecessary surgeries or hospitalizations are prevalent. These practices compromise the ethical standards of medical care. On the other hand, indirect financial communication occurs when a small portion of the healthcare cost is paid by the patient, while the majority is covered by intermediary institutions like insurance companies or the Ministry of Health. The family physician system, with accurate patient referrals and cost management, supports this model. Under such a system, service tariffs align with actual costs, creating "real" tariffs, and reducing opportunities for many ethical challenges to arise. The current health system provides practical examples of the disconnection of financial relationships, notably through policies such as the Accident Insurance Law (Article 92 of the Fourth Development Plan) and the family physician system within the Imam’s Relief Committee. Health centers involved in treating injured patients and staffed with experienced personnel have observed and reported significant improvements following the implementation of the Accident Insurance Law, highlighting the positive impact of financial disconnection on healthcare ethics. This study demonstrates that cutting financial ties between doctors and patients, through indirect financial communication models and accurate referral systems, is an effective solution to addressing a wide range of ethical challenges in healthcare.

Challenges of Human Resource Allocation in the Health System
Kourosh Delpasand,
Volume 17, Issue 0 (12-2024)
Abstract
All health systems face the dual challenge of resource shortages, which prevent them from providing all the services needed by society, while also striving to enhance justice in access to health services and care. The prioritization and allocation of resources are critical issues in the health sector, and ensuring fairness in these processes requires consideration of various criteria. This study aims to examine the methods of allocating human resources in the health sector and explain the challenges associated with allocating skilled human resources in the country. This qualitative study involved faculty members and individuals with a history of responsibility in the university. Data collection was conducted through interviews, which were arranged based on mutual agreement with participants. Interviews continued until saturation was reached, meaning they concluded when participants had no further information to provide and the interviewer had no additional questions aligned with the research objectives. The findings were categorized as follows:
  • Prioritization Issues: The prioritization of resources is often directed towards newly established departments and hospitals, and personnel are allocated to new branches to launch new fields. The definition of processes important to the Ministry of Health is based on specific provincial conditions, which may not be included in standard lists. Prioritization should, therefore, be determined based on relevant indicators and the performance of personnel.
  • Organizational Challenges: Organizational charts are outdated, and organizational structures are often unresponsive. Recruitment is based on obsolete charts, and there are discrepancies between created positions and the personnel recruited to fill them. Political influences, such as deception and hypocrisy, also complicate the allocation process.
Population Considerations: The floating population of each province must be considered in resource allocation. The periodic involvement of some individuals as companions and contract personnel in advisory roles alongside university presidents poses challenges. A gradual approach with well-defined management and realistic goals should be implemented over a five-year period.
  • Management and Decision-Making: Human resource managers in universities lack decision-making authority. A national team of managers, specialists, and experts should be formed to address human resources needs. Human resources should be identified based on the estimated needs of existing fields. It is also essential to establish efficiency measurement frameworks grounded in relationships, but the Ministry of Health lacks specific notifications regarding these matters. Efficiency should be measured based on personnel performance and appropriately defined indicators.
  • Emerging Challenges: The migration of specialists in various fields, combined with reluctance among doctors to pursue specialist-level studies in areas such as emergency medicine and pediatrics, further exacerbates human resource allocation challenges. Adding specialist experts and evaluating personnel before hiring are essential measures to address this issue. Additionally, consideration should be given to restructuring the Ministry of Health by dividing it into separate sub-units with distinct financial and management mechanisms.
This study identifies and extracts the criteria used for prioritizing and allocating resources within the health system. According to experts and policymakers in health and medical organizations, additional criteria should be considered beyond traditional metrics when prioritizing and allocating human resources.

The Necessity of Social Solidarity and Sustainability Principles in Health System Programs
Mehran Seif-Farshad,
Volume 17, Issue 0 (12-2024)
Abstract
Health care services, in addition to being recognized as fundamental rights in various global human rights declarations, play a crucial role in advancing the development of human societies. The four principles of biomedical ethics introduced by Beauchamp and Childress—autonomy, non-maleficence, beneficence, and justice—are pivotal for ethical analysis and decision-making. However, certain other dimensions, which may not be explicitly addressed within these principles, are essential for policymaking at both macro and micro levels in health care. Two such important principles are social solidarity and sustainability, both of which hold a prominent position in health systems planning. The principle of social solidarity refers to the ways in which unity, cohesion, and collaboration are fostered within a community. A socially cohesive society embraces cultural diversity, respects human rights and the rule of law, and demonstrates a shared commitment to social order and collective responsibility. Social solidarity can significantly reduce health risks by creating a strong societal framework where cooperative efforts foster conditions for well-being, minimizing disability and disease. On the other hand, a health care system is fundamentally responsible for establishing and maintaining a sustainable and high-quality care environment. Sustainability in health services is achieved when ethical obligations—such as maximizing possible benefits, balancing risks against benefits, ensuring fairness (including for future generations), and respecting public rights—are prioritized. Continuity of health care ensures better coordination and improved delivery of services. Disruptions in health policies or intermittent provision of health services can severely undermine public trust. A conceptual understanding of sustainability and continuity in public health ethics is crucial, as these principles ensure that health policies, programs, and services enable access to the highest attainable standard of health, free from economic, social, or political instability. However, sustainability should not imply stagnation; services must remain responsive to the evolving needs of populations and societies. Ignoring these two principles in health policymaking and program design can seriously erode public trust and ultimately harm individual and Health system planning, should be changed to Health care programs.

Telehealth: Ethical and Legal Challenges in the Healthcare System
Hooman Heydary, Shakila Belkafeh, Mohammadreza Dinmohammadi,
Volume 17, Issue 0 (12-2024)
Abstract
Telehealth has emerged as a rapidly expanding method for delivering healthcare services, especially during the COVID-19 pandemic. This approach has opened new avenues for accessing medical care and contributed to reducing healthcare costs. However, the growth of telehealth has introduced significant legal and ethical challenges that warrant thorough investigation. This review study employed keywords such as "telemedicine," "telehealth," "ethical challenges," "legal challenges," and "healthcare system" to search scientific databases including PubMed, Scopus, CINAHL, and Google Scholar. Articles published in English and Persian between 2010 and 2024 were reviewed. Eligible sources included research articles, systematic reviews, and case reports focusing on legal and ethical issues related to telehealth. Following an initial screening, articles were assessed based on quality and scientific credibility, and the selected works were analyzed for the final synthesis. Telehealth presents several critical challenges that must be addressed to ensure safe and equitable care delivery. One of the foremost concerns is patient privacy and data protection; the exchange of sensitive health information necessitates robust security protocols and adherence to data protection regulations to uphold patient confidentiality and trust. Another key issue is informed consent, which must be adapted to the virtual context to ensure patients are adequately informed of both the benefits and potential risks associated with telehealth services. While telehealth enhances healthcare accessibility, it may also deepen existing health disparities due to unequal access to digital technologies. Therefore, investments in communication infrastructure and digital literacy are essential to promote inclusivity and equal access to care. Although telehealth offers substantial benefits—including improved access, convenience, and enhanced coordination of care—its legal and ethical implications must not be overlooked. To fully realize its potential, stakeholders must collaborate in developing comprehensive regulations and ethical frameworks. Addressing these challenges is imperative to advancing telehealth in a manner that ensures patient safety, protects rights, and promotes health equity.

A Critical Review of the Ethical Aspects of the Electronic Health Record System (SPAS in Iran)
Shiva Khaleghparast, Saied Bagheri Faradanbeh, Samaneh Karimian, Fahimeh Khosrobeigi Bozchaloei, Seyed Ebrahim Hoseini Zargaz, Ehsan Shamsi Gooshki,
Volume 17, Issue 1 (3-2024)
Abstract
The electronic health record system (SPAS in Iran) records information related to the health of individuals in an electronic format. It is the center for collecting health information and data on outpatients and inpatients. This system records information such as the patient's full name, marital status, gender, date of admission, level of education, occupation, type of admission, and other relevant medical data. The core values and ethical requirements of SPAS include safeguarding citizens' rights, respecting individuals, observing justice and fairness, transparency, encouraging participation, and accountability. In this study, the ethical aspects of SPAS were evaluated using the model proposed by the World Health Organization (WHO) for ethical evaluation. This model emphasizes fundamental ethical principles such as human well-being and health, respecting individuals and communities, justice, and fairness. Concerning human well-being and health, SPAS can prevent unnecessary and redundant interventions and provide physicians with quick access to an accurate patient history. Furthermore, the system ensures the confidentiality of information, which is essential to respect individuals and communities. Regarding justice and fairness, the system can improve access to health services for disadvantaged and remote areas. Moreover, SPAS adheres to procedural ethical principles such as solidarity, transparency, participation, and accountability. Therefore, by critically examining the ethical dimensions of the electronic health record system (SPAS), the findings of the present study provide valuable insights for policymakers, health professionals, and regulatory organizations to ensure the ethical and efficient performance of electronic health record systems in Iran.

Study of Research Misconduct Using an Analytical Approach to the Research System of Medical Sciences
Amirhossein Mardani, Maryam Nakhoda, Ehsan Shamsi Gooshki,
Volume 17, Issue 1 (3-2024)
Abstract
 Since research misconduct can be considered as an adaptive reaction against the limitations, pressures, and demands arising from inappropriate functions of the research system, to manage it, the activities of the research system should be investigated and traced during the path of transferring research policies (macro level) to research development programs in institutions (meso level) and research implementation by researchers (micro level). By introducing the macro-meso-micro analytical framework, this study clarified the tasks, strategies, and activities formed at three levels of the research system of medical sciences in Iran; from macro policies of research (macro) to operational plans for the development of research in universities and research centers (meso) and researchers as research conductors (micro). For this purpose, three analytical levels of the research system were explained and defined according to the assumptions of this framework. By performing a qualitative content analysis of the relevant texts, those activities that could be useful at different levels to support the research integrity were identified and presented as different strategies. The results showed that the research system, based on the existing analytical framework, is not seen as a mere macro-system without regard to the interaction of its parts, but rather a system in which there is cross-sectional influence and interaction among the components. This approach can improve the focus, clarity, and capability to study research misconduct, and by using micro, meso, and macro levels, it can trace challenges in the interactive path of various activities and functions of the research system and their intertwining.

Assessing Responsiveness to Non-Medical Needs of Inpatients in Educational-Therapeutic Hospitals in Gorgan, 2022
Alireza Heidari, Seyed Hamed Atashi, Farideh Kouchak, Zahra Khatirnamani,
Volume 18, Issue 1 (3-2025)
Abstract
Addressing patients’ non-medical needs reflects the desires of patients and their families to engage more actively in decision-making and treatment processes. The present study aimed to assess the level of responsiveness to the non-medical needs of hospitalized patients. This was a cross-sectional study conducted using a descriptive-analytical approach. A total of 392 patients hospitalized in Shahid Sayad Shirazi and 5 Azar educational-therapeutic hospitals, affiliated with Golestan University of Medical Sciences in Gorgan, were included in the study. Participants were selected through systematic random sampling. Data were collected using the validated and reliable responsiveness questionnaire developed by the World Health Organization (WHO). The mean (±SD) age of participants was (45.17 ±16.92) years, with 55.1% being male. The mean (±SD) overall score for the importance of responsiveness was (33.37 ±4.45), which was above the average. The majority of patients (over 65%) rated all dimensions of responsiveness as very important or extremely important. The most important dimension from the patients' perspective was the quality of the surrounding environment (95.9%), while the least important was the confidentiality of personal information (34.7%). The mean (±SD) overall score for responsiveness performance was 54.54 (0.70 ± 8), which was above the average. The overall score of the responsiveness performance and importance in Sayad Shirazi and 5 Azar educational hospitals was above average. Dimensions deemed important by patients but with weaker performance should be prioritized, and educational and therapeutic centers should pay more attention to patients’ non-clinical expectations.

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