|
 
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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 5
| Issue : 3 | Page : 79-88 |
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Work–family conflict as a stressor in the lifestyle of nurses: A content analysis
Fatemeh Alhani1, Gholam Reza Mahmoodi-Shan2
1 Department of Nursing, Medical Science Faculty, Tarbiat Modares University, Tehran, Iran
2 Nursing Research Center, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
| Date of Submission | 20-Aug-2018 |
| Date of Acceptance | 29-Sep-2018 |
| Date of Web Publication | 10-Dec-2018 |
Correspondence Address:
Dr. Gholam Reza Mahmoodi-Shan
Assistant Professor, Faculty of Nursing and Miwifery Golestan University of Medical Sciences (GUMS) Gorgan
Iran
 Source of Support: None, Conflict of Interest: None  | 6 |
DOI: 10.4103/JNMS.JNMS_26_18
Context: Work–family conflict (WFC) is a consequence of imbalance and incompatibility, which influences the health and family relationship of nurses negatively and creates challenges for the individual and the organization.
Aim: To explain the nurses' view on the stressful effects of conflict between work and family on their lifestyle.
Setting and Design: This qualitative investigation was a conventional content analysis and conducted by the use of purposive sampling selecting 25 nurses.
Material and Methods: Unstructured interview was performed, and data were analyzed using inductive content analysis. The credibility and objectivity of the data were repeatedly checked by incorporating the data-gathering process, variety of participants and monitoring the participants in the investigation.
Statistical Analysis Used: Data analysis was conducted by Graneheim and Lundman approach. The unit analysis in this study was the whole interviews, and the meaning units were distinguished in the statements and texts of the interview in the form of “sentence” or “paragraph” from which the open codes were extracted. Then, the categories, main categories, and themes were abstracted.
Results: The final findings consist of two main themes: (i) the predisposing factors/the sources of WFC and (ii) coping/stress management and obstacles that each of which is formed by some categories. The core of the nurses' efforts for eliminating WFC is creation of balance between different factors.
Conclusion: Thus, resolving the problem is possible to use in access to resources and proportional circumstances. We propose that, in different societies, qualitative study be conducted on to explore preventive strategies and policies. Keywords: Coping, Lifestyle, Nurses, Role conflict, Stressor, Work–family conflict
How to cite this article:
Alhani F, Mahmoodi-Shan GR. Work–family conflict as a stressor in the lifestyle of nurses: A content analysis. J Nurs Midwifery Sci 2018;5:79-88 |
| Introduction | |  |
Conflict between work and family is a consequence of incompatibilities between different roles of nurses.[1] Nurses need to equilibrium between the demands of work and family life[2] because it is important for their mental health and health behaviors.[3],[4]
Nurses try to establish a balance between numerous demands in the process of spending energy and time.[2] The conflict between work and family is a role conflict, and it is indicative of situations in which the demands and responsibilities emanating from work and family roles are simultaneously incompatible in some respects.[5]
Work–family conflict (WFC) is created along two directions such that family life can interfere in work life and vice versa.[6]
Contradictory demands of work and family create challenges for both the individual and the organization.[7] Role conflict acts as a stressor for nurses. The stressor influences the physical and mental health, family relationships negatively[8] and raises difficulties in the way of performing family roles.[7]
A nurse may experience the difficulties of interference of work in the family when accomplishing family duties at home.[9] Work stressors such as work hours, work overload, and stressors of interaction between work and family are such role conflicts.[3]
About 92% of nurses have reported having the interference of work in family affairs during the past 6 months.[9] The relationship between work and family is dynamic and affect each other seriously.[10]
Nurses having rotating shift work have experienced more WFC compared to those having fixed shift.[11] In general, nurses are experiencing high levels of stress.[12] The nature of work, nurse role, individual viewpoints, organization structure, lifestyle, family, concerns/fears, and loneliness are the main resources stress for nurses.[6],[13]
The WFC exerts a negative impact on the individual health, decrease in the workplace productivity, causes increased family tension, escalation of stress in the individual and the family members, increased incidence of stress-related diseases, absence from work, and psychosomatic disorders.[14] Qualitative studies with regard to conflicts among Iranian hospital nurses indicated that the participants had frequently experienced conflicts in their work.[15]
Furthermore, most of the families in Iran are nuclear. Nuclear family composed of parents and children.[16] The main responsibility of family (preparation of subsistence) is legally on the spouse. However, customarily and on the basis of mutual understanding, wife and husband try together for running the life. A problem that has engaged the family in the recent decades is the escalation of responsibility load of women, who customarily both manage the intra-family and children's affairs and work outside the home. This matter doubles pressure on them and causes their physical and mental fatigue.[17]
The nurses are responsible for the health of the society and sustain doubled physical and mental stresses at the workplace. They are engaged in moral rules and obligations which, constantly, entangle them in the dilemma of selecting between them, family, or organizational considerations. There are differences between countries with regard to friendly regulation of WFC.[18]
The WFC subject has been less studied qualitatively from the viewpoint of the experiences of nurses in their own professional and family life. Qualitative study on WFC in nurses is of importance because work and family aspects are related to cultural beliefs, norms, and values;[19] therefore, qualitative study will be able to extract the new agents from WFC relation.
Perhaps, this is one reason for the present stagnation of the case and the fact that the authorities in charge of planning pay less attention to the work domain and the cultural backgrounds of this profession. Therefore, the purpose of this study was the extraction of nurses' experiences of WFC in their lifestyle as a stressor.
| Methods | | |
Design
This survey in the arena of WFC has been conducted on the lifestyle of nurses based on their experience and the conventional content analysis type in.
The qualitative content analysis is a convenient method for gaining valid and reliable results out of the text data to create knowledge, new ideas, presentation of facts, and guidelines for work. The purpose of this method is briefing and providing an extended description of a phenomenon, the result of which is descriptive concepts or categories. As is usual, the aim of these concepts or categories of structures is a conceptual system, conceptual map, or categories.[20]
Participants and setting
Participants in the investigation (samples) were 25 nurses, aged 25–55 years, and were selected by the use of purposive sampling method, which is a convenient method for qualitative research. The study was carried out in 2014–2015 in Gorgan, Iran. Data-gathering was done in three teaching hospitals.
The investigator sought out individuals with full experience and capabilities to express and intention to participate in the research.[21]
Ethical considerations
The participants enter the research first with oral consent and later by giving written consent. The ethical norms consisted of anonymity, confidentiality of the information, right of resignation on the desired time, and obtaining permit from the Ethics Committee of Golestan University of Medical Science with code: 1913908831.
Data collection
The data-gathering method was an unstructured interview. This method, due to depth and flexibility, was the most convenient method for qualitative investigations.
The first question is raised in a most general way, and the interpretative and explanatory response of the participant will direct the course of the subsequent questions.[22] This survey began with questions on individual general information, track record, and variety of wards which was, then, connected to the main question: “explain your experience concerning the conflict between work and your family life affairs” or “explain your lifestyle with respect to work and family conflict.” The replying process of the participant determined the direction of subsequent questions. The interview was recorded by an MP3 player; then, a handwritten draft was prepared which was later typed by the use of computer software. The original codes were prepared in WORD, and the code sheet and categorization were performed in OneNote.
The inclusion criteria for the research consisted of graduation in nursing and having a minimum work experience of 1 year, and the criterion for ceasing the sampling was repetition of data, that is, information saturation not leading to new information and a new category.
The interview duration varied from 30 to 60 min, performed in one or two sessions. Therefore, some participants were interviewed more than once. The interview was performed at predated times in the hospital environment and in a calm and convenient atmosphere.
Data analysis
The data analysis method was content analysis with an inductive approach using Graneheim and Lundman method. The unit analysis in this study was the whole interviews which were reread repeatedly after typing the handwritten materials. Thus, the meaning units were distinguished in the statements and texts of the interview in the form of “sentence” or “paragraph” from which the original or open codes were extracted. Then, the categories, main categories, and themes were abstracted. The analysis process was repeated with the addition of each interview, and the codes and categories were amended.
Trustworthiness
Lincoln and Guba provided criteria including credibility, transferability, dependability, and confirmability. They stress the close ties between credibility and dependability.[23]
The credibility criterion which is equal to the content validity was promoted by the use of different strategies, such as variety of participants from the viewpoint of age, gender, work track record, variety of wards, different work, managerial and family member categories. Also, to promote data gathering, the researchers used different method such as observation, handwritten materials, recorded cases, reviewing, repeated monitoring of data, member check (internal validity), and external check (by two expert persons). For controlling the objectivity (reliability of findings), the monitoring method of the participants and two contributors of the research was probed and repeated monitoring was accomplished. For controlling the objectivity (reliability of findings), the monitoring method of the participants and two contributors of the research was probed and repeated monitoring was accomplished.
| Results | | |
The participants were 25 nurses, with 16 females and 9 males; majority of them (45%) were 25–35 years old. They have worked from 3 to 29 years and in different wards. In this study, two final themes, seven categories, 22 subcategories, and 1100 codes emerged.
Although the WFC is mutual, in this qualitative study, the effects of work factors have been emphasized more by the nurses. The findings are summarized in [Table 1] and [Table 2]. | Table 1: Themes, categories, subcategories, and definitions abstracted from nurses' view about work-family conflict on their lifestyle
Click here to view |
 | Table 2: Examples of subcategories, codes, condensed meaning and meaning units extracted from nurses' view about work-family conflict on their lifestyle
Click here to view |
First theme: Predisposing factors/sources of work–family conflict
This theme consisted of categories and subcategories as detailed below:
The nature of the profession
Nurses are witness the death of patients or are engaged in the affairs of chronic patients and observe numerous problems or complications in patients. However, the nurses bear huge responsibilities leading to their physical exhaustion and diminution of their mental capacities and decrease of their mood level, and even, the problems are inadvertently derived into the family which may lead to a kind of conflict in the family members.
A hard and sensitive job
A nurse said, “I did not think that nursing might be so hard; it has physical and mental tiredness. Working with illness brings about much stress … the work pressure is high” (Nurse 14). “… nursing is very hard, the work is really hard” (Nurse 16). “The nurses are always dealing with patients and sighing” (Nurse 7).
Working on holidays
Nurses should work in rotating shifts and on holidays; consequently, they face the protest of their children and family members. A nurse said,
“I face difficulties during New Year's holidays. I have been on shift on the transition to New Year;… my husband and our children said, ‘wasn’t it possible not to go on shift on that day?' or ‘when we want to go somewhere on those days it interferes in my shift’” (Nurse 5).
Working with ill patients
“The nurses with the tasks in the home, working with such ill patients and in such conditions,… their living, and their job is hard” (Nurse 18).
Work milieu/organizational factors
Organizational facilities
Insufficiency of protective resources is another category. Insufficiency of welfare and lack of supportive strategies may induce difficulties for the nurses and their families.
“ …to compensate these deficits, we are compelled to extra work that is accompanied to decrease of our presence at home…, and our presence at home is associated with tiredness, conflict with demands and needs of our family members” (Nurse 12). On the other hand, they also experience the economical reward of this absence with delay. A participant said,
“Extra work fees are paid with delay … The fees of 1 year of extra work have not been paid yet” (Nurse 10).
Safety/security factors
A factor which may gradually induce conflict is constant fear, and concerns regarding their work circumstances, risk of contagious diseases, or feeling insufficient security with regard to protection in the work milieu are more tangible and more eminent in nursing than other professions. Usually, the effects of feeling insecurity are transferred to the family, too.
“… The patient has had a psychiatric problem or has been restless; she has struck her head and face with the fist, has bitten and kicked herself; these happenings are usual here;… or When raising the patients, our backs are harmed” (Nurse 3).
“We always have anxiety and stress lest no one is exposed to beating and foul language; this is despite our being exposed to all kinds of diseases” (Nurse 10).
“For nurses working at infectious diseases ward, emergency room, or internal medicine ward, is much higher stressful; they should be much cautious not to be afflicted with the patient's disease, but, sometimes, they get the disease” (Nurse 7).
Inappropriate expectations of the nurses
If the patients' expectations or doctors' expectations are out of the normal range, unpleasant feelings are induced in the nurse. A nurse stated,
“They, families, expect that their patients be managed as soon as possible. This really occurs but they don't know; sometimes, their expectations are improper, that is, their expectations are irrelevant” (Nurse 13).
“Both patients and doctors have irrelevant expectations of the nurses” (Nurse 1).
Workload/role load
Assigning responsibility to nurses more than their capacities induces dissatisfaction in them and their families that need them. For example, some wards, due to shortage of workforce, assign unwanted extra work on nurses. A nurse said,
“Work pressure is very high; extra work is really high” (Nurse 14). “Sometimes due to shortage of manpower, the nurses are transferred to other wards, therefore, we must increase our shifts, this is tiredness” (Nurse 11).
Managers' strategy
“Every time, the hospital supervisor comes here, finds fault, finds fault in such a way that we are compelled to keep silence. While our colleagues sustain the hard work in twos; she doesn't understand at all” (Nurse 14).
Rotating shift
Shift work is one of the main subjects of nursing job.
“There are some difficulties; for someone who has small children, night work is very hard; they have to accept much indebtedness for their children to be kept by others to be able to work at nights” (Nurse 13).
“Stresses sustained in the shift continue up to the time of sleep at home; this really happens for me” (Nurse 8).
“When I came off the shift in the mornings, my kid had completed their night sleep and had just waked up; then, I got angry saying ‘for my God, sleep because I want to sleep” (Nurse 9).
Family factors
According to nurses' experiences, WFC produces stresses and complications. It leads to aggressive behavior, children affective problems, relationship between family members disorders, insufficient time to care of family members, parenting role disorder, disturbance in regulating children program, disturbance in family affective circumstance, distress about children in night shift, and dissatisfactory of spouse about night shift.
Family supportive network
“For example, on a Friday (holiday), I had some business forcing me to put my kid in my mother's home, but she suffers from osteoarthritis; I try to take her situation into account, but I can't leave the child to my mother-in-law; I can't expect cooperation of anybody except my own mother” (Nurse 5).
Role expectation in family
Some works are expected to be done for the family members only by the nurse. If the nurse, due to tiredness and plenty of occupations, is not able to meet those expectations, conflict will arise.
“In fact, all works and therapeutic problems are imposed on the nurse. Brother, sister, and in-laws, when becoming ill, expects to be taken care of and their primary affairs be attended to; they expect such and think that such should be done” (Nurse 13).
Role conflicts
“You have been out of home the night before and have not rested in the morning, your husband would come back on 2 in the afternoon, he was also out of home in the morning, and just coming back from work, but you want to rest” (Nurse 14).
“Sometimes, your shift having been terminated, a patient's situation deteriorates, so you may remain an hour more; in such cases, problems are raised for the colleagues and your husband or children may get in trouble” (Nurse 6).
Role stress
Lack of mutual understanding
Nurses sustain stresses which the family members may not be able to understand. A nurse said,
“… Work shift, I think difficulties arise from it, but, in the home, they don't know it properly. They only know that you have shift work and the shifts are different, but they don't know the hardness of the job” (Nurse 6). “I am not successful in my housekeeping; they understand me, but not all the time. My mother-in-law came to me from village without coordinating, while I was working in hospital.… After some night shifts, I was annoyed, because, I would make prepare lunch. Therefore, I quarreled several times with my husband. I had been become aggressive that time” (Nurse 4).
“…My husband is not consent with my working in the emergency room; on many occasions, he has said that he would not let me work, due to my working in the emergency room” (Nurse 6).
Incoordination of work with family roles
“… My spouse works in the morning shift, he has some work in the afternoon, he has some work at night, then, it is very difficult, we may not see each other for 2–3 days or if we see each other, it is for a short interval” (Nurse 13).
“I am forced to put my children with my mother. The kid has not seen the mother at night; in the morning, he/she should go to the day care center, such that the mother rests” (Nurse 14).
“I experience plentiful stressor in my work and family, the life is tedious, sometimes, I say it's enough, I got tired of my life” (Nurse 5).
Second theme: Coping methods, stress management, and obstacles
The second theme abstracted is about the ways and methods used by the nurses for preventing or controlling the work and family conflict to continue life and work in a balanced situation. Nurses, despite enjoying professional knowledge or skills, are not always capable of selecting the best function because all factors are not under their control. The extracted categories of the mentioned theme are as follows:
Regulating of programs
Leave of absence plan
Interference in plans is an event occurring in the work and life affairs of nurses, because all life events are not predictable, although one can minimize them. A nurse said,
“Sometimes, a planning is accomplished, but, due to deficit, leave of absence is hardly given to the nurse. The nurses cannot coordinate their plans, because they face difficulties” (Nurse 13). “Leaves of absence must be already determined” (Nurse 6).
The interference of plans
The nurses must plan accurately for accomplishing professional duties and running family affairs such as keeping children and doing works and plans. A nurse said,
“We work in rotating shift; it has made some interference in the life issues. But one can decrease these difficulties with proper management; anyway, it leaves some impacts.… We are not able to have extra-curricular programs, sometimes, the plans interfere and we face difficulties” (Nurse 8).
Role management
Appropriate role management creates balance between work and life affairs of the individual, although it is possible that, sometimes, one is forced to select a situation and tolerate high stress and protest of family members, or involvement in the management of work milieu. A nurse stated,
“In general, when you look at a nurse's life, you see that he/she is a manager and enjoys a regular lifestyle” (Nurse 6).
Interference in role management
“I like to see my colleague, associates, sisters and brothers much, but, it can't be as we like to be, because we are much busy working” (Nurse 7).
Problem-solving strategies
Nurses, with the knowledge and skills they enjoy, problems solve in different way. In this regard, a nurse stated,
“The life is not as you desire, but, anyway, you should cope with these problems” (Nurse 10).
Control and planning
“If the stresses were ordinary, with measures and planning, they would be controllable. I think I know how to react to the stresses or control them” (Nurse 7).
Capacities
“By increasing your capabilities, the potentialities of colleagues, decreasing the work hours, the stresses can be lessened a bit” (Nurse 8).
Making use of exercise
“I had some stresses; I attended a class (yoga) which was very effective for me” (Nurse 17).
Making use of religious capacities/promotion of spirituality
“My spiritual feelings and religious beliefs are causing comfort and tolerance in me” (Nurse 2).
“When I had problems, I shared it with the patients; even when I had problems in my life, I asked the patients to pray for me … I try to cope with my stresses, I trust in God to a great extent” (Nurse 3).
A nurse stated, “concerning the stressful conditions,… only strong people enjoying high mental and spiritual capacities should enter this job. There are harsh circumstances, job identity problems, relationship with patients, all kinds of illnesses and individuals expressing pain and suffering. So, the job requires people with high self-esteem, capable of controlling not only their own mental and spiritual problems but also supporting the mental and spiritual problems of others” (Nurse 18).
Effective interaction
“But, anyway, the nurses can overcome these hardships with the patience and tolerance they have” (Nurse 18).
“A problem arose with our chief nurse with respect to my being off on a Friday and her insisting on my going on duty, which I wasn't really able to. She became angry with me. …We were compelled to share it with the Chief nursing manager. They became aware that I really was not go on shift work with my explanations, and the problem was solved” (Nurse 14).
| Discussion | | |
In this investigation, two main themes were gained each of which having categories and subcategories. In qualitative studies, although the investigators achieve categories and final themes, but one cannot claim that the categories are perfectly separate from each other; some categories may overlap.
The source of WFC (SOWFC) was a main theme. According to the experience of nurses, the nursing is hard and sensitive, because nurses are responsible for the patients' lives; they look after ill persons and face much demand. They work in different shifts and on holidays, too. Therefore, they sustain much stress which can be the SOWFC. Thus, nursing profession has a specific nature differing from other professions.
A study indicated that nurses, due to the nature of the profession and its changes, suffer from much stress and tension.[24] Studies indicated different source of conflicts between work and family some of them are shifts of work, rotating shifts, workload, or ward rules.[25],[26]
Another study found that mutual understanding and interaction were two main factors to prevent and resolve conflict effectively. Organizational structure and the nature and conditions of job assignment were two of them that somewhat congruent with our findings.[15]
A deep probe into the SOWFC demonstrates that some of these are modifiable and some not. For example, with planning, observance of scientific principles and selections of nurses with high mental capacities, and organizational family support, their complications can be lowered.
Ineffective support is another category which may occur with respect to organization or family. Inadequate financial supports, inattention to the welfare of nurses, and/or network support of families are cases mentioned by nurses.
Ineffectiveness support on the part of colleagues, chief nurses, or other staff is one of the drawbacks in the way of adaptation of nurses.[27]
The role overload and the role expectations were of the sources of conflict. Paralleling that, increased workload caused dissatisfaction in some nurses, particularly; the fees were paid with delay.
Studies have indicated that most nurses experienced exhausting the extra workload, inadequate staff number, and misunderstanding on the part of directors;[28],[29] the impact of which is directed toward the family and strengthens the WFC.[8] Increasing workloads and lack of resources have been indicated as sources of increasing stress and burnout.[30]
Family factors including the expectations the family members have of the nurse, the contradictions raised between the family roles and work roles, and the role stress were part of cases the nurses experienced. Hence, the nurses having small children, those with employee husbands, nurses with rotating work shifts, and those working in wards rushed by patients or sustaining overwork faced more role difficulties.
A study indicated that having children at home, family/social support, friendly manner of the family, support of the supervisor, and age affect the individual's sources.[31] Furthermore, lack of support concerning the responsibilities of looking after small children increases conflict in the family.[32]
The second theme extracted in this survey was the coping methods and management of stress which includes the categories: regulation of programs, role managements, problem-solving strategies, and effective interaction. Nurses, due to the knowledge and skills they enjoy, probably perform better in this dimension compared with other professionals. However, anyway, they may encounter difficulties because not all factors are under control of the nurse.
Investigations have demonstrated that nurses have often used behavior-centered, social-support-seeking, and self-control problem-solving coping strategies.[8]
Planning is an inherent part of nursing. Nurses have gradually achieved such a skill. Undoubtedly, not all factors are controllable, Therefore, disturbances and incoordination arise which may induce stress in them, leading to impairment of their life process. The essence of this part is management of time and situations, such that, if management is performed appropriately, lots of interferences, pressures, and stresses will not occur and the life will continue in balance and comfort.
Time management is a useful method for explaining the contradictions of work–family interference.[31]
The nurses should be able to use other methods for eliminating conflict and establishing balance in their own life. In this survey, they used various methods for problem-solving and mitigating pressure and stress and preventing conflict in the work and family. The most important of which were coping, increasing individual capacity and potentiality, patience and tolerance, decreasing work hours, use of sports such as Yoga, use of beliefs and religious capacities, praying and trusting in God, and logical interaction with authorities for problem-solving.
A study found that religious coping strategies were the major strategies of coping among participants.[33]
Sometimes, the reactions have been expressed in emotional forms such as aggressiveness and rejecting the kids in over tiredness.
A research showed that peer support, personal approaches which included activities such as relaxation and belief in one's own abilities, good communication skills, and receiving clinical supervision were significant management strategies of nurses in stressful condition.[34] The emotion-centered coping with unpleasant emotional effects includes avoidance of difficulties and distancing from stressful situations. It is while the emotion-centered coping strategies may lead to negative consequences. Some surveys show that avoidance and self-control may really predict a better mental health for nurses.[8] Important positive and negative events at the end of workday affect the positive and negative emotions and significantly the work satisfaction of the individual.
Limitations
Although we attempted to execute the interview in a quiet room, since some interviews were conducted in a room in the wards, it is likely that the person was worried about the work within the wards and they may not have expressed deeply their viewpoints. The next limitation may be related to the participant who has not expressed his/her work problems, and finally, some of the participants may not have deeply expressed some issues within the family and the relationship between himself and his or her spouse/wife or others.
| Conclusion | | |
Nurses are constantly exposed to the risk of diseases, occupational complications, and unwanted interferences of work and family. They are engaged in work shifts disharmonious with, work rhythm of their spouses, and working on holidays. Their rest hours are inconsistent to that of other family members which may be a source of conflicts between work and family.
What is perceived as the core of all these factors is the nurses' seek for balance and equilibrium between all these factors. Cultural factors, intra-family attitudes, potentialities, and personal capacities of the nurses, too, are effective in the management of policies or controlling the complications of this conflict. It appears that time management, strengthening of psychic, spiritual energy, or exploiting the support resources, self-control, and managers' insights are effective in balancing the demands between work and family.
Relevance to clinical practice
The findings of this study lead to a deep knowledge of the nurses' work and family relations, social-cultural context, circumstances, and the resources in access that help to nurses in coping and management of different stressors in work and life and promote mental health. Therefore, we propose that the family–work conflict and the preventive strategies and policies in different societies qualitatively be studied.
Conflicts of interest
There are no conflicts of interest.
Authors' contributions
F. Alhani contributed with designing, data analysis, interpretation and writing the first draft of the article and translating of article. Gh. R. Mahmoodi Shan contributed with designing, data collection, data analysis, interpretation, writing the first draft of the article, translating of the manuscript into English.
Financial support and sponsorship
Financial support to this research was provided by Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran. The study was approved by Deputy of Research and Technology of Golestan University of Medical Sciences (code number:PG/35/451).
Acknowledgment
We appreciate and acknowledge all those who cooperated in this investigation, particularly nursing research center of Glestan University of Medical Sciences and the nurses who appeared in interviews as participants of the investigation spending their time.
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[Table 1], [Table 2]
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