نشریه پرستاری ایران
پیاپی 131 (شهریور 1400)

World Health Organization (WHO) greatly recommends exclusive breastfeeding as the perfect nutrition for infant feeding. Breastfeeding is associated with short -term and long- term advantages for maternal and child health. Short term advantages in children include reduction of diarrhea and pneumonia. And the long- term advantages of breastfeeding include reduced risk of obesity and chronic diseases such as type I & II diabetes, hypertension, heart diseases, and hyperlipidemia in adulthood and improved cognitive functions. Breastfeeding advantages for mothers include more mother–infant bonding and reduced risk of breast cancer, ovarian cancer, and type II diabetes. Many studies have documented the relationship between healthy behaviors and personality traits, so it seems that breastfeeding is related to such traits. So, this study aimed to investigate predicting exclusive breastfeeding based on maternal personality traits.

A descriptive-predictive study was used to achieve the research purpose. The study followed random cluster sampling method. For this purpose, first Valfajr and Enghelab Centers were selected as clusters, and three comprehensive health care centers were selected randomly from these clusters. Finally, 120 eligible mothers referring to 6 comprehensive health centers of Shiraz participated in this study.  In order to determine the sample size, the rule of sixty in the structural equation prediction model was employed. According to this law, 10 samples were selected for each parameter. Data were collected between May to December 2019. The inclusion criteria were willingness to participate in the study, Iranian mothers with an infant aged 6-12 months and the experience of exclusive breastfeeding, singleton pregnancy, lack of any breast disorders, normal vaginal delivery, not using any lactation-inducing medications, not having any medical complications, not having been hospitalized for any reasons, not using any psychiatric medications during the breastfeeding period, and term pregnancy. The exclusion criteria were incomplete questionnaires. Data were gathered using a demographic questionnaire which included items relating to maternal and child age, education level of couples, income, occupation, breastfeeding education during pregnancy and after childbirth, emotional support during the breastfeeding period on the part of the husband or family, and delivery type. The other instruments included Exclusive Breastfeeding Scale with 23 items on attitude, abstract norms, perceived behavior control, and behavioral intention; and the shortened scale of Big Five Factors (BFF) about Personality Traits which included 21 items relating to extraversion, neuroticism, openness to experience, task-orientation, and agreeableness. The researcher selected the samples who met inclusion criteria; and then, she introduced herself to them and explained the research objectives. The participants were also ensured about the confidentiality of the data. A written consent form was obtained from anyone who agreed to participate in the study. Afterwards, the questionnaires were completed in the presence of the researchers. Descriptive statistical methods (mean, standard deviation, and Pearson correlation coefficient) were used to analyze the data. In order to predict exclusive breastfeeding based on personality traits, multiple linear regression through Enter method was used in SPSS 16. Before the multiple regression analysis, the presumption of multicollinearity and normality effects of the data were evaluated, which indicated the normal distribution of the variables and there were no outliers in data. The variance inflation factor (VIF) index was accounted to be less than 1.5. The P -value was set at 0.5 for all tests.

The participants aged 17-45 years ((M = 31.04, SD = 5.12).  The infants aged 6-12 months (M = 9.56, SD = 2.41). In this study 88.3% of the participants were housewives. Almost half of them had a Bachelor’s degree and above (48.3%) and their spouses had diplomas (45.8%). The majority of the participants (91.7%) were emotionally supported and encouraged to breastfeed by their spouses and 95% by their families. Also, the majority of subjects (89.2%) received breastfeeding training during pregnancy and 95.8% of them received the training during the postpartum period. The table of mean scores of personality traits showed that individuals with agreeableness showed the highest mean score (16.13, SD =2.16) and individuals with neuroticism characteristics showed the lowest mean score (12.13, SD =2.68). The results of the Pearson correlation coefficient showed that among the personality traits, the extraversion component had a meaningfully positive relationship with exclusive breastfeeding (r =. / 36, p=0.024). The results of linear multiple regression analysis showed that the predictor variables were the extraversion (P=0.0001, β = 0.43) and task- orientation (P=0.048, β = 0.18). These variables explained 21% of total variance. All other variables were not meaningful.

It can be concluded that extraversion and task- orientation predicted exclusive breastfeeding positively. Given that personality traits are relatively stable, the relationship between extraversion and task- orientation with exclusive breastfeeding has beneficial outcomes for maternal and child health. Positive emotion is one of the features of extravert people and competency is the feature of task- oriented people. If it is possible to provide situations for mothers to experience more positive excitement or to feel more adequacy and competence, breastfeeding quality will be improved. For this purpose, it is necessary to teach the discipline in breastfeeding, tell the mothers to have a happy life, and tell them about mother- infant intimacy. It is hoped that presenting the results of this study to health care providers leads to more encouragement and support for women in the field of exclusive breastfeeding and the provision of safe breastfeeding counseling in health centers. One of the limitations of the present study was inadequate access to eligible mothers participating in the study due to the restricted time of the researcher in collecting data and reduced mother’ desire to exclusive breastfeeding, which can be effective in the lack of significant relationship between other components of personality traits and exclusive breastfeeding. The strength of this study was that it was one of the few studies conducted in Iran which investigated the relationship between two essential and vital variables, i.e. personality traits and exclusive breastfeeding in analyzing the mother and infantschr('39') health. Future researches should examine the role of mediator variables in the relationship between these personality traits and exclusive breastfeeding and effect of socio-cultural and economic factors on exclusive breastfeeding. Finally, designing qualitative study to determine other barriers to exclusive breastfeeding is recommended.

Autism spectrum disorder is a complex neurodevelopmental disorder whose clinical manifestations include impaired social communication, behaviors, interests, and limited and repetitive activities. Poor eye communication, lack of emotion or social interaction, impaired use of non-verbal behaviors, and lack of age-appropriate communication are the main manifestations of this disorder. This disorder is one of the main causes of disability in children under 5 years old. The exact cause of this disorder has not yet been determined, and it can often be diagnosed by comparing autistic childrenchr('39')s speech and performance with those of their peers. In comparison to parents of typically functioning children or parents of children with other developmental disabilities (i.e. Down’s syndrome or cerebral palsy), parents or caregivers of children with an autism spectrum disorder experience more parenting stress which makes its management imperative. Parenting stress in this group of women results in depression, anxiety, divorce, reduced family cohesion and physical health, more incidence of behavioral problems in the children, and problems related to parenting. Thus, it is imperative to identify effective methods that target improvement in caregiverschr('39') mental health. The problems that mothers face in raising their children from an early age put a lot of pressure on parenting skills, and if the parentschr('39') understanding of the demands of their role is greater than the resources and methods available for coping with them, so that they will be unable to restore balance in the usual ways, it will lead to stress in parents. In the case of parents of children with autism, maternal stress is reported more than the paternal stress, and more than mothers of children with other developmental disorders and mothers of normal children. Therefore, given that the caregivers of (75%) of children with autism are their mothers, it is not unbelievable that mothers of this group of children struggle with a lot of stress. Mothers of children with autism are their primary caregivers, leading to depression, anxiety, quitting job, and suicide. Thus, effective interventions to improve the mental health of caregivers of children with autism seem necessary and the need to improve their mental health is felt. However, the results of studies that have been done so far indicate that this emotional revelation intervention through writing has been inconsistent or even ineffective on the mental health of mothers of children with autism. This study aimed to evaluate the efficacy of written emotional disclosure in parenting stress of mothers with autistic children.

In this study, conducted in 2019, a quasi-experimental design including pre-test, post-test, and control group was used. First, a sample size of 70 mothers with autistic children were selected and tested from the autistic schools in Tehran. In pre-test, the Parenting Stress Index-short form (PSI-SF) was administered individually to experimental group (n = 35) and control group (n=35). Then, written emotional disclosure, at least 15 minutes, twice a week over an 8-week period was conducted in experimental group whereas the control group received no intervention. Three mothers in the experimental group withdrew from the study due to personal reasons. Therefore, the study continued with 67 mothers. After the intervention, the parenting stress was measured again in both groups. In the intervention group, the mothers first wrote about their deepest feelings and negative experiences of caring for an autistic child. Topics for mothers to write about included their feelings when they found out their children were diagnosed with autism; writing down the most difficult situations they had experienced in communicating with their autistic children; the most important issues that had made them upset in their daily lives about their children; and what do they do when their children do not cooperate with them?
Ethical considerations of the research, including informed consent to participate in the research and obtaining consent from the participants, observing the principle of confidentiality and avoiding bias in announcing the results of the study, have been observed. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (independent t-test and paired t-test) in SPSS 16.

The results of independent t-test showed that there was no statistically significant difference between parenting stress of mothers (P = 0.881) and its subscales (P <0.05) before the intervention, but after the intervention this difference was significant (P <0.001), so that in the experimental group, the scores of parenting distress were significantly lower than the control group but the scores of parenting stress of mothers and other subscales were significantly higher. The results of paired t-test showed that parenting stress of mothers and its subscales in the control group were not significantly different before the treatment and after the treatment (P <0.05), but the scores of parenting distress after the intervention decreased significantly in the experimental group and parenting stress scores and its other subscales increased significantly (P <0.001). The results of independent t-test showed that the reduction of parenting stress scores of mothers and its subscales was less in the intervention group than the control group (P <0.001).
In addition, the independent and paired t-test analysis showed that written emotional disclosure was effective in reducing parenting distress sub-scale in experimental group (29.06 + 6.01) (p< 0/001). Also٫ the intervention could not improve the scores of parenting stress among experimental group (128.78 + 12.29) (p< 0.001).  

Written emotional disclosure, as a useful therapeutic intervention could be effective in improving parenting distress sub-scale٫ but ineffective in improving parenting stress. The findings of this study could also reinforce the hypothesis that expressing positive emotions about chronic stress may lead to more adaptive functions. This study suffers from some limitations. It was conducted on limited number of mothers with autism children, the same gender, and therefore, its generalizability is reduced. The results of this study show that the intervention of written emotional disclosure has been effective in increasing parenting stress of mothers with autistic children. Therefore, it is recommended to perform this method under the supervision of a consultant to control its negative effects. It is also suggested that future research, in addition to examining the variables affecting the effectiveness of this intervention, standardize the intervention pattern in writing positive, negative, and neutral emotions and use more follow-up sessions to enable more comparison.

Procrastination is a very common phenomenon and almost a global problem that exists in all cultures. Studies show that (80-95%) of students are involved in some form of procrastination and (50%) of them are always procrastinating in doing homework and learning subjects. Academic procrastination is one of the factors affecting studentschr('39') academic achievement and many students cannot use their maximum existential capacity due to this problem. In fact, procrastination causes a high degree of anxiety and depression in the person, which lowers his self-esteem. Self-esteem is one of the most important factors modulating psychosocial stress, which is based on family relationships, academic success, physical image, social interaction, and self-worth. The importance of these issues depends on individual differences and growth. Studies show that the way parents relate to their children and how they raise their children affect procrastination. In addition to common problems of other students, medical students also face special problems in their field, such as the stress of the hospital environment and dealing with the problems of patients, and are more at risk of injury. Therefore, it is necessary to examine different academic problems such as academic procrastination and its related factors including relationship with parents and self-esteem of this group to prevent the academic failure of these students as the future workforce. Training students who, due to academic procrastination, have not been able to acquire sufficient educational competence to provide services to patients will cause several problems in the health system in the future. This study aimed to determine the relationship between self-esteem and relationship with parents with academic procrastination in nursing students.

This predictive, correlational, cross-sectional study was conducted on nursing students of Shahrekord University of Medical Sciences during November-December 2019. The statistical population of this study was all students at the School of Nursing and Midwifery, Shahrekord University of Medical Sciences (nursing, midwifery, operating room, and emergency medicine). In total, 410 students were selected through quota sampling and included in the study. The inclusion criteria were being a student, nursing students in one of the intended disciplines, non-employment in the health system and other organizations. The exclusion criteria were being married, having a history of mental illness and not having parents. The measurement tool was a four-part questionnaire, with the first part related to demographic information (age, gender, field of study, semester, and degree), the second part was Solomon and RothBlumchr('39')s academic procrastination questionnaire, the third part was Rosenbergchr('39')s self-esteem questionnaire, and the fourth part of the questionnaire was the parent-child relationships devised by Fine, Moreland, and Schwebe. Data were analyzed in SPSS version 16 using descriptive (mean and standard deviation) and inferential statistics (t-test, one-way ANOVA, Pearson correlation coefficient, and linear regression) at the significance level of 0.05. The Kolmogorov-Smirnov test was used to evaluate the normal distribution of data, and Levene’s test was set as default in t-test. One-way ANOVA was also used to assess the equality of the variances.

Evaluation of the frequency distribution of quantitative variables using the Kolmogorov-Smirnov test showed a normal distribution of data (P>0.05). In terms of age range, the highest frequency belonged to the age range of 18-32 years and the average age of students in this study was 20.82 ± 1.83. Most participants were female. The participants were studying nursing, operating room, emergency medicine, and midwifery, with nursing having the highest ratio. Students in this study were classified into four semesters, with the highest ratio belonging to the first and fifth semesters and the lowest ratio to the third semester. The mean and standard deviation of the academic procrastination score in this study was 64.2 ± 4.48 which was moderate. The mean score of relationship with parents was at the desired level of 142.61 ± 7.11, and the mean score of self-esteem was 24.12 ± 1.45 which was at the average level. Pearson’s correlation-coefficient regarding the correlation between the studied variables indicated a negative and significant relationship between academic procrastination with relationship with parents (P<0.001; r=-0.54) and self-esteem (P<0.001;-r=0.32). Regression test showed that self-esteem (adjusted R2=0.102) and relationship with parents (adjusted R2=0.291) significantly predict academic procrastination. The unstandardized beta value showed that the share of self-esteem in predicting academic procrastination was 0.21, and the share of relationship with parents was 0.27. Mean scores of self- esteem, relationship with parents, and academic procrastination were 12.24 ± 1.45, 142.61 ± 7.11, and 64.2 ± 4.48, respectively. The standardized beta value showed that a one-unit increase in the standard deviation of the relationship with parents will decrease the standard deviation of academic procrastination by 0.40 (standardized β=-0.405). 1 unit increase in the standard deviation of the self-esteem variable will decrease the standard deviation of academic procrastination by 0.36 (standardized β=-0.363).

The study aimed to investigate the relationship between self-esteem and relationship with parents with academic procrastination. The results showed that increasing self-esteem and relationship with parents will significantly reduce academic procrastination in students. Self-esteem and relationship with parents also predict academic procrastination. According to these results, it should be said that studying self-esteem and relationship with parents in students is necessary and, these variables should be improved in educational systems with appropriate education, and therefore action should be taken to improve the situation of academic procrastination. The results of this study have some implications for administrators of educational systems to avoid the academic procrastination of medical students whose educational competence is of great importance. Using psychological counseling to assess mental health and its parameters, including self-esteem, helps in identifying students at risk. Also, identifying studentschr('39') broken relationships with parents through counseling can play an important role in improving their mental health and thus reducing their academic procrastination.

An efficient family cannot be defined as one that is free of mental stress, conflicts, and problems, but rather, it is defined based on the extent to which the family is capable of fulfilling its duties and functions. Poorly functioning families have difficulty dealing with emotional issues. In these families, communication is neglected or unqualified, the range of emotional reactions is limited, and the quantity and quality of these reactions is abnormal depending on the context and environment. These issues highlight the need to provide psychological training to the families of patients with chronic mental disorders. The variety and intensity of caring roles may lead to mental disorders in family members. If these individuals receive no intervention, their mental health will decline, thereby rendering them as ‘hidden patients’. Family interventions could reduce the recurrence and frequent hospitalization of patients with mental disorders. Therefore, the involvement of the families of patients with chronic mental disorders is paramount. The families who live with these patients are exposed to the challenges associated with their illness and are often responsible for their care and wellbeing. Life skills training is an effective psychological intervention that helps families promote adaptive and positive behaviors to manage the challenges of daily life. Life skills training for the families of patients with chronic mental disorders could also reduce the stigma associated with the disease, improve familial relations, and decrease the burden or stress of the caregivers. The present study aimed to evaluate the effect of life skills training on the performance of the families of patients with chronic mental disorders.

This single-group quasi-experimental study was conducted with a pretest-posttest design on 37 family members of patients with chronic mental disorders admitted to Iran Psychiatric Center in 2020. The sample size was calculated to be 32 considering the error rate of 0.05 and test power of 0.80, which was almost equal to 37 participants with 10% attrition. The participants were selected via convenience sampling from the family members of the patients. After obtaining the required permit to conduct the research, the researcher began the sampling process. Due to the simultaneity of the intervention with the Covid-19 pandemic, it was not possible to hold meetings in person, and the intervention was performed virtually. For this purpose, the researcher referred to the research environment, and after coordination with the educational supervisor, obtained the contact number recorded in the patientschr('39') files, and the families were contacted. While explaining the objectives of the research, the researcher convinced the families to participate in the study. To have access to all the subjects, the researcher formed a group in WhatsApp, which was called Life Skills, where all the subjects had direct access to the researcher. After completing the informed consent form and to perform the pretest, demographic forms were distributed among the families to measure the variables of age, gender, marital status, education level, relationship with the client, economic status, type of mental disorder, and family performance tools. One month after the pretest and at the end of the training course, the posttest was conducted electronically via WhatsApp by the researcher. The research samples were taught online in six 60-minute sessions for three weeks using recorded audio, PowerPoint, PDF files, and clips, which could be uploaded to WhatsApp. Initially, the demographic form and McMaster family assessment questionnaire were completed, and the life skills training was provided afterwards. The posttest was performed one month after the intervention. Data analysis was performed in SPSS version 16 using descriptive and analytical statistics. The study protocol was approved by the Ethics Committee of Iran University of Medical Sciences, and written informed consent was obtained from the participants electronically. Participation was voluntary, and the subjects were assured of the confidentiality and anonymity of the data. 

 The majority of the participants were aged less than 30 years (51.4%), female (75.7%), and married (56.8%). In addition, most of the subjects had academic education (73%) and a moderate economic status (75.7%), and the client-parent relationship was most frequent (40.5%). According to the posttest results, the mean scores of overall family performance (P<0.001) and its dimensions, including problem-solving (P<0.001), communication (P<0.001), roles (P<0.001), emotional response (P<0.001), emotional mixing (P=0.045), and behavior control (P=0.006) significantly decreased compared to the pretest, indicating the positive effect of the training intervention on family performance and its dimensions. Based on the calculated effect size, the maximum effect of the intervention was on the problem-solving dimension (0.93), and the minimum effect size was observed in the emotional response dimension (0.34).

 According to the results, life skills training for the families of patients with chronic mental disorders had a significant impact on all the aspects of family performance and could be used as an effective method in psychiatric centers to improve the performance of these families. Furthermore, it is suggested that psychiatric ward nurses become familiar with the educational content of life skills and family performance to implement these interventions for patientschr('39') families if necessary. Our findings could also help nursing managers and head nurses of psychiatric wards for the better management of care provision to patients with chronic mental disorders and supporting the families of these patients after discharge. The life skills educational content provided to our participants could also be provided to clinical professors, so that students would become familiar with these outlines and incorporate the content into their care plans. Since the implementation of an intervention based on life skills training improved family performance of clients with chronic mental disorders, it is suggested that a similar intervention be evaluated to improve variables affecting life skills areas such as communication skills, problem solving skills, and Behavior control.

Successful aging is a positive inner feeling and satisfaction from the past and present life. The subjective meaning of successful aging focuses on the inner dimensions of the aging experience such as happiness, self-fulfillment, emotions, perceived social support, satisfaction, and vitality in life. Perceived or subjective social support refers to individualchr('39')s cognitive evaluation of their relationships, and studying and evaluating perceived social support is closely related to self-assessment of health, and paying attention to its understanding is of utmost importance in health care. One of the variables that effect successful aging, and improves health and quality of life of the elderly, is mental vitality which is somehow tied to the concept of psychological well-being and this concept refers to being positive, full of energy and cheerful. In other words, there is a very close relationship between mental vitality and happiness and social interactions. All of these states are positive and favorable concepts and are therefore associated with positive emotions and mood, which are very important in old age. Today, with the increase in the number of the elderly and the prolongation of life and life expectancy, efforts are being made to identify the components and factors associated with successful aging that guarantee a better quality of life, to provide an accurate sociological picture for proper health planning for the elderly. Therefore, the aim of this study was to determine successful aging in the dimensions of perceived social support and mental vitality in the elderly referred to the health centers of Iran University of Medical Sciences in 2020.

This is a descriptive cross-sectional study. The research samples included 245 elderly people referring to the health centers of Iran University of Medical Sciences (in Tehran) in 2020 who were selected by continuous sampling method and entered the study after obtaining informed written consent. Data collection tools included Abbreviated Mental Test form (AMT), elderly demographic characteristics form, Multidimensional Scale of Perceived Social Support developed by Zimmet, and Mental Vitality questionnaire developed by Ryan & Frederick. The questionnaires were completed in person and by interview (conducted by the researcher) during three months. Data were analyzed using descriptive statistics (frequency distribution tables and numerical indices) and inferential statistics (independent t-test, variance, Pearson correlation coefficient, and regression) in SPSS 16 at the significance level of p ≤0.05.

The results of the present study showed that the mean age of the elderly was 68.18 ± 6.25 years. In total, (55.5%) of the subjects were women. Most of them were literate with undergraduate and postgraduate education and about (76.5%) were married and over (80%) had social security insurance. More than half of the surveyed elderly (53.4%) considered their current health status better than their peers and (96.8%) stated that they were able to perform their daily tasks and activities independently without the help and supervision of others. (66.8%) of the elderly surveyed considered religion to play a significant role in reducing stress and 51.4% stated that they were very satisfied with their lives. Perceived social support was at a high level for (65.6%) of the studied units. This component was the highest in the family dimension with an average of 22.76 and the lowest in the friends dimension with an average of 16.24 among the dimensions of perceived social support. Also, education at the diploma level with a standard coefficient of -0.261 had the greatest effect on perceived social support. Regarding the mental vitality variable, 76.1% of the studied units were at the average level. The results showed that satisfaction with the insurance situation in terms of coverage of medical expenses with a standard coefficient of 0.232 and poor economic status with a standard coefficient of -0.235 had the highest direct and inverse effect on mental vitality.

Perceived social support and high mental vitality in the elderly can pave the way for achieving a successful aging phenomenon. This concept includes the recognition of various components of successful aging such as perceived social support and mental vitality, longevity, independence in life, and other factors in health and social planning. According to the results, more than half of the studied elderly had high perceived social support, which can be considered as a positive factor affecting successful aging, because perceived social support decreased with age of the participants in this study. Also, perceived social support in the family dimension with the highest average among its dimensions showed the impact and importance of family relationships in successful aging. However, most of the elderly participated in this study were "young seniors" who were between 60 and 75 years old, and therefore it is possible that the high perceived social support in the samples be related to their young age, their independence, and their living with a spouse and family. Also, a significant percentage of the samples in this study had moderate and high mental vitality, which was influenced by their independence and satisfaction and benefiting from the insurance covering medical expenses. A better understanding of the two concepts of perceived social support and mental vitality can be the basis for successful aging-related interventions. It seems that the Holistic Care approach in modern nursing can empower the elderly with lower education and income and those who are single, unmarried, incapable, and independent in carrying out daily activities of life, and with an unfavorable understanding of their health status by performing health interventions, feeling of vitality and having perceived social support, and take an effective step towards achieving successful aging. One of the important goals of this study is to use its results to increase the quality of services and solve existing problems. The researcher hopes that the findings of this study can be useful in improving the goals of healthy, successful, and active aging in society in the following areas. Due to the descriptive cross-sectional nature of this study and the fact that in the studies conducted in the world, perceived support and mental vitality, two components of successful aging are influenced by several factors, it is suggested that future studies evaluate the longitudinal and trend of these two indicators in the elderly to get more accurate results from these two components.

Rheumatoid arthritis is an autoimmune disease with a chronic and progressive nature. It starts with periods of inflammation in the synovium, and causes it to be thicken resulting in edema in the synovial tissue. It affects 1% of people worldwide, but its prevalence varies among different regions, different races, and different groups of people. Like other chronic diseases, this disease not only has no definitive cure, but also leads to a severe decline in the performance of the affected people and a decrease in independence in performing their daily activities. Studies show that structured educational approaches about self-care can improve the performance and health of patients with chronic diseases such as rheumatoid arthritis. Accordingly, individuals must learn the knowledge and skills needed to make decisions, solve their problems, and communicate with others. Self-care education in these patients helps them to reach a level of health where they not only feel satisfaction with their personal life, but also can contribute effectively and significantly to the community as a citizen. Therefore, encouraging patients to adopt appropriate self-care behaviors is an important factor in the management of rheumatoid arthritis. People with high levels of self-care have more access to health care, experience shorter periods of hospitalization, and subsequently less complications caused by hospitalization in these centers. Without education and patientschr('39') participation in the self-care process, health care programs will be more expensive and the patient’s quality of life will be reduced. Thus, self-care education along with other treatment and rehabilitation processes seems necessary in patients with rheumatoid arthritis. Despite the importance of self-care, studies suggest that patients with rheumatoid arthritis have little knowledge and information about their disease and self-care methods, and lack of knowledge leads to frequent recurrence of the disease and an increase in the frequency of their hospitalizations. Likewise, there is a gap in the studies about education of affected people and few studies have investigated this issue. Therefore, the researcher decided to conduct a study to evaluate the effectiveness of self-care education on the functional status of people with rheumatoid arthritis.

This is an evaluation and single group study conducted on 40 patients with rheumatoid arthritis, and evaluated the effect of self-care education on functional status of patients with rheumatoid arthritis. The sampling process continued from October 2019 to February 2020 among patients hospitalized in the rheumatology wards of Imam Reza and Ghaem educational-research center and treatment centers in Mashhad. Before the intervention, the samples were asked to complete demographic and functional status questionnaire. They also completed the form of informed consent and the researcher ensured that their information would remain confidential. Five 25-minute self- care educational sessions were held for samples individually and at their bedside every other day. The researcher was responsible for holding educational sessions and presenting educational contents. Two weeks after the last educational session, functional status questionnaire was performed again to record the patientschr('39') function scores in different areas after the intervention. After the data collection process, data were analyzed using statistical tests in SPSS 16. Frequency and percentage were used for qualitative variables and numerical indices including minimum, maximum, mean, and standard deviation were used for quantitative variables. Paired t-test was used for inferential statistics for comparison before and after the intervention.

This study included 40 patients with rheumatoid arthritis hospitalized in rheumatology wards of Imam Reza and Ghaem hospitals. The Findings showed that the mean age of the samples was 45.72 ± 9.77 years, most samples (%70) were female, married (%87.5), housewives (%57.5), had a diploma and lower degrees (90%), and 55% reported an underlying disease. Most of them (%62.5) had rheumatoid arthritis for five years and less. Table 1 shows these findings. The results of t-test revealed that the score of activities of daily living (P<0.001), basic activities of daily living (P<0.0001), psychological function (P=0.001), job function (P<0.001), and social activities (P=0.002) increased significantly after the intervention.  However, the increase in the dimension of the quality of social interaction was not significant (P=0.77). In terms of tool cut point, the findings showed that the mean score of activities of daily living was at warning zone before the intervention for all samples, but after the intervention, (15.0%) showed good performance. In activities of daily living, before intervention all samples were at the warning zone but after the intervention, (12.5%) ​had a good performance. In terms of psychological function, before the intervention, 80% of the samples were at warning zone, but after the intervention, (25%) showed good performance and (75%) were at the warning zone. In job function dimension, all patients were at warning zone before the intervention, but after the intervention, (10%) had good performance. In social function dimension, 95% of the subjects were at the warning zone. After the intervention, (75%) were at warning zone and (25%) showed good function. In quality of social interactions dimension, before the intervention, (85.0%) were at the warning zone and after the intervention, (72.5%) of the subjects were at the warning zone and (27.5%) showed good performance.

The results of the present study indicated that a self-care education approach plays an effective positive role in the treatment and rehabilitation of people with rheumatoid arthritis and these programs can be used as a part of the healing process of these patients along with other treatment and rehabilitation processes. In addition, the research hypothesis concerning the positive effect of self-care education on the functional status of people with Rheumatoid Arthritis was confirmed using the research data. There was no statistically significant increase in the quality of social interactions, which may require more time, and it is suggested that future studies devote more time to examining changes. Also, using more specialized educational contents for quality of social interaction can improve and enhance the results of educational process in this area of functional status of rheumatoid arthritis patients.

Epidemics and their consequences have widespread effects on health care workers. Since hospital work environments are under high workload, complexity, and chaos, and are constantly changing due to different medical and care developments. During epidemic and pandemic crises, this situation is exacerbated by an increase in the number of patients and lack of resources, resulting in an increased likelihood of physical and mental vulnerability of staff. In this regard, the Covid-19 pandemic has caused physical and psychological challenges for hospital staff more than the previous epidemic, especially since the high prevalence and mortality rate of the virus is the most important challenge in this field. The other common unprecedented consequence of these conditions can be depression, anxiety, insomnia, and burnout of staff especially among the elderly and experienced staff. These secondary consequences have negative impacts on the quality of the services provided by the staff and act as major barriers to effective health care delivery. However, despite the many barriers, some facilitators can facilitate and improve the delivery of different services. For example, protective actions, social distancing, and widespread detective strategies, and detection of patients can play an important role in controlling the disease and thus reducing the workload of health staff.  Therefore, identifying barriers and facilitators in health care delivery for patients can be helpful in the management of this pandemic and we can rely on them to provide the basis for further studies and thus better planning. Therefore, this study aimed to explore the barriers and facilitators of caring for Covid-19 patients.

This qualitative study was conducted in 2020 employing Conventional content analysis Approach. In this study, semi-structured interviews were conducted with 11 physicians and 14 nurses who were working in the Covid-19 units of hospitals affiliated to Tehran University of Medical Sciences and were willing to participate in the study. In order to follow the social distancing, all interviews were conducted virtually via Skype, WhatsApp, and by phone at intervals of 45 to 60 minutes by an experienced interviewer. Some interviews were conducted visually and some orally at the request of the interviewee. Interviews were continued until the data saturation and not reaching the new code in the last three interviews. Data analysis was performed according to the proposed steps of Granheim and Landman. Finally, the interviews were transcribed, typed, and read several times to extract the original codes. The codes were then merged and classified based on the similarities, and finally the hidden concepts were extracted from the data.

A total of five themes and 14 subthemes were extracted from 340 initial codes in this study. The themes of this study were double-edged sword culture, individual factors, changes in care approach, organizational factors, and ethical challenges. In the theme of double-edged sword culture, two sub-themes of ‘collectivistic culture’ and ‘facilitator culture’ emerged. The cultural diversity of the community has created problems for the management of this disease and even the care of patients. Ignoring social distancing despite the warnings of Ministry of Health officials due to adherence to customs such as visiting and handshaking, had led to the spread of the disease and made its control difficult. Especially in the dominant Iranian culture, shaking hands is a custom and wearing gloves and masks is not a routine. On the other hand, in the culture of collectivism, they also help and cooperate with others, as they produced protective equipment and disinfectants through teamwork. Others encouraged inpatients by providing virtual communication through virtual networks which helped the treatment team and facilitated the caring process. Due to the rapid spread of the disease, the treatment team, in addition to being afraid of being a carrier, also had emotional problems due to quarantine. But having the idea that the nurses should not put stress on others, enduring psychological and physical stress as a result of the situation became more difficult. In this regard, in the theme of individual factors, three sub-themes of ‘fear’, ‘emotional emptiness’, and ‘ambassador of peace’ emerged. The nature of the disease, the use of protective equipment by the personnel, social distancing, changes in patient communication, changes in professional interactions, and feelings of powerlessness in virus management have all been challenges for the treatment team in caring for these patients. This condition has also affected nurse-nurse or physician-nurse interactions. But the pandemic made another change in the treatment team, and that was teamwork. Medical and nursing staff stated that they had not cooperated closely before for various reasons and refused to work as a team, but lack of equipment, insufficient knowledge about the disease had instinctively brought the treatment team closer to each other and all tried to do their best to eliminate the disease. Thus, ‘care metamorphosis’, ‘communication’, ‘missing links in care and treatment’, and ‘integration’ were the three sub-themes emerging in the theme of change in the approach to care. The themes of organizational factors included lack of necessary infrastructure, lack of equipment, manpower and lack of adequate space for patient care, but they were encouraged and continued to work with the support of hospital managers, the Deputy Minister of Health and the support of the Minister of Health. The four sub-themes of ‘structural problems’, ‘lack of manpower’, ‘insufficient equipment’, and ‘lack of organizational support’ were the most important obstacles for the treatment team in providing the best therapeutic performance. Another theme that emerged in this study was moral distress with two sub-themes of ‘guilt’ and ‘moral helplessness’ in which the individual raised issues such as lack of privacy, and not being at the bedside of a dying patient as his main concerns. Lack of privacy, reliance on writing the last name on the clothes and not introducing themselves to the patient at the beginning of the patient admission due to high workload and lack of time, elimination of the principle of respect for autonomy, lack of regular patient visits in the final stages of life except moral distress are discussed and classified.

According to the results, culture, individual, and organizational factors can be considered as both barriers and facilitators. But ethical challenges, as an important obstacle, can cause burnout in the medical staff. It is suggested that the authorities provide more psychological support to the treatment team, or give them a recovery period by employing new staff and reducing the workload of the treatment team. Also, getting help from a psychologist and psychiatrist, encouraging people to exercise, meditation and music can help strengthen the workforce in hospitals. Therefore, authorities should plan to increase the resilience of the medical staff in emerging and man- made phenomena such as the Covid-19 pandemic.