Nursing leadership competency learning- an integrative review

Document Type: Systematic review/Meta analysis

Authors

1 Ph.D. Student, Faculty of Economics and Administrative Sciences, Lorestan University, Khorramabad, Iran

2 Department of Business management, Faculty of Economics and Administrative Sciences, Lorestan University, Khorramabad, Iran

Abstract

Background: In the last decade literature, inquiries and reports into the short comings in health services have highlighted the vital role of leadership in clinical practice and the impact on patient care and effective workplace culture. Given the important role of nurses as the largest therapeutic group in health systems, the question is how nurses acquire clinical leadership abilities? and what is the situation in our country?This study has reviewed related literature.
Methods: In this review paper, the databases such as Science Direct, ProQuest, PubMed and Scopus databases, Emerald and Google Scholar search engine and also the Scientific Information Database and Magiran databases for Iranian articles searched for valid English and Persian articles from 2008 to 2018 using keywords combination of keywords such as “nurses leadership competency” in 2019. After reviewing the papers24 relevant cases were selected.
Results: In the first phase, 136 articles were selected and after careful examination, 24 papers were approved at the final stage, it was found that education and leadership development is the most important factor for gaining managerial competencies for nurses. Also, the status of teaching leadership skills for nursing in Iran has a weak position. Because there are no plans for leadership skills training either in the educational curriculum or after graduation.
Conclusion:  It is imperative nursing managers and planners need to revise the current curriculum incorporate leadership training. Also, in the post-graduation period in continuing education, the courses of applied management and leadership should be identified and trained according to the real problems of country's health systems.
 
 

Keywords


INTRODUCTION

Demographic change, lack of appropriate global and regional health care, digital technologies, limited financial resources and economic pressure have affected health care delivery. These factors affect the relationship between healthcare providers and health clients. To meet these challenges, health care leaders are forced to redesign new models of new services that may deliver the best affordable, reliable and cost-effective care (1).

The foundation of any successful organization is its human capital, and the use of the most qualified people is a prerequisite for any organization's success. Weakness in selecting and recruiting qualified people leads to lack of effective leaders in health care organizations (2).

 

Currently, the health system in our country has major problems and disadvantages due to lack of proper leadership and management. Identifying and resolving these gaps leads to training successful managers and improving the quality of services (3). Leadership has existed in all societies since the earliest times. However, despite numerous models and extensive exploration of this concept, efforts to define leadership in nursing and other disciplines continue (4).

 Leadership effectiveness, management experiences, and core competencies of nurse administrators in healthcare settings are interesting concepts that are dominant in the leadership repertoire. The concept of leadership, especially clinical leadership, has become one of the most popular and hot topic in health care (5).

There are different expectations in nursing, physicians, and other health care providers today, because many of them are in managerial positions that should perform their correct role there. Nurses are the largest working group in health care, nearly about 50% of health care services; however, in some countries this rate reaches 80%. Nurses are at the forefront of serving patients. In addition, educational, research, communication, and counseling roles highlight the role of nurses in health care settings. Academically, the value of a good nurse is equally valuable to a good doctor. In today's health care system, nursing managers should use appropriate leadership styles for a complicated, troublesome, and ever-changing health care systems (6).

In the clinical field, changing the roles and challenges of nurses' duties has made nursing a complex occupation and requires a variety of skills. This can lead to more attention to the clinical relevance (7).

 In addition, nursing managers can significantly affect overall hospital organization performance and quality of patient care. Therefore, nursing unit managers must have appropriate management capabilities, as they can influence the professional performance of their nurses. Nursing managers devote a great deal of time and energy to educating patients and families, nursing staff, nursing students, local residents, as well as coordinating with various departments inside and outside the hospital (8). Globally, leadership in nursing has become a significant issue, and emphasizing on ‘leadership as a key component in all industries’ is well recognized (9). In different departments of clinical organizations, roles, levels of responsibility and expertise determine the type of leader. Nurses need to develop their professional and managerial excellence by developing their leadership abilities during their education and after graduation. (10). It has been noted that there is a lack of preparedness for leadership at every level of nursing practice, from the direct care level through the administrative level, and particularly among recent graduates (11). Nowadays, nursing organizations in advanced countries that create educational reforms face with many challenges such as achieving competency for nurses, creating inter-organizational partnerships and developing more practical nursing programs, increasing clinical skills, and unifying theoretical and clinical courses (12). Although many studies have been conducted on the leadership styles and competency models of nursing, the key challenge is how nurses can learn leadership skills, and How the situation will be for them in Iran.

Considering the mentioned problems, the aim of this study is to evaluate how nurses get clinical leadership competency according to the published articles and what their status in our country is.

Methods:

In this review paper The Science Direct, Proquest, PubMed and Scopus databases, Emerald and Google Scholar search engine and also the Scientific Information and Magiran databases for Iranian articles were searched using the keywords of clinical leadership, nursing leadership, clinical organization leadership, nursing leadership competency, education, while they were mixed with “AND” and “OR” as a search strategy to investigate the status of learning leadership skills in nurses and its status in Iran. The articles published from 2008 to 2018 were selected. The importance of this time period is due to rapid changes in advanced technologies such as computers, IT, and virtual systems, also the importance of managing healthcare organizations has been highlighted (13). The inclusion criteria of the articles focus on the problems or challenges proposed in clinical and nursing leadership, access to full-text articles, and papers written in English and Persian languages. This study was conducted in accordance with the standard systematic review and meta-analysis protocols (PRISMA-P). This protocol is used as a guide for researchers in improving the presentation of systematic review articles. In this study, CASP was used to evaluate the quality of papers by researchers. First the title and abstract of articles were reviewed and unrelated articles were removed.

The exclusion criteria comprised of abstracts without the text and articles. The main focus was not leadership competency in health care organizations. After searching by two researchers, the papers were reviewed and unrelated papers were identified and excluded from the review cycle. Then, full-text articles with a focus on nursing leadership competency were reviewed by the research team.

All disagreements were resolved by scholarly discussion between the two authors or, if necessary, with the advice of a third author. The process of information quality management consists of all three main steps: collecting, processing and presenting data and information. Therefore, this study was conducted in all dimensions.

 

Results:

Throughout the first step of the “screening” phase, from among 136 articles searched in databases, 110 papers were exited the review cycle, since their title, keywords, or abstract did not show the desired themes, so 24 articles were remained in the final analysis. As table 1 shows. Most of the articles published in this field were in the United States, and most of them were survey methods.

In addition, training programs as leadership development courses were identified as the most important tool for nurses' leadership skills development. An interesting point in this study was to examine leadership competence in different academic theses because theses have special values in the scientific strategy of countries. The lack of attention to this issue was also evident in our country's dissertations.

Table1. A summary of extraction table of reviewed articles’ result

Study author and year

year

Participants

Aim of the study

Main findings

Jane M. Milesa, , Elaine S. Scottb (4)

2018

review

To establish an integrated leadership development model for pre licensure nursing students

Design Leadership Development Model

Brown A , Crookes P, Dewing J (5)

2015

418 nurses

To identify what the profession's views are on proposed indicative curriculum content suggested for

clinical leadership development in a pre-registration nursing degree in Australia

This survey has identified curriculum content, endorsed by professional nurses that

could be included in a pre-registration nursing programme for clinical leadership

Berman A (14)

2015

Eight faculty  nursing members

Leadership development program for early- to

mid-career nursing faculty consisting of one 4-hour evening session per academic quarter for 7 quarters.

the value of the program as preparation for academic nursing leadership roles, and broad program

applicability

Daniel J. Pesutabc Sarah A (15)

2018

review

discuss insights derived from adult cognitive developmental theories and relate

the insights to vertical leadership development in academic nursing contexts

 

Leadership wisdom is a function of horizontal (acquisition of information, skills, and competencies) and vertical development (the development of more complex and sophisticated ways of thinking).

Laurence Ha, Pepin J (16)

2018

with

23 students and 6 nursing educators

report the qualitative evaluation of a co-constructed educational

intervention on clinical nursing leadership, developed for 1st year preregistration nursing students

Thematic analysis revealed three intervention components

that supported learning: visual examples at the student's level, observation of role models and animated discussions in small groups.

Dierckx de Casterlé B, Willemse A, Verschueren M, Milisen K (17)

2008

17 participants(nurse and medical doctors

explored the dynamics related to a leadership development programme

and their impact on the clinical leader, the nursing team and the care-giving

process

Improved clinical leadership

seemed also to influence patient-centred communication, continuity of care and

interdisciplinary collaboration

Deacon KS etal (18)

2017

review

Critical Care nursing community about a lack of consistency in post-registration education programmes.

introduces the National Competency Framework and provides an overview of

its background, development and implementation.

Deborah A., RN, CKirsten N.,Catherine L, Donald E (19)

2011

56 nursing students

describes an integrated instructional approach to

developing clinical leadership competencies in a cohort of accelerated, second-degree,

baccalaureate nursing students

Nurses

need to seek challenges by developing their leadership

abilities in pre licensure education and continuing

their leadership development throughout their career

mahdavisaeb F, ruhani M, hanifi N, kamali K (20)

2016

148 nurses

study was conducted to compare CCNs' clinical competency using self-assessment method and

assessment by their Head nurses

current study revealed that there is no agreement between the evaluation of CCNs' clinical

competency by own nurses and their head nurses indicating these two methods are not interchangeable

Eun HaChoi ,Eun-KyungKim,Pil BongKim (21)

2018

216 nurses

identifies the effects of the educational leadership of nursing unit managers on team

effectiveness and the mediating effects of organizational communication satisfaction;

Educational leadership was significantly positively correlated with team effectiveness and organizational

communication satisfaction.

Reem Nassar Al-Dossary, Panagiota Kitsantas, Peggy Jo Maddox, (22)

2016

98 nurses

assess the impact of residency programs on leadership skills of new Saudi

graduate nurses who completed a residency program compared to new Saudi graduate nurses

who did not participate in residency programs

residents were significantly

more likely to show higher levels of leadership skills compared to their counterparts. Attending a

residency program was associated with a significant increase in clinical leadership skills

Rezapour Nasrabad R (23)

2016

19 nurses

Explain the main component of leadership skills in the nursing profession.

designing proper policies and

strategies to create and strengthen of these skills in nurses

Should be considered. In this way improve the quality of nursing

services will be provided

Meeks F, (24)

2018

review

Compare existing leadership competencies to identify and highlight gaps in clinical

staff nurse leadership role competency development and validation.

competencies nursing leadership model could be the basis for training, education, and evaluations of leaders in both the academic and

clinical settings

Ghorbani M, Ghamari Zare Z, Haghani F, Purfarzad Z (25)

2016

review

to set forth the procedural guidelines of situational leadership style in clinical education for nursing students

Enhancing the nursing educators’ leadership skills is of utmost importance for achieving greater clinical efficacy; therefore, educators should apply situational leadership to clinical education.

Carolene G. Stephensonphd thesis (26)

2017

100 of the American Organization of Nurse Executive

(AONE

determine if management experience and leadership effectiveness predicted

core competencies of nurse administrators

The

significance of a strong relationship between Critical Thinking Skills and leadership

effectiveness

Salehmoghaddam A, Halakou S, Heshmatinabavi F, Mazlum S (27)

2015

37 head nurses, 72 newly nurses by

census method and, 283 non-newly nurses participated

determine of relationship between

head nurses' technical-clinical competency and organization

competency and newly nurses' clinical competencies

based on findings suggested that nurse managers' stress

on in-service education for head nurses strongly, for improving their managerial competencies

Hafsteinsdóttir TB1, van der Zwaag AM2, Schuurmans MJ (28)

2017

review

investigating leadership programs and mentoring for postdoctoral nurse researchers

positive influence of mentoring on research productivity, including

increase in publications and grant writing and research career development, improved leadership skills and

knowledge

Savage GT, Duncan WJ, Knowles KL, Nelson K, Rogers DA, Kennedy KN (29)

 

 

 

 

 

2014

120 faculty members and non-faculty

administrators

escribes the genesis of the University of Alabama at Birmingham’s Healthcare Leadership

Academy (HLA), highlights the HLA’s outcomes, discloses how the HLA has changed, and delineates future

directions for academic health center (AHC) interprofessional leadership training.

Interprofessional leadership training expands individuals’ networks and has multiple

organizational benefits.

Lee E, Daugherty J, Hamelin T (30)

2018

review

Challenges that healthcare leaders will face in redesigning

the health care ecosystem in the 21st century

Effective nursing leadership in a healthcare organization

correlates with staff job satisfaction, retention, turnover and quality of care. Nursing leadership development must be supported by appropriate

level of educational preparedness, and requisite set of competencies and

skills

Zarei E etal(31)

2013

227 of middle managers

assessing management development needs from the viewpoint

of middle managers of hospitals affiliated to Tehran University of Medical Sciences

Managers need to develop administrative skills, abilities, knowledge, personality and philosophic mindedness to play the best managerial roles.

PAUL J. BABINSKI PhD thesis(32)

2015

313 clinican manager

Health role competency

there was a significant difference on rating the perceived importance of

specific leadership competencies by the health care leaders between each competency

domain

Elliott N, Higgins A, Begley C, Lalor J, Sheerin F, Coyne I, Murphy K (33)

2012

23 Directors of Nursing/Midwifery

To report a case study that identifies how leadership is enacted by advanced

practitioners in nursing and midwifery and differentiates between clinical and

professional leadership in advanced practice.

leadership activities identified provide greater clarity in

distinguishing between professional and clinical leadership and in specifying the

nature and scope of leadership activities.

LN Chapman A, Johnson D, Kilner K (34)

2014

224 medical leaders

determine the predominant leadership styles used by

medical leaders and factors influencing leadership style use

Leaders used a range of styles, the predominant styles being democratic, affiliative and

Authoritative. Organizational culture, context, individual

propensity and “style history” emerged during the inductive analysis as important factors in

determining use of leadership styles by medical leaders.

Martha A. van der Wal et al (35)

2015

117 residents

investigate which leadership behaviors residents observe throughout their training, which behaviors supervisors

report to display and whether residents and supervisors have a need for more formal training.

Moreover, residents and supervisors

Both express a need for more formal leadership training. More explicit attention should be paid to leadership

Development, for example by providing formal leadership training for supervisors and residents.

 

 

 

Discussion:

This integrative review aimed at Assessment of Leadership Skill Learning in Nurses and its Status in Iran by searching, analyzing, and synthesizing papers on nursing competency leadership from 2008 to 2019.

The results showed that special training courses and leadership development projects are the most important learning tools for clinical leadership competency improvement for nursing. Educational programs in any country can be considered as a long-term investment for the new generation as its aim is to develop human capital (36). Therefore, it is necessary to design training programs to create the necessary managerial competencies to perform occupational and professional duties in health and clinical organizations. Thus, after completing their clinical education, students acquire managerial competencies beyond clinical skills, including communication skills, collaboration, ethics in medicine, and management (37,38).

 

 In Zaemipour's study, implementation of the program for improving the leadership skills of managers in group training led to the promotion of perceptualization of nursing pressures from 11% to 23%) (39). There is also a lack of consistent attention toward leadership education and a lack of a broadly recognized structure for leadership competencies and development within the nursing profession. Additionally, there is a paucity of related research to support best practices in leadership education for nurses (25,30).

Newly graduated nurses are widely expected to perform managerial and leadership tasks in addition to specialized health care. According to the institute of Medicine (2011), Future Nursing Scenario Include Leading Change and Advancing Health.It is vital that nurses be able to handle multiple capabilities such as: lead committees, inter-professional teams, hospitals and health care management.

However, according to Heller et al. (2004), nurses do not acquire leadership skills in a clinician role by their current nursing education programs (20).

Ensuring clinical competences is a goal of nursing education, which strives to performance of specialized clinical skills, effective communication, problem solving, clinical decision making and judgment. It is important that nurses are aware of their clinical competence and strive to develop their competencies (40).

A review of the nursing education literature illustrates the increasing importance of awareness of the need for leadership as well as a wide range of educational approaches to developing leadership skills in nurses. Nurses are highly trained in managing symptoms of illnesses and care, but are not trained in human relationships and behavior in the organization.

Many international studies show that nurses are increasingly dissatisfied with the hospital work environment. Many factors affect the negative work environment, such as insufficient management support, lack of proper communication and information flow from nursing management to nursing staff, lack of teamwork between nurses and doctors, lack of equipment and financial problems (33,25,18).

Nursing instructors are responsible for preparing nursing students for clinical leadership. Therefore, designing a curriculum that contains applied content is crucial for upgrading leadership skills.

To bridge the gap in leadership skills, nursing educators need to redesign strategies such as integrating management programs into the clinical environment with innovative approaches and educating students (10).

Competent-led nursing leadership in a health care organization guarantees job satisfaction, proper turnover, and quality of care. Furthermore, nurses acquire the necessary leadership skills to achieve effective leadership, during college education, or after graduation. Clinical specialists are trained to think in a Specialized one-dimensional, with a strong emphasis on individual responsibility.

Many organizations have rewarded expert clinical nurses with management promotion without consideration for competency in the new role (39,41).

90 percent of nursing students believe that clinical nursing education is not associated with a problem. So more attention is paid to clinical education in nursing to resolve problems and identify challenges as an important issue (42).

Some training problems for nurses are summarized as follows:

The academic education does not work on its core mission because of not paying for clinical education ,unavailability of clinical instructors, the lack of coordination between theoretical and practical lessons ,not encouraging students, unclear job descriptions in the department, understanding the inadequacy of society and people in nursing, initial care by the student, not using the nursing process in care and lack of facilities for students, compliance with the usual and improper regulations governing the educational environment, not paying attention to student's insights on apprenticeship planning, Dissemination of theoretical and training courses, lack of amenities ,the role of the student in planning patient care, lack of educational facilities in the clinical setting,  lack of evaluation of clinical instructors by student, the high number of students in the department, inconsistency in educational goals with the expectations of the department staff and the insufficient number of patients to learn sticking, inadequate facilities and facility for educational centers, lack of experienced coaches for training in clinical education environments; however, despite these problems, we expect to train qualified clinical leaders (42,43).

 Evidence suggests that nursing education in Iran is not suitable and theoretical and practical courses for nursing students are not appropriate to future job needs, so leadership training has become a basic need for nursing students.

For example, In the bachelor's degree, two management units are taught, while in the PhD there are so many challenges, so PhD nursing in Iran is teaching nursing philosophy, in other words, student do not train for clinical work at all (44). While higher education courses in nursing education could provide an opportunity for educating powerful mentors to train nurses' competencies and empowerment, there is no good exploitation of this potential (45). We will continue the discussion in two parts:

 1) Nursing student education curriculum

2) After graduation with an emphasis on continuing education

 

1)      curriculum education

 

Although clinical practitioners such as nurses have been learning about physiology, anatomy, and biochemistry for a long time, but there are limited formal opportunities for learning fundamental leadership skills such as team building and teamwork, how to interact with difficult staff, coaching and developing others and solving organization conflict. Nurses are not trained for supervisory responsibilities in different parts of the health system. Also, studies on clinical education in Iran show that there is no compatibility between academic education and clinical work environment (46).

Today, leadership competence is a necessity for nurses. All top clinical training centers have made many changes to their old training courses upbringing clinical professionals with leadership skills. They use an integrated and competency basis curriculum because their goal is to bring up a 5-star doctor. Compared to the advanced countries of the world, Iran's clinical education curriculum has a weak position and needs serious reforms.

The nursing curriculum must also be consistent with these changes. Empowering students will enable them as tomorrow’s leaders to tackle the challenges of modern medicine. Management courses must teach such skills and emphasize the importance of organizational behavior and human resource management. Many surveys showed that most of medical and nursing students thought that they should be taught leadership, communication, teamwork, and quality improvement skills in health-care schools (47).

 

2)      continuing education problem

 

The main problem is the content of continuing education programs is, lack of management training and clinical leadership competencies for professionals. Although the philosophy of continuing education is to promote the comprehensive professional skills of clinical professionals in terms of clinical, managerial, social, and ethical skills, but it seems to be unilaterally focused on clinical problems (48).

So, the question arises that where is the place of continuing education to strengthen qualified clinical leaders?

Most medical students and clinicians in various researches have stated that management skills cannot be achieved on the basis of experience over time and it needs to be trained. In Iran for nursing training curriculum, no educational content has been considered for management competency training. After graduation, by the pathology of continuing education, the lack of well-trained and managerial issues is quite evident. Unfortunately, this process is very unilateral and clinical (49). Continuing education should shift the outcome rather than the process oriented. Many scientists have identified leadership and management as the most important challenges for health organizations. Peter Drucker said "you educate the managers, everything will be right and he believes that there is a consensus in the management world about the fact that leaders are made and are not born; therefore, the concept of competency-based training was created” (50).  

If clinical practitioners are committed to strategic planning and hospital landscape design, continuing education is successful in its workflow. Therefore, after graduation, continuing education becomes a strategic asset. After graduation, the only formal training of nurses is through continuing education, while there is no option for leadership training that leads to major problems (48).

Findings from several studies suggest that teaching leadership skills to students at a modest cost at universities is practical. Otherwise, the training of management skills at the workplace will be accompanied with a lot of errors and mistakes. The results of the study by Bahadorian et al (2015) showed that leadership training should be transformed from theoretical issues into operational and innovative programs. When training combines management and clinical skills, students in clinical settings in internships have the opportunity to actually apply their learning skills at the same time (45,47,50).

In the nursing literature, leadership is usually related to the nurse managers and does not play a significant role in the nursing process.Leadership is an important factor in the nursing profession and must be included in the nursing process.Because leadership is an essential element of excellence in patient service.Good clinical leadership skills give nurses the opportunity to succeed in their organization in addition to performing specialized clinical work and optimal patient care, thus improving productivity and promoting organizational behavior of health organizations (51).

Theories about how students learn from college / university suggest that leadership skills improve over time through experience and leadership development courses, especially in continuing education. National Health Service Leadership Academy (2011) plans to train nursing leadership skills from the beginning of student enrollment whereas in the past, leadership skills were limited to the final year before graduation (52,53).

For the first-year students, the workshop of leadership skills and discussion in multiplayer groups was found to be very useful in strengthening communication skills (54).

Providing more information and workshops for clinical managers about leadership styles, strengths and weaknesses of each and the requirements for their application can lead to the correct implementation of leadership styles and more efficiency (55). The interest in leadership development for nurses has been significant. Referring to the implications of the American Association for Colleges of nursing (AACN; 2008) document, Curtis, suggested the possibility of integrating leadership education “longitudinally through the continuum, as such an approach could prepare nurses to see practice as part of leadership instead of the current situation whereby leadership is being presented as part of practice”. Different research clarifies the need for more consistent approaches to leader development and advocate for the nursing profession to “commit to a course of education for tomorrow’s leaders by creating relevant, flexible, innovative curricula, and life-long learning plans” to ensure that future leaders are well-served and as a result, the health of the country is advanced. Scott and Miles (2013) asserted that all nurses, not just those in administrative roles, must be equipped with leadership skills and attitudes that allow for contribution, innovation and health advancement (56).

Residency plans for first-year nurses enhance their management skills and also provide benefits to patients. In fact, the Nurses' residency program reduces the gap between the university and the complex clinical work environment (57). Additional modifications were advancement in nursing education, increased doctoral-prepared nurses by 2020 to double the diversity of qualified academic faculty members, and encourage nurses’ engagement in lifelong learning to improve their competencies to deliver high standards of care (58). Formal hospital leadership training planning can demonstrate clear organizational commitment to career development and professional development for staff (59). Innovation in leadership and clinical leadership training seems to have a positive impact on leadership effectiveness at the individual and organizational levels

(60). The main limitation of this research can be pointed out to the lack of access to some articles which were resolved with the innovation of the research team and they were more time consuming.

The findings of this study showed that the best way to acquire leadership skills is to educate nurses.
  Various studies suggest that leadership skills are taught during college education or as post-graduate leadership development workshops. Also, the position of leadership skills training in Iran is very poor in nursing curriculum and after graduation.

Since nurses are the largest group of therapists in the health system, and the most of the treatment process is done by nurses, also they are given the managerial responsibilities and challenges of the health system; today's expectation is for nurses to go beyond the one-way clinical specialist. Job satisfaction, greater productivity and customer orientation (patient satisfaction and safety), and in summary health system excellence are the most important achievements of clinical leadership competencies. This will have greater political and social gains at the community level.

So it is recommended that the academic curriculum and continuing education correction, succession planning, applied workshops and benchmarking of the successful universities of the world are done so that they can lead to better results and fill the gap. Therefore, attention to courses has been important using modern educational techniques for managers and it is recommended that the improvement program to be used to train managers and nurses in educational and management departments in appropriate health and medical settings.

Ethical considerations 

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

Financial Support:

This research was part of an organizational behavior management PhD thesis approved by the Ethics Committee of Lorestan University. Ethical aspects were considered in all steps of study and texts belonging to other authors that have been used in any part of this study have been fully referenced.

Conflict of interests

The authors decla

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