Vol 8 (2015)

Original Article(s)

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    The challenging nature of neonatal medicine today is intensified by modern advances in intensive care and treatment of sicker neonates. These developments have caused numerous ethical issues and conflicts in ethical decision-making. The present study surveyed the challenges and dilemmas from the viewpoint of the neonatal intensive care personnel in the teaching hospitals of Tehran University of Medical Sciences (TUMS) in the capital of Iran.
    In this comparative cross-sectional study conducted between March 2013 and February 2014, the physicians’ and nurses’ perceptions of the ethical issues in neonatal intensive care units were compared. The physicians and nurses of the study hospitals were requested to complete a 36-item questionnaire after initial accommodations.
    The study samples consisted of 284 physicians (36%) and nurses (64%). Content validity and internal consistency calculations were used to examine the psychometric properties of the questionnaire. Data were analyzed by Pearson's correlation, t-test, ANOVA, and linear regression using SPSS v. 22. Respecting patients’ rights and interactions with parents were perceived as the most challenging aspects of neonatal care. There were significant differences between sexes in the domains of the perceived challenges. According to the linear regression model, the perceived score would be reduced 0.33 per each year on the job. The results of our study showed that the most challenging issues were related to patients’ rights, interactions with parents, communication and cooperation, and end of life considerations respectively. It can be concluded, therefore, that more attention should be paid to these issues in educational programs and ethics committees of hospitals.

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    Special characteristics of care environments have always presented nurses with some challenges. One particular situation is futile care, which is frequently accompanied by countless moral and legal challenges. The dominant atmosphere in futile care may cause moral distress to nurses and lead to a sense of guilt, pain, suffering, job dissatisfaction, and eventually cause nurses to leave the job. This descriptive-analytical study attempted to investigate the relationship between futile care and moral distress in intensive care nurses. Study subjects were 300 nurses in intensive care units in Kerman, Iran and were selected by convenience sampling based on inclusion criteria. Study tools included Corley’s 21-item questionnaire on moral distress and a researcher-made 17-item questionnaire on futile care. Data analysis was performed using SPSS version 16 and suitable analytical and descriptive tests.
    The results showed a significantly positive relationship between moral distress and futile care ( P  = 0.03, r = 0.4). Based on the   obtained results, futile care can create conditions that may lead to moral distress in nurses and therefore strategies should be devised to prevent these conditions. Moreover, distress in nurses should be identified by periodical counseling so that it can be managed more efficiently.



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    Professionalism is the foundation of trust on which the doctor-patient relationship is built. This study was performed to measure professionalism in Iranian physical medicine and rehabilitation residents as a baseline assessment tool for future studies. This was a descriptive study. The Persian version of the American Board of Internal Medicine (ABIM) questionnaire was distributed among all the second and third-year residents of the medical state universities of Iran (n=43). Data were summarized as mean (SD), and independent samples t-test was used for comparison of means between genders, and also between the second and third-year residents. Forty questionnaires were analyzed. The mean (± SD) age of respondents was 29.95 (± 2.37) years. The mean score (SD) for the overall score was 115.15 (± 17.36) out of 150, and the mean score (± SD) for all items was 7.67 (± 1.15) out of 10. The respondents averaged 5.88 (± 1.69) for items forming the ‘excellence’ factor, 7.98 (± 1.48) for items in ‘altruism/respect’ and 8.92 (± 1.26) for items in the ‘honor/integrity’ subscale. These data may serve as a baseline for future research in this field. The lowest score pertained to excellence, which needs more focus in future studies.

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    Nurses are often faced with serious situations that require high levels of legal and ethical knowledge, and should therefore be sensitive to the moral issues in their profession in the decision making process. Some studies have investigated nurses’ moral self-concept as an effective factor in moral sensitivity, but there is not sufficient evidence to support this. The purpose of this study was to determine the correlation between moral sensitivity and moral self-concept in nurses employed in the teaching hospitals in Zahedan, Iran. This cross-sectional descriptive study aimed to study the relationship between moral self-concept and moral sensitivity in nurses employed in the teaching hospitals affiliated with Zahedan University of Medical Sciences. Chang’s Moral Self-Concept Questionnaire and Lutzen’s Moral Sensitivity Questionnaire were used for data collection. Data analysis was performed using SPSS software version 17. A total of 188 nurses participated in this study. The results showed that there was a positive and significant relationship between moral self-concept and moral sensitivity ( P  < 0.05). Based on our findings, an individual's attention to moral issues can lead to greater sensitivity and result in morally responsible behavior at the time of decision making. Consequently, promotion of moral self-concept through personal effort or education can increase moral sensitivity, which in turn leads to behavioral manifestations of ethical knowledge.



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    Clinical education is an essential part of medical trainees’ education process, and curriculum planners agree that it should be based on ethical standards and principles in the medical field. Nevertheless, no explained and codified criteria have been developed for ethics in clinical teaching. This study was aimed to develop an ethical guideline for medical students and teachers as the first and most important step in respecting patients' rights in educational centers. The initial draft included the codes of ethics in clinical education and was developed based on library studies. Subsequently, it was improved through a qualitative study using semi-structured interviews and focus group sessions with medical students, patients, and medical teachers in educational hospitals affiliated to Tehran University of Medical Sciences. The improved draft was reviewed and validated by a medical expert panel to prepare the final draft. The codes derived from this study included patients’ choices and rights in purely educational procedures, and special considerations for a) obtaining informed consent for educational procedures; b) performing procedures on deceased persons, patients under anesthesia and those lacking decision making capacity; c) educational visual recordings of the patients; and d) safety monitoring in clinical education. The guideline developed in this study incorporates codes of ethics into clinical training. Therefore, in addition to providing efficient education, the interests of patients and their rights are respected, and the ethical sensitivity of learners in primacy of patients’ best interests will be preserved and enhanced.

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    Preservation of dignity is frequently emphasized as a basic patient’s right in national and international nursing codes of ethics and is indeed the essence and core of nursing care. It is therefore essential to explore the concept based on patients’ lived experiences in order to maintain and respect their dignity and consequently improve the quality of health services and patient satisfaction. The present study aimed to discover the lived experiences of Iranian patients regarding maintaining their dignity at the bedside. This qualitative study was conducted using an interpretive phenomenological approach. A total of 14 participants (9 women and 5 men) were purposefully selected, and data were collected through individual, semi-structured and deep interviews. The recorded interviews were transcribed and analyzed by the Diekelman, Allen and Tanner approach. The findings of this study revealed three main themes and related subthemes regarding the meaning of preserving patients’ dignity. The first main theme was “exigency of preserving the innate human dignity” and comprised two subthemes: “respect for the intrinsic equality of all humans” and “treating the patient as a valued person, not an object”. The second theme was “service based on love and kindness” and included two subthemes: ‘being with the patient” and “inspiring the sense of being accepted and loved”. The third main theme emerged as “dignifying and transcendental professional service” and consisted of two subthemes: “professional commitment to uphold patients’ rights” and “enlightened practice”. This study revealed that the concept of maintaining patients’ dignity is related to health providers’ duty to preserve patients’ dignity and also their moral obligation to manifest the human love that is in their own as well as their patients’ nature. In conclusion, if nurses reflect on the transcendental nature of nursing care, they will value and prize their everyday bedside nursing practice and will utilize their capacities to be more human as well.

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    Ethics are related to the structure and culture of the society. In addition to specialized ethics for every profession, individuals also hold their own personal beliefs and values. This study aimed to investigate Iranian occupational therapists’ perception of ethical practice when working with children. For this purpose, qualitative content analysis was used and semi-structured interviews were conducted with ten occupational therapists in their convenient place and time. Each interview was transcribed and double-checked by the research team. Units of meaning were extracted from each transcription and then coded and categorized accordingly. The main categories of ethical practice when working with children included personal attributes, responsibility toward clients, and professional responsibility. Personal attributes included four subcategories: veracity, altruism, empathy, and competence. Responsibility toward clients consisted of six subcategories: equality, autonomy, respect for clients, confidentiality, beneficence, and non-maleficence. Professional responsibility included three subcategories: fidelity, development of professional knowledge, and promotion and growth of the profession. Findings of this study indicated that in Iran, occupational therapists’ perception of autonomy, beneficence, non-maleficence, fidelity and competence is different from Western countries, which may be due to a lower knowledge of ethics and other factors such as culture. The results of this study may be used to develop ethical codes for Iranian occupational therapists both during training and on the job.

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    Physicians’ knowledge of therapy and counseling stands among the most important issues in the viewpoints of clients who refer to psychiatric centers. Transsexual patients are very important in this regard. The goal of this research is to study their attitude toward doctors’ empathy. A group of transsexual patients who referred to the Tehran Institute of Psychiatry, Iran, answered the Jefferson Scale of Empathy. The relationship of the patients’ age, gender, education level, and lifestyle with their attitude was measured.
    This study was conducted on 40 patients, including 16 women (40%) and 24 men (60%). In terms of education, 8 patients had a degree below high school diploma (20%), 9 had high school diploma (22.5%), and 23 patients were university students or of higher education level (57.5%). Among these patients, 6 were unemployed (15%), 10 were students (25%), and the rest were employed. Moreover, 8 participants lived alone (20%), 5 lived with their friends (12.5%), and 27 lived with their family (67.5%). Gender had no influence on the average score of the questionnaires, yet level of education had some influence. Lifestyle also had a significant influence on the patients’ attitude. On the other hand, patients whose problems began before the age of 12 had lower score than others. Experienced psychologists in referential centers can express greater levels of empathy to specific diseases and this trend is very effective on the patients’ cooperation level. In order to create an effective relationship between physicians and patients, the efficiency of the health system and increasing satisfaction of specific patients should be considered.

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    In research on the history of medicine, less attention is paid to the subject of historical geography. Considering the importance of this subject in the history of science, this paper discusses one of the most important science centers in the world. This outstanding medical research center was located in Gorganch city, Chorasmia area, in the Eastern part of the Islamic. Chorasmia medical school was one of the important Iranian medical schools before the Mongols’ attack. Its history (305-1231 A.D.) can be divided into three eras; Ale Iraq, Ale Ma'mun, and era of the Khwarazmian dynasty. This geographical area in the Northeast of Iran has escaped the notice of researchers in recent studies. The presence of great Persian physicians and scientists throughout history in this area indicates its scientific importance. The present article focuses on Chorasmia Medical School since its establishment until the Mongols’ attack.

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    The patients’ rights status is one of the essential elements in defining norms related to the concept of clinical governance system. In addition, the patients’ rights status is an important index for quality of care offered in the health care system. However, the lack of a coherent instrument makes it difficult to evaluate patients’ rights status in hospitals and clinics. The aim of this study was to develop an instrument for the evaluation of patients’ rights prerequisites at educational hospitals in Iran.
    This study was conducted using the modified Delphi technique. In this study, 36 experts in the fields of law, medicine, and professional ethics were participated. The panel of experts participated in 3 rounds. First, experts were asked to judge some pre-identified items, and then, excluded items were judged again in the second round. At the end of the third round, all of the agreed items were included in the final list to form an evaluative scale on practice of patients’ rights.
    Experts were asked to judge a total 171 items in 3 rounds. Around 31% (n = 53) of items obtained the panel’s approval to be included in the final version of the scale. The experts’ opinions were collected using face-to-face interviews and electronic email during a 6-month period of data collection from October 2013 to February 2014. This study developed a 53-item scale for evaluation of patients’ rights prerequisites in educational hospitals in Iran. This scale was developed in 7 areas of commitments including university education, research, supervision, process management, physical structure, organizational policy, and human resources management.
    This study developed an evaluative scale to assess the practice of patients’ rights in educational hospitals. The items in the final version of this scale were obtained from a consensus of experts and the instrument can be used to evaluate the context and prerequisites for practice of patients’ rights in Iranian educational hospitals.

Review Article(s)

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    T Ferdous al-Hekma (Paradise of Wisdom) is one of the oldest medical texts in the Islamic world written in Arabic in 850 AD by Ali ibn Raban Tabari. He was a Persian physician who moved from Tabaristan (Mazandaran province of modern day Iran) to Samarra during the reign of the Abbasid Caliph al-Mutawakkil (847-861 AD). We studied the book of Ferdous al-Hekma fil-Tibb, in an attempt to comprehend its general outlook on diseases of different organs, their classifications and the associated signs and symptoms. The book is one of the earliest medical pandects of the period of translation, adaptation and expansion of knowledge in the Islamic world during the 9 th  century AD. Tabari was mainly influenced by Hippocrates, Galen and Aristotle, as well as his contemporaries Johanna ibn Massavieh and Hunayn ibn Ishaq. The book is written in thirty chapters in a total number of 308 subtitles. In each part there is an introduction to the symptomatology, followed by organ specific diseases and therapeutic recommendations. Symptoms and physical signs of different diseases are vividly described in Ferdous al-Hekma, and some of them are even understandable for contemporary medical students.