Abstract
Aim
This study aims to determine and compare the achieved competencies of graduating nursing students of public and private universities in Iran.
Background
The main responsibility of nursing education is to train nurses who possess the necessary competencies to provide safe and high-quality care. Given that a significant proportion of nursing education in Iran is the responsibility of private universities, it is essential to ensure that nursing graduates acquire the required competencies.
Design and methods
A quantitative study with a comparative descriptive design was conducted. A convenience sample of 721 graduating nursing students, including 301 from private universities and 420 from public universities, participated in the study. Data was collected using a nursing competence questionnaire developed in the Iranian cultural context and rated on a 5-point Likert scale (1 = dependent to 5 = independent). The research findings were analyzed using descriptive statistics and the independent t-test.
Results
The students from public and private universities achieved the highest scores in work readiness and professional development, with means of 3.58 (SD = 0.39) and 3.48 (SD = 0.37), respectively. The lowest scores were obtained by both the public and private groups for evidence-based care, with means of 2.89 (SD = 0.54) and 2.54 (SD = 0.50), respectively. The mean score of core competence obtained by public nursing students across all 5 themes was higher than that of private students, and this difference was statistically significant (p < .05). The evidence-based nursing care showed the greatest difference in means (mean difference = 0.35), while individualized care had the smallest difference (mean difference = 0.09) according to the results of the independent t-test.
Conclusion
Neither public nor private university nursing students achieved an independent level in any of the competencies. However, public university students demonstrated greater success in acquiring most of the competencies compared private students. To enhance nursing students’ competencies, future studies should focus on developing operational solutions, particularly for students at private universities.
Keywords: Nursing education, Competency, Self-assessment, Nursing students, Professional competence
Introduction| background
In the medical sciences, competence is broad concept encompassing the knowledge, attitudes, expertise and experience required for effective performance within a role or profession [1]. Three theoretical approaches to competence exist: behaviorism, which emphasizes the ability to perform individual core skills; trait theory, which focuses on individual traits necessary for efficient task execution; and holism theory, which considers competence as a combination of knowledge, skills, attitudes, thinking skills, values, and professional judgment required in specific contexts [2].
Today, competence and its assessment are crucial in nursing education and practice to ensure safe and high-quality care [3]. The American Association of Colleges of Nursing (AACN (has established nursing competencies and their assessment as a standard of care at the professional level [4]. The World Health Organization (WHO( has also proposed strategies to improve patient safety, including ensuring competency acquisition by students and guaranteeing the quality of nursing education [5]. Assessing competencies, identifying weaknesses, and implementing corrective measures can improve care quality, reduce costs, enhance professional development, and increase patient satisfaction [6]. Conversely, neglecting competence assessment can lead to an increased in nursing errors [7], a disconnect between theory and practice, and job burnout [8].
The main responsibility of nursing education is to train nurses who possess the necessary competencies to provide safe and high-quality care [3]. The AACN (2020) recognizes competency-based education as the future goal of nursing education [9]. Nursing graduates are therefore considered products of the education system, and feedback on acquired competences can guide educational improvement [10]. However, the inadequate preparations of newly graduated nursing students (NGNSs) have become a global concern [11, 12]. Recognizing this concern, the WHO recommends investing in nursing education and emphasizes the need for theoretically and clinically competent nurses [5].
The rise in demand for higher education since the late 20th century has made it impossible for governments to provide higher education to everyone. This has led to the emergence of private universities. Today, most countries have a combination of public and private institutions for higher education [13]. This has raised questions about the quality of education and the challenges related to competencies acquired by private universities nursing students (PrUNSs). Critics argue that some private universities prioritize cost minimization, employing low-paid instructors, which can negatively impact teaching quality and the acquisition of competencies by graduates. Proponents of private universities counter that concerns about low teaching quality are not unique to private institutions and that tuition fees incentivize quality education [13–16]. Iran is no exception to this trend. Nursing education is provided by both public and private fee-paying universities in Iran. In Iran, the admission of nursing students to public and private universities is primarily determined through a competitive entrance exam, commonly referred to as the “Konkur.” This exam assesses a range of subjects, including biology, chemistry, and general knowledge, and serves as a crucial criterion for evaluating candidates’ academic readiness for nursing education. Additionally, the Grade Point Average (GPA) from high school courses plays a significant role in the final admission results. The combination of the entrance exam score and GPA allows universities to comprehensively assess candidates’ qualifications and potential for success in nursing programs [17].
The increase in private universities, often exceeding societal needs, has resulted in many nursing graduates lacking the necessary competencies. This phenomenon has raised concerns among policymakers in Iranian nursing education. There are limited studies in this field, and many are confined to a single university. Even the exiting research findings are diverse and sometimes contradictory. For example, Farajpour et al. (2017) found that despite limited research on the educational environment of private universities in Iran, students at these institutions report satisfaction levels comparable to public university Nursing Students (PuUNSs) [18]. However, Hakimzadeh et al. (2012) demonstrated that PrUNSs scored lower in certain emotional competencies, such as patient and family participation in care decisions [19]. Also, Parsa et al. (2015) showed that final year PrUNSs faced serious problems in the domains of patient and family comfort, nursing management and teamwork, clinical judgments and decision making, creative thinking and problem solving [20]. The study by Forouzi et al. (2018) reported that the clinical competence of PrUNSs were moderate [21], while the study by Mirzaei et al. (2017) found that the communication competence of PuUNSs were low [22]. Therefore, this study was conducted to determine and compare the achieved competencies of graduating PuUNSs and PrUNSs in Iran, utilizing Benner’s novice to expert theory (1984) as a guiding framework.
Materials and methods
Aims
This study aims to determine and compare the achieved competencies of graduating nursing students of public and private universities in Iran.
Design
The present study is a comparative descriptive quantitative study.
Sample
The Ministry of Health of Iran initially presented a list of all active nursing schools, including public and private, in 31 provinces of the country (208 universities). Subsequently, 72 nursing universities (36 public and 36 private) were selected with convenience sampling method. From the selected universities, 721 final-year nursing students who agreed to participate in the study were enrolled.
Instrument
The questionnaire used in this study was designed and psychometrically tested as part of a nursing doctoral thesis [23, 24]. Face and content validity were confirmed, and the instrument’s reliability was established through internal consistency analysis, so that Cronbach’s alpha for the entire questionnaire in the nursing instructor and nursing student groups was 0.97 and 0.91, respectively. The questionnaire assesses 17 competencies across five domains, using 85 items: “individualized care” (4 competencies with 21 items), “evidence-based nursing” (2 competencies with 10 items), “professional nursing process” (3 competencies with 13 items), “nursing management” (2 competencies with 16 items) and “work readiness and professional development” (6 competencies with 25 items). Nursing students were asked to indicate the extent to which they had achieved each competence, using the Bondy Rating Scale, a 5-point Likert scale ranging from 1 to 5 (1 = Dependent, 2 = Marginal, 3 = Assisted, 4 = Supervised, and 5 = Independent) [25].
Data collection
Initial contact was made with the deans and managers of the selected nursing schools via email to request permission for participation in the study. The study’s objectives, sampling method, and ethical considerations were explained, and contact information for the representative of the final-year nursing student group was obtained. The representative was then asked to distribute the questionnaire link to 10 students who were willing to participate. Informed consent was provided electronically through the questionnaires, outlining study objectives, ensuring respondent anonymity, emphasizing voluntary participation, and granting the right to withdraw consent at any time. A total of 900 final-year nursing students was contacted electronically from March to July 2023. A response rate of 79% was achieved, with 721 students completing the questionnaire.
Analysis
The collected data were analyzed using descriptive and inferential statistical methods via SPSS software version 22 (IBM Inc., Armonk, NY, USA). Frequencies and percentages were used to report categorical variables, while mean and standard deviations were employed for quantitative variables. The normality of the quantitative data was confirmed using the Shapiro-Wilk and Skewness tests. An independent t-test was utilized to compare differences between PuUNSs and PrUNSs.
Of the 721 students, 420 (58.25%) were from PuUNSs and 301 (41.75%) were from PrUNSs. The majority of the participants were female (Table 1).
Table 1.
Characteristics of participants
| Variables | Public University (n = 420) | Private University (n = 301) |
|---|---|---|
| Gender | Frequency (%) | Frequency (%) |
| Male | 163 (38.80) | 117 (38.90) |
| Female | 257 (6.20) | 184 (61.10) |
| Educational semester | ||
| Semester 7 | 105 (16.60) | 38 (8.40) |
| Semester 8 | 315 (49.80) | 263 (57.90) |
| Mean (SD) | Mean (SD) | |
| Age (Years) | 22.21 (0.98) | 22.91 (1.38) |
The study results showed that PuUNSs and PrUNSs achieved the highest scores in work readiness and professional development (M = 3.58, SD = 0.39); and (M = 3.48, SD = 0.32), respectively. Conversely, the lowest scores in both groups were recorded for evidence-based care (M = 2.89, SD = 0.54); and (M = 2.54, SD = 0.50), respectively (Table 2).
Table 2.
The Core competencies Achieved from the Public and private universities of graduating nursing student’s perspective (ranked from highest to lowest scores)
| Core competences achieved (public universities) | Mean (SD) | Core competences achieved (private universities) | Mean (SD) | Mean diff |
|---|---|---|---|---|
| Work readiness and professional development | 3.58 (0.39) | Work readiness and professional development | 3.48 (0.32) | 0.10 |
| Nursing administration | 3.46 (0.32) | Nursing administration | 3.30 (0.31) | 0.16 |
| Individualized care | 3.43 (0.45) | Individualized care | 3.34 (0.49) | 0.09 |
| Professional nursing process | 3.26 (0.54) | Professional nursing process | 3.16 (0.49) | 0.10 |
| Evidence-based nursing care | 2.89 (0.54) | Evidence-based nursing care | 2.54 (0.50) | 0.35 |
Table 3 presents the average scores of sub-core competences in descending order. The Bondy Scale was utilized in the research, revealing that 8 sub-core competences among the PuUNSs, and 4 sub-core competences among the PrUNSs had mean scores above 3.5, indicating that the students needed “supervision” to perform these competencies. Furthermore, the results showed that the mean scores of PuUNSs in 4 sub-core competences and PrUNSs in 8 sub-core competences required “assisted” (Table 3).
Table 3.
The Sub-core competencies achieved from the Public and Private Universities of graduating nursing students’ perspective (ranked from highest to lowest scores)
| Core competencies domains | Sub-core competences achieved (Public Universities) | Mean (SD) | Core Competencies Domains | Sub-core competences achieved (Private Universities) | Mean (SD) |
|---|---|---|---|---|---|
| (WRPD) | Safety | 3.76 (0.49) | (WRPD) | Safety | 3.78 (0.52) |
| (NAC) | Informatics & documentation | 3.74 (0.48) | (ICC) | Value and ethical codes | 3.64 (0.45) |
| (WRPD) | Preventative health services | 3.73 (0.59) | (WRPD) | Preventative health services | 3.64 (0.61) |
| (WRPD) | Clinical/Procedural skills | 3.71 (0.50) | (WRPD) | Clinical/Procedural skills | 3.60 (0.52) |
| (ICC) | Value and ethical codes | 3.68 (0.48) | (NAC) | Informatics & documentation | 3.48 (0.47) |
| (ICC) | Cultural humility | 3.61 (0.70) | (ICC) | Therapeutic communication participatory decision making | 3.47 (0.47) |
| (IC) | Therapeutic communication participatory decision making | 3.60 (0.45) | (ICC) | Cultural humility | 3.46 (0.63) |
| (WRPD) | Personal Characteristics | 3.52 (0.39) | (WRPD) | Personal Characteristics | 3.41 (0.39) |
| (PNP) | Specific critical thinking | 3.47 (0.71) | (PNP) | Specific critical thinking | 3.37 (0.67) |
| (WRPD) | Legality | 3.41 (0.70) | (WRPD) | Legality | 3.30 (0.74) |
| (WRPD) | Mentoring | 3.37 (0.73) | (PNP) | General critical thinking | 3.13 (1.07) |
| (PNP) | Professional critical thinking (Using the nursing process) | 3.23 (0.48) | (NAC) | Management & leadership | 3.13 (0.36) |
| (NA) | Management & leadership | 3.17 (0.36) | (WRPD) | Mentoring | 3.12 (0.65) |
| (PNP) | General critical thinking | 3.06 (0.92) | (PNP) | Professional critical thinking (Using the nursing process) | 3.00 (0.41) |
| (EBC) | Knowledge acquisition | 3.03 (0.60) | (ICC) | Holism | 2.79 (1.31) |
| (IC) | Holism | 2.83 (1.12) | (EBC) | Knowledge acquisition | 2.70 (0.62) |
| (EBC) | Critical appraisal of evidence and implementing of applicable evidence | 2.75 (0.61) | (EBC) | Critical appraisal of evidence and implementing of applicable evidence | 2.37 (0.51) |
| (PNP) | Professional critical thinking | 3.14 (0.47) |
Core competencies domains: EBC: Evidence-based nursing care, IC: Individualized care, NA: Nursing Administration, PNP: Professional nursing process, WRPD: Work readiness and professional development
The findings indicate that PuUNSs obtained higher average scores in all 5 core competencies compared to PrUNSs (p < .05). Table 4 presents the results of the independent t-test, indicating that the evidence-based nursing care had the highest difference (mean diff = 0.35) and individualized care had the lowest difference (mean diff = 0.09).
Table 4.
Comparison of the Core competencies achieved from the public and private universities of graduating nursing students’ perspective*
| Core competencies domains | Groups | Mean (SD) | Mean diff | P-value | 95% CI** | |
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| Individualized care (IC) | Public | 3.43 (0.45) | 0.09 | P < .05 | 0.02 | 0.16 |
| Private | 3.34 (0.49) | |||||
| Evidence-based nursing care (EBC) | Public | 2.89 (0.54) | 0.35 | P < .001 | 0.28 | 0.43 |
| Private | 2.54 (0.50) | |||||
| Professional nursing process (PNP) | Public | 3.26 (0.54) | 0.10 | P < .05 | 0.02 | 0.17 |
| Private | 3.16 (0.49) | |||||
| Nursing administration (NA) | Public | 3.46 (0.32) | 0.16 | P < .001 | 0.11 | 0.20 |
| Private | 3.30 (0.31) | |||||
| Work readiness and professional development (WRPD) | Public | 3.58 (0.39) | 0.10 | P < .001 | 0.05 | 0.16 |
| Private | 3.48 (0.37) | |||||
*Independent t-test, **Confidence interval
The results of the independent t-test (Table 5) revealed significant differences in competencies between PuUNSs and PrUNSs in four sub-core competences: using the nursing process, informatics and documentation, mentoring, and personal characteristics (p < .001). Additionally, significant differences were observed in five sub-core competences: holism, specific critical thinking, legality, clinical/procedural skills, and cultural humility (p < .05).
Table 5.
Comparison of the sub-core competencies achieved from the public and private universities of graduating nursing students’ perspective*
| Core competencies | Sub- core competencies | Groups | Mean (SD) | Mean diff | P-value | 95%CI** | |
|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||
| Individualized care | Cultural humility | Public | 3.61 (0.70) | 0.15 | P < .05 | 0.05 | 0.25 |
| Private | 3.46 (0.68) | ||||||
| Value and ethical codes | Public | 3.68 (0.48) | 0.04 | P > .05 | − 0.30 | 0.11 | |
| Private | 3.64 (0.45) | ||||||
| Holism | Public | 2.83 (1.12) | 0.04 | P < .05 | − 0.15 | 0.22 | |
| Private | 2.79 (1.31) | ||||||
| Therapeutic communication participatory decision making | Public | 3.60 (0.45) | 0.13 | P > .05 | 0.06 | 0.20 | |
| Private | 3.47 (0.47) | ||||||
| Evidence-based nursing care | Knowledge acquisition | Public | 3.03 (0.60) | 0.33 | P > .05 | 0.24 | 0.42 |
| Private | 2.70 (0.61) | ||||||
| Critical appraisal of evidence and implementing of applicable evidence | Public | 2.75 (0.61) | 0.37 | P > .05 | 0.29 | 0.46 | |
| Private | 2.37 (0.51) | ||||||
| Professional nursing process | General critical thinking | Public | 3.06 (0.92) | − 0.06 | P > .05 | − 0.21 | 0.08 |
| Private | 3.13 (1.07) | ||||||
| Specific critical thinking | Public | 3.47 (0.71) | 0.10 | P < .05 | − 0.00 | 0.20 | |
| Private | 3.37 (0.67) | ||||||
| Professional critical thinking (Using the nursing process) | Public | 3.23 (0.48) | 0.24 | P < .001 | 0.17 | 0.30 | |
| Private | 3.00 (0.41) | ||||||
| Nursing administration | Management & leadership | Public | 3.17 (0.36) | 0.04 | P > .05 | − 0.01 | 0.09 |
| Private | 3.13 (0.36) | ||||||
| Informatics & documentation | Public | 3.74 (0.48) | 0.27 | P < .001 | 0.20 | 0.39 | |
| Private | 3.48 (0.47) | ||||||
| Work readiness and professional development | Personal Characteristics | Public | 3.52 (0.39) | 0.11 | P < .001 | 0.05 | 0.17 |
| Private | 3.41 (0.39) | ||||||
| Legality | Public | 3.41 (0.70) | 0.11 | P < .05 | 0.00 | 0.22 | |
| Private | 3.30 (0.74) | ||||||
| Clinical/Procedural skills | Public | 3.71 (0.50) | 0.12 | P < .05 | 0.04 | 0.19 | |
| Private | 3.60 (0.52) | ||||||
| Safety | Public | 3.76 (0.49) | − 0.02 | P > .05 | − 0.10 | 0.05 | |
| Private | 3.78 (0.52) | ||||||
| Preventative health services | Public | 3.73 (0.59) | 0.09 | P > .05 | 0.00 | 0.17 | |
| Private | 3.64 (0.61) | ||||||
| Mentoring | Public | 3.37 (0.73) | 0.25 | P < .001 | 0.14 | 0.35 | |
| Private | 3.12 (0.65) | ||||||
*Independent t-test, **Confidence interval
Discussion
This study aims to determine and compare the achieved competencies of PuUNSs and PrUNSs in Iran. Determining and comparing competence levels showed that none of the two groups could acquire the competences at the independent level. However, PuUNSs were more successful in achieving most of the competences.
A comparison of core competencies revealed that PuUNSs consistently scored higher than PrUNSs across all five core areas. Work readiness and professional development emerged as the highest-scoring core competence for both groups, while evidence-based nursing care was the lowest-scoring. However, a notable difference was observed in the level of independence required for these two areas: PuUNSs required “supervision”, while PrUNSs needed “assistance.”
The comparison of sub-core competencies revealed that, out of 17 sub-core competencies, PrUNSs scored lower than PuUNSs in 16 areas. Notably, PrUNSs were rated at a “Marginal” level for “critical appraisal of evidence and implementing applicable evidence”. The findings of studies in this field vary depending on the specific dimensions of competence, numerous studies report lower competency levels among PrUNSs compared to PuUNSs. Heidari et al. (2018) found that PrUNSs demonstrated slightly higher competency in three domains: Patient-centered care, management and clinical skills. However, PuUNSs were deemed more competent in personal management and research [26]. Arabameri et al. (2023) found that a significant proportion of PrUNSs possessed a moderate level of competence in “ethical standards”, and “care management, accountability, and responsibility” [27]. Other studies have reported low competencies among PrUNSs in communication skills, respect for the patients [28], and critical thinking [29]. Conversely, limited studies have suggested that PuUNSs possess lower communication skills compared to PrUNSs [18].
The observed differences in competence levels between PrUNSs and PuUNSs can be attributed to various factors. Assessing nursing competence is a complex, dynamic, and multifaceted nature of clinical setting [6]. Some of these contributing factors are discussed below:
Educational environment, atmosphere, and facilities
Clinical education plays a pivotal role in patient care, making the learning environment and atmosphere critical for quality education. This includes physical, mental and emotional conditions and facilities that significantly influence learning. A positive clinical environment fosters success, increase experience, professional competence, and student satisfaction through enhanced motivation [30]. Clinical experiences are crucial for developing clinical and professional competencies, including problem solving skills and personal and social development [31].
The findings of the studies show that insufficient space and inadequate clinical facilities, equipment, and educational resources are important challenges in the clinical education of PrUNSs [32, 33]. While these shortcomings are not exclusive to private universities, and exist to some extent in public institutions, they appear less severe in public schools. The learning environment is a key predictor of clinical education effectiveness, yet a significant gap often exists between the expectations and the actual clinical learning environment in private universities [34, 35]. Addressing these deficiencies in Iranian nursing education, particularly in private universities, is crucial to enhance student professional competencies.
Faculty, lesson planning, teaching styles, and evaluation methods
Lesson planning involves defining goals, objectives, content, teaching styles, and evaluation methods. Dynamic and flexible lesson planning fosters student creativity and acquisition of expected competences [36]. Studies have shown dissatisfaction among PrUNSs regarding teaching styles, dynamics, and quality of education [33, 37, 38], as well as faculty proficiency in utilizing educational technologies [39, 40]. Inconsistent evaluation methods for nursing competence further challenge faculty in private universities [37, 41]. Empowering nursing faculty in private universities is therefore essential.
Teacher-Student relationships
Effective teacher-student relationships foster self-confidence, motivation, positive learning experiences, professional identity, and the acquisition of expected nursing competencies [42, 43]. However, studies have identified ineffective teacher-student relationships in private universities as a source of stress for nursing students [44, 45]. One possible explanation is the employment of less experienced faculty. Rezaei et al. (2018), found that students reported fewer sources of stress as faculty age and work experience increased [44]. Recruiting experienced instructors and providing in-service training for faculty in private nursing programs is recommended to ensure effective relationship skills.
Student characteristics, motivation, and attitude towards the nursing Profession
Nursing students require psychological preparation and certain characteristics, such as interest, motivation, positive attitude, and adaptation to nursing practice. These traits are critical for developing behaviors and acquiring professional competencies [23]. This study highlights the concerning negative attitudes of some PrUNSs towards specific professional competencies, which may hinder the effective learning of expected competencies, ultimately impacting the quality of nursing care and patient safety. Careful consideration of individual student characteristics during recruitment and selection is therefore crucial.
Factors related to the undergraduate nursing curriculum
The study results indicate that neither PrUNSs nor PrUNSs achieved the maximum score (independent = 5) on the competence assessment. Studies in this field have also highlighted a concerning decline in the readiness of newly graduated nursing students to enter practice settings in Iran over the past decade [46, 47]. This decline can be attributed, in part, to the shift toward routine-centered care in Iranian nursing education, which has replaced evidence-based and patient-centered care. This shift is often attributed to the lack of a competency-based curriculum and a mismatch between educational goals and real-world practice needs [17]. Implementing or Modifying a curriculum that is explicitly grounded in expected competencies could significantly enhance the acquisition of essential skills for clinical care by nursing graduates.
Limitations and strengths
This study represents a unique contribution to the Iranian nursing education landscape by comparing the competencies of PuUNSs and PrUNSs at a national level. However, a limitation of this study is the reliance on self-report data through a questionnaire. While self-assessment is a fundamental aspect of competency evaluation, it is important to acknowledge the potential for bias. Additionally, the study’s timing coincided with the first and second academic years of students experiencing the COVID-19 pandemic, which may have influenced the quality of education and the acquired competencies of both PuUNSs and PrUNSs. The pandemic-related restrictions imposed on nursing education worldwide necessitate considering this potential impact.
Conclusion
Nursing competency attainment is a direct outcome of the educational system. This study found that neither PuUNSs nor PrUNSs achieved an independent level in any of the assessed competencies. However, PuUNSs demonstrated greater success in acquiring most competencies. The findings suggest that the nursing education system in private universities faces more challenges than its public counterparts. Notably, the recruitment process for nursing graduates in Iran currently does not consider the type of university (public or private) or the level of competency acquired by students. Therefore, private universities, as crucial institutions for quality enhancement in higher education, require fundamental changes in nursing education policies. In recruiting NGNs, it is essential to consider their acquired competencies, taking into account the type of university they attended. However, given the subjective and multidimensional nature of nursing competencies and their evaluation, further research is recommended to clarify the underlying causes of observed differences and to develop operational solutions to enhance the competence of nursing students, particularly those from private universities.
Acknowledgements
The authors extend their gratitude to all the nursing students and teachers who took part in this study.
Author contributions
M P: conceptualized the study, data collection, analysis and interpretation, drafting of manuscript; V Z: conceptualized the study, analysis and interpretation, drafting of manuscript; LV: conceptualized the study, data collection and analysis, manuscript revision; A Gh: conceptualized the study, data collection, analysis, and drafting of manuscript; S M: conceptualized the study, analysis, and drafting of manuscript; M Gh: data collection, analysis, and interpretation, drafting of manuscript; All authors read and approved the final manuscript.
Funding
This article is part of research approved with the financial support of the deputy of research and technology of Tabriz University of Medical Sciences.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This research was conducted with financial support from the Deputy of Research and Technology at Tabriz University of Medical Sciences. The approved code for this project is IR. TBZMED. AC.REC.1400.791. Informed consent was provided electronically through the questionnaires, outlining study objectives, ensuring respondent anonymity, emphasizing voluntary participation, and granting the right to withdraw consent at any time.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.