Holistic Nursing Experience of Implementing Hospital Accreditation in Iran: A Qualitative Study

ABSTRACT

Aim

Hospital Accreditation (HA) is defined as the systematic evaluation of hospitals against explicit standards. Accreditation is the most important external tool to assess healthcare quality. The purpose of HA is to improve quality and reduce medical errors in healthcare organizations by determining appropriate policies. Nursing staff play a key role in formulating and implementing policies. However, nurses face challenges in holistic nursing (HN). This study was conducted to investigate the HN experience through implementing HA in Iran from the perspective of nurses.

Design

The design was a qualitative study.

Methods

In‐depth, face‐to‐face, semi‐structured individual interviews were conducted with 20 participants. Participants consisted of nurses involved in accreditation with at least 1 year of working experience in the hospital, selected using purposive sampling with maximum diversity. Sampling continued until data saturation was reached. Data analysis was performed through content analysis based on the Graneheim and Lundman method.

Results

This study showed that HN is influenced by quality improvement programmes, especially accreditation. Accreditation is inherently ideal and several factors affect its accurate implementation. Obtaining more knowledge about these factors and utilizing nurses' experiences can significantly affect its better implementation and lead to comprehensive patient care. Data analysis resulted in four themes: ‘structure’ (‘inappropriate standards’, ‘inappropriate assessment system’, ‘lack of resources’, ‘time constraints’), ‘implementation process’ (‘documentation burden’, ‘monitoring and evaluation methods’, ‘team communication challenges’), ‘knowledge’ (‘academic education gaps’, ‘in‐service training gaps’), and ‘attitude’ (‘superiors' views’, ‘nurses' views’, ‘value conflicts’).

Patient or Public Contribution

Twenty nurses were interviewed as healthcare providers.

Implications of the Study's Findings

The results of this study can be effective in changing the attitude of managers toward accreditation programme (AP) implementation as well as developing suitable models for accreditation. The results also clarify the challenges and benefits of accreditation implementation and its impact on HN.

1. Introduction

Hospital accreditation (HA) is a crucial tool for assessing the quality of health services, involving daily actions to maintain a robust system within healthcare organizations (Hussein et al. 2021). Research has shown that HA has the potential to enhance the quality of health services (Aldossary et al. 2022) by fostering a culture of quality, strengthening multidisciplinary teams, promoting patient‐centred care and reducing mortality rates in accredited hospitals (Alhawajreh et al. 2023). Currently, the accreditation programme (AP) is mandatory in Iran (Yousefinezhadi et al. 2020). Iran, with a population of 85 million, is located in West Asia and the Middle East (Mehdipour et al. 2022). In Iran, the Ministry of Health, Treatment, and Medical Education (MOHME) is responsible for the policy, financing, planning, leadership, coordination and evaluation of health and treatment services provided by various public and private health organizations and institutions. The national HA system in Iran was established in 2012. Nurses, as the largest population in the Iran health system, have the most interaction with patients and implement HA (Yousefinezhadi et al. 2020). The implementation of the AP in Iran has affected holistic nursing (HN) (Poortaghi et al. 2020). Holistic nursing care (HNC) includes all nursing practices that improve the whole person (Albaqawi et al. 2021) and lead to the improvement of harmony between the mind, body, emotions and spirit of a person in a constantly changing environment (Mandal et al. 2020). Considering the importance of increasing the quality of care through an AP, the importance of the nursing team in achieving such competencies is clear and important because these professionals, as team leaders, have a direct relationship with multi‐professional actions, developing strategies to improve the care process and providing operational models (Cohen et al. 2021; Gabriel et al. 2018). In Iran, challenges such as nurse shortages, time constraints and lack of emphasis on comprehensive care in nursing education hinder the delivery of quality care (Rajabpour et al. 2019). Studying nurses' experiences with APs can clarify their role in improving care quality and establishing nursing as a science. In addition, research focused on nurses' experiences in the accreditation process can provide information to managers so that they can implement different strategies aimed at improving the quality of services, as well as achieving and/or maintaining certification. Therefore, their role and experience in the accreditation process are beneficial and deserve to be highlighted.

1.1. Background

The global approach to healthcare quality and its improvement has led to efforts to manage resources more effectively (Poortaghi et al. 2020). Currently, the quality of nursing care is considered an important factor in providing quality services to patients. The concept of HN was developed to improve the quality of nursing care, according to which the body, mind and soul are unavoidably combined (Asgari et al. 2019). HN is defined as ‘all nursing practice that has healing the whole person as its goal’. Currently, there are two major challenges in nursing. The first is the integration of the concepts of technology, mind and spirit into nursing practice; the second is to develop and integrate models for quality nursing care. HN is the most complete way to conceptualize and practice professional and comprehensive nursing. The idea of caring for the whole person goes back to Florence Nightingale (Gripshi 2021). Nightingale has left some teaching in this profession to this day. Her idealism has been current for more than 200 years. The current trends are impressively aligned with Nightingale's theory and philosophy. Florence's basic principle of healing (healing process or healing action) is prominent in international literature and includes attention to all aspects of the body, mind and spirit to achieve and maintain wholeness and balance. A balance that represents HNC (Riegel et al. 2021). Florence Nightingale, who is considered to be the founder of HN, taught nurses to focus on the principles of holism (unity, wellness and the interrelationship of human beings and their environment) (American Holistic Nurses Association 2023a). According to Nightingale, treatment can always be performed; however, healing is not always possible. Eliminating the signs and symptoms of the disease only involves the physical aspect of care, leaving the spiritual aspect in the background (Riegel et al. 2021). She introduced HNC by discovering the importance of environment, light, scent, music and silent reflection in the healing process (Gripshi 2021). Holism based on this concept has been used in the health field since the beginning of the 20th century. The American Holistic Nurses Association (AHNA) was established in 1980 (American Holistic Nurses Association 2023c; Sessanna et al. 2021). HN was recognized as a specialized technique by the American Nurses Association (ANA) in 2006 and established a clear framework of nursing practices and standards (Gripshi 2021). Currently, AHNA is well known as the definitive voice for HN (American Holistic Nurses Association 2023b; Sessanna et al. 2021), and is a specialty nursing association serving over 5500 nurses and holistic healthcare professionals in the USA and internationally (American Holistic Nurses Association 2023b). The holistic function of nursing is a communication method focused on nurse–patient cooperation for care, which connects knowledge, theories, expertise, insight and creativity (Ghorbani and Salsali 2018). A holistic nurse is a legally licensed nurse who practices HN according to the ANA Code of Ethics, standards of practice and guiding principles (Sessanna et al. 2021). Holistic nurses use the theory, knowledge, expertise and intuition of nursing to diagnose and care for a person as a whole and foster ‘wholeness, peace, and healing’ by paying attention to the physical, mental, emotional, spiritual and environmental conditions of each person and respecting values, health beliefs and health experiences (American Holistic Nurses Association 2020). Providing holistic care plays a significant role not only in the patient's health process but also in improving nurses' performance, skills, professional status, independence and self‐confidence (Jasemi et al. 2014). Many nursing theorists, including Rogers, Newman and Parse, have also focused on this care method (Leighton 2021; Rajabpour et al. 2019). Unfortunately, despite the constructive effects of holistic care, studies indicate weakness in its application and nurses' insufficient attention to patients' mental, spiritual and psychological dimensions while providing care (Jasemi et al. 2014). According to surveys, 67% of patients in the United States do not receive comprehensive care, while only 5% of patients in Germany do (Ambushe et al. 2023). In Iran, despite a small number of studies on nurses' caring behaviours, the results of the studies show that nurses are more interested in the physical dimensions of care for various reasons and often neglect the psychosocial dimensions of patients, which leads to patient dissatisfaction (Rajabpour et al. 2019). Peyrovi et al. (2013) reported that the care of Iranian patients is more focused on the physical dimensions of care, while nurses are required to pay attention to other dimensions of care to provide HNC. In most cases, nurses provide care based on routine duties and rely on physicians' and hospital managers' opinions. They make an effort only to solve patients' physical problems and implement the physicians' orders. In such a situation, nurses neglect patients' feelings, emotions, and needs, and the patient is treated as a biological machine (Ambushe et al. 2023; Jasemi et al. 2014). The absence of HN increases treatment costs, length of hospital stay and risk of new complications (Ambushe et al. 2023). This is one of the challenges and crises of the nursing profession in today's world, especially in Iran (Jasemi et al. 2014). One of the factors causing such a crisis in Iran is the evaluation and improvement of hospital quality.

Without an efficient assessment system, the growth and development of any system, particularly the healthcare system, lack the necessary and fundamental means to achieve its goals (Sadeghi et al. 2016). In Iran, monitoring and assessment of hospitals are one of the primary responsibilities of the MOHME (Mosadeghrad and Shakibaei 2017). Various approaches have been used globally to regulate the quality of healthcare internally and externally. External review systems facilitate organizational changes and strive toward quality standards and service quality improvements (QI). Accreditation has been cited as the most important strategic external quality assessment tool in healthcare (Hussein et al. 2021). The World Health Organization (WHO) defines accreditation as a systematic assessment of hospitals against explicit standards (World Health Organization 2022). Accreditation is an appropriate strategy for the development of management, leadership and organizational culture. It also improves the quality of healthcare services and reduces medical errors (Mosadeghrad and Shakibaei 2017). Accreditation surveyors collect and record information based on predetermined standards through observations, interviews and document reviews (Yousefinezhadi et al. 2020). Quality standards for hospitals and other medical centers were first introduced at the American College of Surgery in 1917, and officially began in the United States in 1951 (Hussein et al. 2021). The accreditation status varies globally. The American Joint Commission on Accreditation of Healthcare Organizations (JCAHO) model is suitable for continuous QI (Bahmaei et al. 2020). In Iran, MOHME introduced accreditation in 2010 by utilizing checklists and evaluation criteria. Accreditation standards were developed by reviewing those of the United States, France, Egypt and Lebanon. Then these standards were localized based on national laws and regulations (Yousefinezhadi et al. 2020). The standards consisted of 37 chapters, 3754 standards and 8104 measurable elements. The first accreditation survey was launched in 2012, and all public and private hospitals were accredited (Mosadeghrad et al. 2021; Tashayoei et al. 2020). In this round, approximately 71.4% of the hospitals received the first grade and above, and seven hospitals received a non‐accredited grade. At this stage, the number of outcome standards was limited, and the standards were mostly based on structural and process standards. The weakness of accreditation during this period indicated a large number of standards and measures (Yousefinezhadi et al. 2020). Therefore, the second edition of the standards was introduced in 2014, including 36 chapters and 2157 measures (Mosadeghrad et al. 2021; Yousefinezhadi et al. 2020). At this stage, hospital managers complained about the large number and ambiguity of the standards, the bureaucracy caused by the accreditation process, the evaluation method, the uncertainty among the evaluators, and their insufficient knowledge and experience. They stated that clinical staff spent more time on accreditation processes and less time on patients; as a result, job stress increased among hospital staff. Therefore, the third edition of the standards, consisting of 248 standards and 889 measures, was introduced in 2016. In this version, the self‐evaluation of hospitals was also added to accreditation. In the fourth stage, accreditation was conducted using 110 standards and 514 measures in 2020. Now the accreditation evaluation method of Iranian hospitals includes self‐evaluation, on‐site evaluation, periodic evaluation and the accreditation certificate of hospitals in seven levels: excellent, one superior, one, two, three, four and non‐standard. The validity of the accreditation certificate is also 2 years (Mosadeghrad et al. 2021). The MOHME obliges hospitals to comply with accreditation criteria and compulsorily evaluates them based on this model. The hospital tariff is determined based on its accreditation grade (Yousefinezhadi et al. 2020).

Accreditation has been widely discussed globally for its impact on service quality (Bogh et al. 2018). Studies suggest that accreditation standards are more beneficial than general quality management models. Accrediting medical institutions can enhance public trust and satisfaction among healthcare professionals, improving intra‐ and extra‐organizational communication (Yousefinezhadi et al. 2020). A study by Gabriel et al. (2018), shows nurses believe accreditation enhances performance and quality, while in Denmark, some hospital staff view it negatively due to mismanagement, excessive documentation, staff pressure and unnecessary processes (Bogh et al. 2018).

Studies have indicated that the accreditation process in Iran has not effectively improved healthcare performance and satisfaction among patients and managers after several revisions. The implementation of accreditation standards, which have undergone multiple revisions, has not resulted in the desired outcomes (Mosadeghrad et al. 2021). Reports suggest that there is no significant link between accreditation and improvement of nursing services. Issues such as staff workload, inappropriate division of duties, inadequate training, lack of motivation, lack of a workgroup (Bahmaei et al. 2020), excessive bureaucracy and resource shortages hinder the effective implementation of accreditation (Mosadeghrad et al. 2021). Additionally, the hospital standards in Iran, although more quantitative than the Joint Commission's, lack comprehensiveness and practicality, even 50% of them cannot be covered in practice, and their implementation can have contradictory results (Bahmaei et al. 2020). Therefore, simply following accreditation protocols is insufficient to bring about positive HN changes. Structural, evaluative and organizational changes are necessary to successfully implement accreditation standards in Iranian hospitals (Tashayoei et al. 2020). These challenges in accreditation implementation are seen as a crisis in delivering healthcare in Iran. However, accreditation is currently one of the main evaluation systems of Iranian hospitals that needs to be evaluated for efficiency and effectiveness. Understanding programme strengths and weaknesses, along with factors influencing them, requires more research and input from those involved. Despite years of accreditation implementation, few studies have been done. With their significant roles in service provision and decision‐making, nursing staff are vital in crafting quality hospital programmes (Cohen et al. 2021; Gabriel et al. 2018). Nurses' experiences can reveal the advantages and disadvantages of the accreditation process, leading to improvements in HN and healthcare quality. Qualitative research offers flexibility and fosters researcher‐participant interaction (Hashemnezhad 2015). The content analysis method was selected according to the nature of the present study because of its objectivity in identifying implicit and explicit themes. This study aimed to investigate the HN experience with the implementation of HA in Iran from the perspective of nurses.

2. Methods

2.1. Design

This qualitative study used conventional content analysis based on the approach described by Graneheim and Lundman (2004). Content analysis is a scientific method for data analysis (Vears and Gillam 2022). Qualitative content analysis is a systematic and purposeful research method for describing a phenomenon and enabling the researcher to gain a deeper understanding of participants' experiences (Graneheim et al. 2017). A significant characteristic of conventional content analysis is that the analysis is conducted inductively without presuppositions from a close examination of the texts (Vears and Gillam 2022). In conventional content analysis, codes are directly or indirectly extracted from raw data. This type of content analysis is usually used in studies whose purpose is to explain a phenomenon. In such cases, researchers refrain from using preconceived categories and themes, allowing the classes to emerge from the data through induction (Hashemnezhad 2015). In essence, content analysis involves generating a comprehensive summary of the content of various texts within a data set (Vears and Gillam 2022). In this study, this method was selected because it allowed the researchers to observe existing conditions and nurses' experiences following the implementation of HA regarding HNC without imposing prior assumptions (Ashrafi and Nobahar 2023; Graneheim and Lundman 2004). This study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1398.216).

2.2. Study Setting and Participants

The study was conducted in two public teaching hospitals located in Tabriz, East Azerbaijan Province, Iran. Hospital A was a specialized ophthalmology hospital with 120 beds, and Hospital B was a general hospital with 510 beds. Both hospitals were under the supervision of Tabriz University of Medical Sciences. At the time of data collection, both hospitals had achieved Level 1 accreditation certificates from the Ministry of Health, which is the highest level of accreditation. Additionally, Hospital B was recognized as a Hospital Friendly to Patient Safety. Participating wards included medical‐surgical units, intensive care units (ICUs), emergency departments and paediatric wards.

Participants were selected using purposive sampling. The inclusion criteria were: (a) nurses involved in accreditation implementation and (b) a minimum of 1 year of professional nursing experience in the hospital. To achieve maximum diversity, we purposively selected participants based on ward type, work experience, role in accreditation, gender and educational level. The final sample comprised staff nurses, head nurses, clinical supervisors, infection control nurses, QI nurses and safety nurses. These participants were considered key stakeholders for understanding the HN experience following HA implementation, as they were most extensively involved in the implementation of HA standards and measures.

2.3. Data Collection

Interviews were conducted by the first author, who had completed necessary training in interviewing and communication techniques. After explaining the study objectives, the researcher emphasized voluntary participation, data confidentiality and the right to withdraw at any stage and obtained written consent to conduct and record interviews. In‐depth, semi‐structured and face‐to‐face interviews were conducted individually with 20 participants using guiding questions. In addition to audio recording, field notes were taken to ensure accurate data analysis.

Initially, nurses who were more involved in the accreditation process were interviewed, followed by other eligible nurses. The interview questions were designed after reviewing relevant literature and consulting with nursing experts, professors and nurses involved in the accreditation process in another hospital (these individuals were not interviewed). Each interview began with a general question: ‘As a nurse, describe your experiences of HA implementation’. Subsequently, clarifying questions such as ‘Please explain what your hospital does regarding accreditation’, ‘How was accreditation introduced in your unit?’ ‘After the implementation of accreditation, what changes do you think have been made in the way you care for your patients?’ ‘Has the quality of holistic nursing care improved with the implementation of accreditation?’ etc., were asked. Exploratory questions based on participants' statements were also asked, such as: ‘What do you mean?’ ‘Please explain more about this’. ‘Please give an example’. ‘Do you have a particular memory in this regard?’

Data collection lasted 6 months, from January 2021 to June 2021. Each interview lasted between 40 and 60 min, with a total of 20 participants. No repeat interviews were conducted, as the data obtained from a single interview with each participant were rich and comprehensive enough to reach saturation. The research team determined that additional interviews would not yield substantially new information. Data collection continued until saturation was achieved. We pursued both code saturation (no new codes) and meaning saturation (no new dimensions of meaning) based on frameworks by Morse (2015) and Hennink and Kaiser (2022). According to Morse (2015), saturation is attained when the understanding of the ‘phenomenon becomes stronger, more evident, more consistent, more comprehensive and more mature’. In our study, code saturation was achieved after interview 17. Data collection continued until interview 20 to ensure meaning saturation; interviews 18, 19 and 20 added no new concepts and only confirmed previously identified themes and sub‐themes.

2.4. Data Analysis

Data analysis was performed using conventional content analysis based on Graneheim and Lundman's method (Graneheim et al. 2017; Graneheim and Lundman 2004; Mayring 2023). Therefore, categories and themes were extracted directly from the interview without considering pre‐defined categories or themes. Microsoft Word software 2019 was used to transcribe the interview texts, and MAXQDA 2018 software was used to manage and analyze the data.

Immediately after each interview, the first author listened to the audio files and transcribed them verbatim. The transcribed texts were then read several times to gain a sense of the whole, and interpretive notes were reviewed. Next, meaning units, defined as words, sentences or paragraphs relevant to the phenomenon, were identified. These meaning units were then condensed while preserving their core meaning. The condensed meaning units were subsequently abstracted and labelled with codes. This procedure contributes to the reciprocal process between conceptualization and data collection and directs the collection of subsequent data to obtain appropriate information (Polit and Beck 2021). Sentences and paragraphs related to research questions and objectives were identified and inductively coded. Finally, the codes were compared based on similarities and differences, and grouped into sub‐themes and themes. The codes and themes were reviewed by the authors, and a final consensus was reached. Both authors participated in the coding process and theme development. Regular consensus meetings were held to resolve disagreements and ensure analytical rigour.

All interviews were conducted and analysed in Persian. After finalizing the themes and sub‐themes, the entire analysis (including themes, sub‐themes and representative quotations) was translated into English by a professional bilingual translator with experience in qualitative health research. A second bilingual researcher, who was not involved in the initial translation, performed a back‐translation from English to Persian. The original Persian and the back‐translated Persian versions were compared. In cases of disagreement (seven cases across all transcripts), the research team discussed and reached consensus on the final English wording. Finally, a native English speaker with expertise in health sciences reviewed the final translated manuscript for fluency and conceptual accuracy. Each step of the data analysis process is shown in Table 1. Table 2 provides a detailed example of the content analysis process based on Graneheim and Lundman's (2004) method, demonstrating how a raw meaning unit was condensed into a code, then a sub‐theme and finally a theme.

TABLE 1.

Data analysis steps and actions taken.

Steps	Actions taken
1	Preparation of the data
2	Transcribing interviews
3	Reading the text and gaining a general sense
4	Reviewing interpretive notes
5	Identifying meaning units and text coding
6	Formation of themes and sub‐themes through the similarities and differences between the codes and combination of the same codes
7	Review of codes, sub‐themes and themes and reaching final consensus by the research team
8	Translating the explored concepts into English
9	Back‐translation, resolving discrepancies and native speaker review

TABLE 2.

Example of the content analysis process from meaning unit to theme (for the theme ‘Knowledge’).

Meaning unit (Verbatim quotation)	Condensed meaning unit	Code	Sub‐theme	Theme
‘We learn holistic nursing in theory at university. But we never learn how to document holistic interventions in a way that satisfies accreditation. There is a gap between what we are taught and what accreditation demands’. (P3, female, age 34)	University teaches holistic nursing theoretically but does not teach documentation methods required by accreditation	Gap between academic education and accreditation requirements	Academic education gaps	Knowledge

2.5. Positionality and Reflexivity

The research team comprised two authors, both of whom are nursing faculty members. Both authors have prior clinical nursing experience and currently supervise students in clinical settings where accreditation is implemented. Both authors regularly attend clinical wards with students and directly observe the implementation of accreditation processes. Importantly, both authors possess good proficiency in qualitative research methods and have prior experience in conducting qualitative studies.

Our initial assumption was that accreditation, due to its protocol‐driven and audit‐focused nature, might conflict with HN, which emphasizes individualized, flexible and person‐centred care. To minimize potential bias, all interviews were conducted by the first author, who had no prior relationship with the participants. Neither author had any administrative or evaluative role in the accreditation process at the study hospitals, which helped reduce the risk of participants providing socially desirable responses. However, we acknowledge that both authors' ongoing presence in clinical settings and their familiarity with accreditation implementation could have shaped their interpretive lens. To mitigate this, both authors maintained reflexive journals throughout data collection and analysis, recording their assumptions, emotional responses and evolving interpretations. These journals were discussed during weekly meetings to identify and mitigate the influence of preconceptions on the analysis. Both authors collaboratively participated in data analysis, and regular consensus meetings were held to ensure analytical rigor and interpretive credibility.

2.6. Data Trustworthiness

For rigour, four criteria proposed by Guba and Lincoln (1985) including credibility, transferability, dependability and confirmability were considered (Lincoln and Guba 1985).

For credibility, prolonged engagement with the data, frequent reviews, maximum diversity in participant selection (novice and experienced nurses from different wards and roles), integrated data collection methods (individual interviews and field notes), member checking, accurate data collection and expert review were used. Regarding member checking, 12 out of 20 participants reviewed a summary of the initial codes and themes along with representative quotations. Nine participants confirmed that the analysis accurately reflected their experiences. Two participants requested clarification on the naming of one sub‐theme, which was subsequently changed from ‘excessive documentation burden’ to ‘documentation burden’. One participant (a negative case) suggested that positive aspects of accreditation should be more visible, which led to the addition of a separate Negative Case Analysis section at the end of the Results section. No unresolved disagreements remained.

For transferability, sampling was performed with maximum diversity in terms of demographic characteristics. Thick descriptions of the study setting, participants' context and conditions were also provided to enhance transferability.

For dependability, member checking (as described above), integrated data collection processes, regular research team meetings and maintaining an audit trail were used.

For confirmability, regular data collection, review by experts in qualitative studies, preservation of research documents and accurate recording of all research stages (audio recording, transcripts, field notes, analysis files) were established (Johnson and Christensen 2019; Lincoln and Guba 1985; Polit and Beck 2021; Vears and Gillam 2022).

2.7. Ethical Considerations

The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences (ID: IR.TUMS.FNM.REC.1398.216). Informed consent was obtained from all participants. All methods were performed in accordance with relevant guidelines and regulations for human research.

3. Results

In this study, 20 interviews were conducted with 20 participants. The mean age of participants was 40.40 ± 7.32 (years). Eight participants were male and 12 were female; five were single, 15 were married; seven had master's degrees and 13 had bachelor's degrees. The mean work experience of the participants was 15.30 ± 6.10 (years). Other characteristics of the participants are shown in Table 3.

TABLE 3.

Demographic characteristics of participants.

Number	Gender	Age	Marital status	Education	Role	Average work experience (years)	Ward/unit	Shift work
1	Female	36	Married	Masters	Clinical supervisor	10	Nursing office	Rotating shift
2	Female	53	Married	Bachelor	Head nurse	25	Operation room	Morning work
3	Female	34	Married	Bachelor	Nurse	12	Operation room	Rotating shift
4	Female	35	Married	Bachelor	Nurse	10	Paediatric ward	Rotating shift
5	Male	39	Married	Bachelor	Nurse	18	Operation room	Rotating shift
6	Male	44	Married	Bachelor	Nurse	20	Emergency	Rotating shift
7	Male	50	Married	Bachelor	Nurse	24	Emergency	Rotating shift
8	Male	33	Unmarried	Masters	Nurse	9	Emergency	Rotating shift
9	Male	27	Married	Bachelor	Nurse	3	Surgical	Rotating shift
10	Female	57	Married	Bachelor	Infection control nurse	26	Nursing office	Morning work
11	Female	47	Married	Masters	Quality improvement nurse	22	Quality improvement office	Morning work
12	Female	35	Married	Masters	Safety nurse	14	Nursing office	Morning work
13	Female	40	Married	Master	Nurse	10	Clinical	Morning work
14	Female	39	Unmarried	Bachelor	Nurse	12	Emergency	Rotating shift
15	Female	43	Married	Bachelor	Head nurse	18	Emergency	Morning work
16	Female	40	Unmarried	Bachelor	Quality improvement nurse	17	Quality improvement office	Morning work
17	Male	44	Married	Master	Nurse	15	Surgical	Rotating shift
18	Male	35	Unmarried	Bachelor	Nurse	10	Medical	Rotating shift
19	Male	42	Married	Bachelor	Quality improvement nurse	18	Quality improvement office	Morning work
20	Female	35	Unmarried	Master	Nurse	13	ICU	Rotating shift

Based on content analysis, four themes emerged: ‘structure’, ‘implementation process’, ‘knowledge’, and ‘attitude’, yielding 12 sub‐themes (Table 4 & Figure 1). The four themes were distinct in their focus. The theme ‘structure’ referred to macro‐level organizational and policy factors outside nurses' control. The ‘implementation process’ theme referred to day‐to‐day operational execution of accreditation on the wards. The theme ‘knowledge’ referred to educational gaps at academic and in‐service training levels. The theme ‘attitude’ referred to beliefs, values and perspectives toward accreditation. These boundaries were consistently maintained throughout the analysis to prevent conceptual overlap between themes.

TABLE 4.

Themes and sub‐themes extracted from the experiences of participants.

Themes	Definition (Boundary)	Sub‐themes	Implication for holistic nursing
Structure Implementation process Knowledge Attitude	Macro‐level organizational and policy factors outside nurses' control Day‐to‐day operational execution of accreditation on the wards Educational gaps at academic and in‐service training levels Beliefs, values and perspectives toward accreditation	inappropriate standards inappropriate assessment system Lack of resources Time constraints Documentation burden Monitoring and evaluation methods Team communication challenges Academic education gaps In‐service training gaps Superiors' views Nurses' views Value conflicts	Limits time and capacity for psychosocial, spiritual and emotional care Shifts focus from patient interaction to administrative tasks Reduces person‐centred care Prevents development of competencies for holistic assessment, communication and spiritual care Creates value conflicts that hinder integration of holistic values into daily practice

FIGURE 1.

Final thematic map illustrating the holistic nursing experience of implementing hospital accreditation in Iran. The thematic map displays the four primary themes (Structure, Implementation Process, Knowledge and Attitude) and 12 sub‐themes.

3.1. Theme 1: Structure

Structure refers to macro‐level organizational and policy factors outside nurses' control. This theme included four sub‐themes: ‘inappropriate standards’, ‘inappropriate assessment system’, ‘lack of resources’, and ‘time constraints’. Together, these structural factors limited nurses' time and capacity for providing psychosocial, spiritual and emotional care, which is the core of HN.

3.1.1. Sub‐Theme 1.1: Inappropriate Standards

Participants pointed out the inappropriate standards of accreditation, including the large number of standards and their complexity, copying programmes from other countries, lack of localization, ambiguity and non‐specialization. They stated that accreditation did not consider evidence‐based nursing, critical thinking and clinical reasoning and has caused too much bureaucracy. One participant said:

In the accreditation, paying attention to the facilities and their quality has increased the patient's safety; but the provision of these facilities requires the provision of the necessary infrastructure, which itself leads to the imposition of high costs; therefore, the lack of facilities has made it difficult to implement accreditation policies and holistic nursing. (P1, female, age 36)

Another participant said:

Accreditation policies are designed without considering the necessary infrastructure in the country. This program has disrupted nursing practice. So, we can't take good care of our patients. (P16, female, age 40)

A clinical supervisor also said in this regard:

In my opinion, the copying of measures and the lack of proper localization has caused us problems in providing nursing care. I have seen nurses' dissatisfaction many times. Many times they have come to me and complained that I cannot take care of all the problems of my patients because of too much writing. (P1, female, age 36)

Regarding non‐specialized standards, a participant stated:

We don't need radiology in the ophthalmology hospital, but it's emphasized in the accreditation program and even in the evaluation process of hospitals, they reduce the hospital's score due to its absence. (P11, female, age 47)

An infection control nurse described the ambiguity of standards:

I had a problem implementing the accreditation metrics. They were specific issues. Some of them were not easy to understand at all. In fact, we had to go to the coordinator to ask what do you mean by that? What is expected with this standard? (P10, female, age 57)

3.1.2. Sub‐Theme 1.2: Inappropriate Assessment System

Participants pointed out several problems in this field, including the inappropriateness of evaluation checklists, stress caused by evaluation, the lack of continuous and correct evaluation, evaluators' views, evaluators' lack of clinical experience, evaluators' close attention to documentation and their lack of attention to the hospital's budget and facilities. They also stated that on the day of hospital assessment, officials planned the work schedule to have only nurses with sufficient accreditation information in the ward, which dissatisfied them. One participant said:

The assessment process contradicts the goals of the accreditation and holistic nursing. (P10, female, age 57)

Another participant added:

In assessment, they only pay attention to the documents and don't consider the clinical practices. (P14, female, age 39)

A third participant noted:

Each of the accreditation evaluators acts in their style as if there's no single criterion for evaluation. (P18, male, age 35)

3.1.3. Sub‐Theme 1.3: Lack of Resources

Participants consistently reported that insufficient financial resources, equipment and staffing hindered the implementation of accreditation standards. A participant stated:

Increased workload due to accreditation, an increased volume of writings, and the lack of equipment, facilities, personnel, etc., cause us to be away from the patient's bedside. The quality of our nursing performance has decreased. Although we know writing is necessary and useful for the patient and us, we spend most of our time on it. (P15, female, age 43)

Another participant added:

The lack of budget for implementation, the lack of staff, and the lack of proper context and culture have become obstacles to quality nursing care. (P20, female, age 35)

3.1.4. Sub‐Theme 1.4: Time Constraints

Participants described how the combination of accreditation demands and daily clinical responsibilities left insufficient time for comprehensive, holistic patient care. A participant stated:

We fill so much of our time with writing and documenting that sometimes we can only give our patients medicine and nothing more. (P12, female, age 35)

Another participant expressed guilt and frustration:

Sometimes I feel guilty because in some shifts, due to high workload and overcrowding caused by accreditation, I spend most of my time on paperwork, documentation, and other extra tasks imposed by accreditation. Finally, I can only give my patient medicine and check vital signs. I have no time left for my patient's mental and psychological needs. I am very upset about this. (P18, male, age 35)

3.2. Theme 2: Implementation Process

Implementation process refers to the day‐to‐day operational execution of accreditation on the wards. This theme included three sub‐themes: ‘documentation burden’, ‘monitoring and evaluation methods’, and ‘team communication challenges’. Together, these factors shifted nurses' focus from direct patient interaction to administrative tasks, thereby reducing person‐centred holistic care.

3.2.1. Sub‐Theme 2.1: Documentation Burden

Participants consistently reported that the volume of required documentation was excessive and directly competed with time for meaningful patient interaction. One participant stated:

We document everything multiple times. I spend more time with the computer than with my patients. How can I practice holistic nursing when I do not even have time to look into a patient's eyes? (P17, male, age 44)

Another participant added:

The writing never ends. By the time I finish all the accreditation forms, the shift is over, and I realize I never asked my patient how they are feeling emotionally. (P7, male, age 50)

A third participant noted:

In my opinion, careful attention to the documentation can be in the legal authorities supporting the nurse; but due to its high volume, it is an obstacle in the way of nursing care. (P2, female, age 53)

3.2.2. Sub‐Theme 2.2: Monitoring and Evaluation Methods

The frequent monitoring visits and the methods used by evaluators created additional stress and diverted attention from patient care. One participant explained:

Every time the accreditation team comes, we panic. We run to complete files instead of running to patients who need pain relief or emotional support. (P9, male, age 27)

Another participant noted:

The evaluators announce their visit suddenly. On those days, all our energy goes into preparing documents. The holistic needs of patients become secondary. (P13, female, age 40)

Another participant added:

On the day of the hospital assessment, officials plan the work schedule so that only nurses who have enough information about accreditation are present in the ward. The rest of us are moved elsewhere. This disrupts our holistic nursing care because the new nurse does not know the patient's emotional or psychological history. We are very dissatisfied with this practice. (P4, female, age 35)

3.2.3. Sub‐Theme 2.3: Team Communication Challenges

Poor communication among team members during accreditation implementation further hindered holistic care. A participant shared:

Doctors focus on their own accreditation tasks. Nurses focus on theirs. No one talks about the patient's social or emotional needs anymore. Accreditation has fragmented our communication. (P8, male, age 33)

Another participant stated:

Instead of discussing a patient's spiritual distress in our morning report, we discuss which forms are missing. Accreditation has changed what we talk about. (P15, female, age 43)

3.3. Theme 3: Knowledge

Knowledge refers to educational gaps at both academic and in‐service training levels. This theme included two sub‐themes: ‘academic education gaps’ and ‘in‐service training gaps’. Together, these gaps prevented nurses from developing the competencies necessary for holistic assessment, therapeutic communication and spiritual care.

3.3.1. Sub‐Theme 3.1: Academic Education Gaps

Participants reported that university education did not adequately prepare them to integrate accreditation requirements with HN principles. The insufficient coverage of accreditation content, great emphasis on theoretical content and lack of familiarity with accreditation as a main reference for hospital practices were identified as major gaps. Unfortunately, after several years, accreditation training has not yet been included in the students' curriculum, and students are not taught how to implement it to achieve HN. One participant stated:

Accreditation training and holistic nursing should begin at university. Students are faced with a large amount of information upon entering the hospital after graduation, which causes them stress. Students should be familiar with the importance of holistic nursing and removing obstacles to its implementation in the university so as not to get into trouble while working in the hospital. Unfortunately, we always have this problem with new nurses and we have to provide them with the necessary training in this field before starting work. It has been observed many times that these people face stress by seeing a large amount of information that they did not learn in the university, and this itself affects their motivation and work quality. By the way, a nurse started working here last week, and when I was checking her information, I realized that she had little information about accreditation, and my few questions confused her. (P1, female, age 36)

Another participant stated:

I started working in this hospital three years ago. I remember that I was very annoyed at first; because I had only heard the name of accreditation and general things about it in my internships in hospitals and I had no theoretical training course on this matter. In the first days, I had to get a pamphlet from the hospital and read it. However, it took me a long time to fully familiarize myself with the accreditation, but I feel that by implementing the accreditation, I am moving away from the theoretical things about holistic and patient‐centered nursing care that I learned in the university. (P9, male, age 27)

A third participant noted:

We learn holistic nursing in theory at university. But we never learn how to document holistic interventions in a way that satisfies accreditation. There is a gap between what we are taught and what accreditation demands. (P3, female, age 34)

3.3.2. Sub‐Theme 3.2: In‐Service Training Gaps

In‐service training is considered highly significant and necessary to update the nurses' information. Participants mentioned the inappropriate training process, insufficient training, lack of clinical faculty to train staff, and interference of training classes with busy shifts. One participant stated:

For effective staff education, university faculty should be present in hospitals and cooperate in training. The current in‐service training is all about checklists, not about how to address a patient's spiritual needs within time limits. (P16, female, age 40)

Another participant added:

The training classes are unplanned and held during busy shifts. We either can't attend, or if we attend, it disrupts patient care and causes stress for us. They never teach us how to balance accreditation demands with holistic care. (P18, male, age 35)

A clinical supervisor explained:

Our in‐service training is entirely focused on “how to prepare for surveys.” There is no training on how to address a patient's emotional or spiritual distress within the time limits created by accreditation. (P1, female, age 36)

3.4. Theme 4: Attitude

Attitude refers to the beliefs, values and perspectives of different stakeholders toward accreditation. This theme included three sub‐themes: ‘superiors' views’, ‘nurses ' views’, and ‘value conflicts’. Together, these attitudes created value conflicts that hindered the integration of holistic values into daily nursing practice.

3.4.1. Sub‐Theme 4.1: Superiors' Views

Participants stated that the views of officials and managers were critically important for proper implementation of accreditation. They pointed to competition between hospitals to receive high scores and financial resources from the MOHME. They believed that officials should prioritize accreditation to achieve common goals, improve indicators, implement accreditation accurately and remove all obstacles. One participant stated:

At first, managers' belief in the accreditation was very weak. Over time and repeated assessments, their views have changed, and now they are making efforts to implement it together with the staff. (P11, female, age 47)

Another participant added:

The ranking of hospitals and the competition for financial resources have challenged managers. They now pay more attention to the quality of equipment and services and push all their actions to gain more credit. (P10, female, age 57)

Participants with management roles pointed out the increase in the financial problems and workload following accreditation implementation. They consider them obstacles to HN. A nurse manager stated:

Managers' workload has increased due to implementing the accreditation. They are constantly filling out checklists and documentation, which becomes an obstacle to holistic nursing. (P2, female, age 53)

One manager involved in the accreditation process explained:

In my opinion, accreditation measures are good for increasing the quality of services, but there are obstacles in implementation that must be removed to achieve the final goals of accreditation and improving services and improving the quality of nursing care. With the implementation of accreditation, both our workload and nurses' workload have increased. Many times I witnessed nurses' dissatisfaction about increased documentation. We also have to constantly monitor things, update policies, complete documentation, and complete the equipment of the hospital despite the lack of funds. I hope we will achieve the desired result. (P19, male, age 42)

A manager involved in the accreditation process explained:

With accreditation, both our workload and nurses' workload have increased. Many times I witnessed nurses' dissatisfaction about increased documentation. We have to constantly monitor and update policies despite lack of funds. (P20, male, age 45)

3.4.2. Sub‐Theme 4.2: Nurses' Views

Participants believed that accreditation was ideal in theory but improperly implemented in practice. Lack of staff motivation, unfair payments, inattention to nurses' well‐being and lack of physician cooperation were mentioned. One participant stated:

Accreditation is ideal, but due to many problems in its implementation, it's only on paper and not in practice. (P6, male, age 44)

Another participant added:

It is better to pay attention to the salaries and the welfare, as well as the benefits of nurses so that they have enough motivation to work hard. (P19, male, age 42)

A third participant noted:

In my opinion, if the structural and executive problems of accreditation are solved, it can help us to achieve holistic nursing. (P15, female, age 43)

Regarding physician cooperation, a participant stated:

Unfortunately, managers only want us to work exactly according to accreditation standards and policies, not physicians. Sometimes physicians act against the policies. (P3, female, age 34)

3.4.3. Sub‐Theme 4.3: Value Conflicts

The most profound finding was the intense value conflict between professional HN values and accreditation‐driven bureaucratic values. Participants described feeling torn between what they believed was right for patients and what the system demanded. One participant expressed this struggle:

I became a nurse to care for the whole person—body, mind, and spirit. But accreditation makes me feel like a clerk. I hate this contradiction, but I have no choice. (P14, female, age 39)

Another participant shared:

Every day I face a choice: complete the accreditation forms on time or sit with a dying patient who is terrified. The system punishes me if I choose the patient. I cannot integrate holistic values into my practice anymore. (P5, female, age 31)

3.5. Negative Case Analysis

While the dominant pattern across participants was one of conflict and barrier, two participants held views that differed from the main themes. An emergency department nurse and a safety nurse believed that accreditation, by mandating thorough documentation, actually systematized certain neglected dimensions of HN. One participant stated:

With the implementation of accreditation, the importance of patient safety has been emphasized, and this has caused holistic nurses to pay attention to patient safety in all stages of nursing care; of course, if additional accreditation processes allow. Despite the high workload, I always pay attention to preventing my patients from falling. For example, I give the necessary training to my patient in this field, I ask him to always use bedside and use the alarm to ask for help from the nurse. (P17, male, age 44)

Another participant noted:

It's great that all the processes are transparent and easily accessible to us since it reduces the staff's errors and increases the quality of nursing care. If I encounter a problem, including how to send pathology, the needle stick process, etc., I refer to the policies. Therefore, with the implementation of accreditation, my errors in these areas have decreased. This gives me more time to focus on my patient's emotional needs. (P20, female, age 35)

Beyond HN, some participants also acknowledged organizational benefits of accreditation. One participant stated:

Accreditation has led to avoiding individual preferences and creating discipline in the work environment. For everything, we prepared a policy based on accreditation measures, and everyone must adhere to these policies, and no one, even a manager, can make a decision based on personal preferences. Personnel report their errors easily and without fear. (P16, female, age 40)

These negative cases were incorporated to ensure a balanced and credible analysis, as recommended by qualitative methodology guidelines (Morse 2015).

4. Discussion

This study investigated nurses' experiences of implementing HA and its perceived impact on HN practice. Four main themes emerged, including ‘structure’, ‘implementation process’, ‘knowledge’ and ‘attitude’, with 12 sub‐themes.

4.1. Structure

The first theme, ‘structure’, consisted of four sub‐themes including ‘inappropriate standards’, ‘inappropriate assessment system’, ‘lack of resources’, and ‘time constraints’. These structural factors limited nurses' time and capacity for providing psychosocial, spiritual and emotional care, which is the core of HN.

The results of this study showed that structural changes need to be made to the AP to implement it and enhance HN quality properly. These changes could involve modifying the metrics and standards and improving the evaluation process. Standards are considered the core of the AP. WHO has identified several challenges and barriers for HA in the Eastern Mediterranean region. These include assigning numerical scores to findings, failure to consider standards for all hospital services, a different understanding of the role of surveyors, lack of an independent national and inter‐institutional commission, the existence of multiple accreditation institutions and competition between each other and as a result of setting different standards and costs. Defects in the governance structure, procedure, surveyors, training and implementation of accreditation can lead to the hospital's failure to achieve the desired goals. A survey of 547 hospital managers across Iran in 2015 showed that only about 10% were satisfied with the necessary infrastructure to implement the AP. They were dissatisfied with accreditation standards, the content of standards, accreditation method, procedure and surveyors as well as the lack of human, financial and physical resources necessary to implement accreditation standards (Mosadeghrad and Ghazanfari 2021). Similarly, Yousefinezhadi et al. (2017), found that the high number of accreditation standards and measures, and insufficient training of surveyors were main barriers in the implementation of AP. Another survey of hospital managers in Zanjan province regarding the AP in 2016 and 2018 showed that satisfaction with the accreditation system decreased in the third round of accreditation compared to the second round. According to these managers, the hospital's AP in 2016 did not improve its performance compared to previous periods (Mosadeghrad and Nabizade 2018).

These findings align with our study, which identified similar structural barriers in the implementation of AP that prevent us from reaching HN and improving the quality of nursing care, that managers' attention to these intervening factors can be a suitable strategy for the correct implementation of AP and achieving HN in Iran. The consistency of these challenges across different contexts suggests that without addressing structural factors, accreditation cannot support HN practice. Managers' attention to these intervening factors may be a necessary strategy for achieving HN goals in Iran. To address these structural challenges, the principles of continuous improvement should be considered in developing accreditation standards. Standards should be balanced to achieve the programme's final goals, and different models can be used to eliminate existing deficiencies (Ellis et al. 2020). Surveyors should be qualified and have clinical experience to assess hospital structures, processes, procedures and outcomes systematically and reliably. Finally, the governance and management structure of the AP should be reliable, knowledgeable and familiar with hospital conditions and available facilities.

4.2. Implementation Process

The second theme, ‘implementation process’, referred to the day to day operational execution of accreditation on the wards. These factors shifted nurses' focus from direct patient interaction to administrative tasks, thereby reducing person centred holistic care. The excessive volume of required documentation was a major challenge reported by participants. Nurses spent most of their time completing forms and checklists instead of interacting with patients. This finding is consistent with previous research. In the study by Gabriel et al. (2018) in Brazil, nurses declared accreditation time‐consuming and did not improve human resources or encourage staff. The implementation of the Brazilian AP in 1999 was based on the standards of the Joint Commission International (JCI) and ‘National Accreditation Organization’ (ONA, as its abbreviation in Portuguese) and was carried out by a private organization without economic order and collective interest. Its main objective is to implement a continuous process of improving the quality of healthcare at the national level and to encourage all health services to reach high‐quality standards. In Brazil, ONA and JCI are responsible for most of the accreditation processes in hospitals. Both developed several process‐focused standards, but the JCI process focused the main evaluation on indicators related to patient care processes and humanization. ONA evaluation is based on structure, process and result and provides three levels of certification (compliance of structural, and service activities with safety criteria, excellence in management and excellence). The study of Gabriel et al. examined nurses' experiences in a quantitative, descriptive and exploratory study in seven dimensions, and the relevant information was obtained through the questionnaire; in our study, we examined the nurses' experiences using in‐depth and complete interviews, the participants freely declared their experiences in full. According to this study in Brazil and our study, the time‐consuming nature of accreditation and the lack of attention to the well‐being of nurses are basic challenges requiring serious measures. In the study by Gabriel et al. (2018) in Brazil, nurses considered the accreditation process a factor in improving quality and increasing patient satisfaction and staff participation in improving the quality of the hospital (Gabriel et al. 2018). According to the results of the studies, we conclude that the correct and thoughtful implementation of accreditation can lead to improved HNC and patient/staff satisfaction.

In Denmark, staff mentioned challenges such as time‐consuming and excessive documentation, which reduced the time spent with patients and QI activities (Bogh et al. 2018). The Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) was a mandatory AP for all Danish public hospitals, implemented from 2009 to 2015 by the Danish Institute for Quality and Accreditation in Healthcare (IKAS). DDKM was conceptualized as a virtual quality circle analogous to the Plan‐Do‐Study‐Act (PDSA) (Ellis et al. 2020). The purpose of the DDKM was to create a framework for continuous QI, documenting and clarifying healthcare quality and harm prevention (Bogh et al. 2018). The first version of DDKM was launched in August 2009 and the second version was launched in April 2012. Over time, DDKM was not supported by some politicians and healthcare professionals, and after an intense political debate, due to the imposition of additional funding, reduced direct patient care time, bureaucracy and poor evidence for its effects, mandatory AP for public hospitals ended in 2015, and the revised version of the DDKM, which was supposed to be launched in 2016, was not implemented (Bogh et al. 2018; Ellis et al. 2020). In this study, like our study, semi‐structured interviews were conducted with staff. The staff mentioned challenges such as time‐consuming and excessive documentation, which reduced the time spent with patients. According to them, organizational structures improved during preparation for accreditation. The results show that, like Iran, challenges in implementing accreditation and its impact on nursing care exist in other countries, indicating global concern about this issue. Documentation is one of the problems that can be seen in various studies. Nursing records are one of the ways to show the work done by the nursing staff and it is also an important indicator for the quality of nursing care; however, their time‐consuming nature is a major obstacle in providing nursing services.

Participants in our study also reported that frequent monitoring visits and the methods used by evaluators created additional stress and diverted attention from patient care. This finding aligns with challenges identified in the Eastern Mediterranean region, where surveyors' lack of clinical experience and inconsistent evaluation criteria have been reported as barriers to effective accreditation implementation (Mosadeghrad and Ghazanfari 2021).

Another important finding was that accreditation fragmented team communication. Doctors focused on their own accreditation tasks while nurses focused on theirs, with little discussion of patients' social or emotional needs. This finding is supported by Bogh et al. (2018), who reported that accreditation in Denmark led to departmental silos and reduced interdisciplinary communication.

In Iran, Yahyavi et al. (2018) identified challenges including personnel shortage, a large number of standards, hard shifts for hospital staff, lack of budget and non‐participation of physicians. Algunmeeyn et al. (2021), reported barriers such as lack of motivation, low salaries, heavy workload of nurses, high implementation costs, staff shortages and increased nurse turnover. The results of this study are completely aligned with the findings of the present study and indicate common challenges in the implementation of APs in most countries (Algunmeeyn et al. 2021). Yousefinezhadi et al. (2017), found that non‐participation of physicians, insufficient resources and low motivation for work were main barriers. These findings are consistent with our study and indicate common challenges in implementing accreditation across different countries. Proper implementation of the AP requires the elimination of obstacles and limitations. AP aims to enhance health service structures and processes, although the evidence for their success is uncertain. Evaluating the impact on clinical care and service quality relies heavily on clinical performance indicators. Progress varies across different specialties, emphasizing the importance of considering the causal relationship between clinical indicators and accreditation implementation due to the complexity of healthcare systems (Alhaleel 2018). While participants in our study primarily focused on barriers and challenges, some also acknowledged organizational advantages of accreditation (reported in the Negative Case Analysis section), including improved system accountability, transparency of processes, patient safety and legal support for nurses.

4.3. Knowledge

The third theme, ‘knowledge’, referred to educational gaps at both academic and in‐service training levels. These gaps prevented nurses from developing the competencies necessary for holistic assessment, therapeutic communication and spiritual care. Nurses need training and awareness raising to provide HNC in line with accreditation standards. Our study revealed two specific educational gaps. First, ‘academic education gaps’ indicated that university education did not adequately prepare nurses to integrate accreditation requirements with HN principles. Participants reported that accreditation training was not included in the nursing curriculum, and students graduated without familiarity with accreditation as a main reference for hospital practices. Second, ‘in‐service training gaps’ showed that hospital training programmes focused almost exclusively on accreditation checklists and survey preparation, with no training on how to address patients' emotional or spiritual needs within time constraints created by accreditation. These findings are consistent with previous research. El‐Gendy et al. (2021) found that nurses have low awareness of APs, highlighting the need for healthcare managers to increase technical capabilities and training of staff. Yousefinezhadi et al. (2017) reported that insufficient training of surveyors and lack of adequate preparation for accreditation were main barriers to implementation. Mosadeghrad and Ghazanfari (2021) also emphasized that training of personnel and students leads to improvement of processes that enhance service quality. The lack of accreditation content in nursing curriculum appears to be an international concern. In Brazil, Gabriel et al. (2018) noted that nurses felt unprepared for accreditation requirements due to gaps in their academic education. Similarly, in Denmark, staff reported that accreditation training was often provided through written materials rather than structured educational programmes, which limited their understanding and ability to implement accreditation effectively (Bogh et al. 2018). Given these findings, revising nursing curriculum to include accreditation content and providing structured in‐service training that emphasizes holistic competencies are essential steps for aligning accreditation with HN practice.

4.4. Attitude

The fourth theme, ‘attitude’, referred to the beliefs, values and perspectives of different stakeholders toward accreditation. Together, these attitudes created value conflicts that hindered the integration of holistic values into daily nursing practice. Management's attitude toward accreditation is critically important, as managers are known as key success factors for accreditation implementation and QI (Ellis et al. 2020). In the study by Yousefinezhadi et al. (2017), poor hospital managers' commitment and low employee motivation were introduced as the main barriers to accreditation implementation. Kamali et al. (2022), examined nursing managers' experiences of implementing accreditation and identified three main themes including ‘negative emotions toward the evaluation process’, ‘inappropriate evaluation procedure’, and ‘increased workload’. Although nursing managers experienced improvements during the three accreditation courses, their experiences showed barriers worthy of consideration. Attention to these challenges by MOHME can facilitate accreditation implementation (Kamali et al. 2022). These findings are consistent with our study, as our participants also reported that managers' views shifted over time but remained focused on scores rather than holistic outcomes. Hospital management should ensure the availability and safety of resources to achieve accreditation objectives. Improving the policy process and implementation procedure, including reducing bureaucracy and documentation, can help solve existing problems. Staff management is a key responsibility of hospital managers for proper accreditation implementation, as hospital staff are mostly conservative and resist changes. Nursing managers are directly involved in multi professional actions and adopt necessary strategies to implement changes for HA. They are also responsible for convincing hospital managers to achieve and maintain accreditation (El‐Gendy et al. 2021). Therefore, their attitude and perseverance can be useful in implementing the AP and, consequently, in implementing HN practice.

Our study also highlighted the importance of nurses' perspectives in implementing accreditation. Nurses showed greater involvement in implementing accreditation standards compared to other hospital groups. Their crucial role in patient care and safety makes them primarily accountable for upholding these standards (Kakemam et al. 2020). The effectiveness of hospital services depends on employees' perseverance and their proper role in achieving common goals. Healthcare providers acknowledge the importance of accreditation for patient safety. Employees believe accreditation fosters QI, community among staff and mutual care (El‐Gendy et al. 2021). However, according to Kakemam et al. (2020), nurses had a negative attitude toward APs due to the lack of positive impact of accreditation on nursing care quality, low training in accreditation and negative attitudes of managers with lack of support. These findings align with our study, where participants described accreditation as ideal in theory but only on paper and not in practice.

One of the most profound findings of our study was the intense value conflict between professional HN values and accreditation driven bureaucratic values. Participants described feeling torn between what they believed was right for patients and what the system demanded. This finding is supported by the literature, as Kamali et al. (2022) reported that nursing managers experienced negative emotions due to the conflict between their professional values and accreditation requirements. El‐Gendy et al. (2021) also noted that employees often feel caught between QI demands and direct patient care responsibilities. While our participants primarily focused on barriers and challenges, some also acknowledged organizational advantages of accreditation (reported in the Negative Case Analysis section), including elimination of personal preferences in managerial decisions, increased transparency and safer error reporting without fear. These benefits, while not directly related to HN, represent positive outcomes of accreditation that can improve the overall work environment.

Hospital staff should be flexible and continuously interact and cooperate and try to improve teamwork and interdisciplinary cooperation. Therefore, effective management of employees, motivating them, solving existing challenges and improving opportunities can improve the views of nurses and other personnel and help us achieve accreditation goals. Improving nurses' attitudes toward AP and QI programmes will have a very high impact on the correct implementation of QI standards and principles.

Based on participants' suggestions, several strategies can help align accreditation with HN goals. These include solving nurses' problems and motivating them, reducing bureaucracy, reviewing and revising accreditation measures with localization, revising nursing and paramedical curriculum, strengthening teamwork and interdisciplinary cooperation, planning effective in‐service training, increasing nurse‐to‐patient ratios, shortening processes, allocating sufficient funds, providing suitable facilities and equipment and reducing documentation through electronic systems. The surveyed nurses showed that they are involved in the HA process and understand this concept. According to participants, accreditation can be useful to increase the quality of HNC, but to achieve this goal, existing limitations and barriers must be removed.

5. Relevance to Clinical Practice

According to the results of this study, AP and the quality of HN are related, and how accreditation is implemented has a great impact on the quality of nursing care and patient satisfaction. Many factors influence the implementation of the accreditation process and consequently HN. Nurses have a central role in the accreditation process because they actively participate in decisive, strategic and operational moments (Almeida de Caldas et al. 2021; Trisno et al. 2019). Paying attention to nurses and their needs leads to a better implementation of the accreditation process. Therefore, by using the opinions of nurses involved in the accreditation, it is possible to identify factors affecting the implementation. Managers should pay more attention to these factors to improve quality and remove existing problems. Although accreditation is a management tool, its quality is mainly reflected in the state of patient care, a large part of which is performed by nurses. Therefore, it can have contradictory effects on patient outcomes. In the participants' statements, it can be seen that nurses encounter challenges due to accreditation implementation, and plenty of time is spent on writing and documenting rather than providing services. The participants' experiences showed that inaccurate implementation of accreditation could be an obstacle to HN, which can be overcome with the necessary arrangements and appropriate policies. The results of this study highlight important considerations to include interventions that improve and facilitate accreditation implementation, resulting in more integrated and quality care.

Holistic nurses provide optimal and complete care to patients by identifying and meeting the patient's comprehensive needs (Asgari et al. 2019). HA to improve healthcare quality requires interdisciplinary activities and overcoming barriers to care, which leads professionals to understand the logic of holistic care and thus improve quality (Ghorbani and Salsali 2018). As a health care science, nursing focuses on meeting the needs of human beings as psycho‐social and spiritual beings. Doing so requires scientific knowledge and interpersonal, intellectual and technical abilities and skills. Nursing is a combination of knowledge, art, clinical work and interpersonal communication. Nurses are the heart of the health system and the basis of providing health services.

Communication is an essential element of nursing in all fields of prevention, treatment, rehabilitation, education and health promotion. Successful teamwork is recognized as an essential component of effective healthcare. Patient safety and effectiveness of care depend on collaboration between multidisciplinary health professionals to communicate. Team communication in health care is an important factor in preventing medical errors (Alkhaqani 2022). Communication and teamwork among staff are essential milestones in all accreditation initiatives. Therefore, our nurses can overcome these challenges to some extent by improving teamwork and establishing effective communication with other colleagues. In this field, the necessary training should be given in the university and workplace. Also, our nurses can try to improve the quality of nursing care by increasing their awareness and knowledge in the field of HN and AP.

In Iran, the effort to institutionalize the holistic view of nurses through training and removing obstacles to its implementation requires the serious attention of educational and managerial officials (Ghorbani and Salsali 2018). To overcome the existing challenges, the nursing curriculum should be revised and AP should be considered as a factor to achieve HN. Providing the well‐being of nurses and facilitating nursing affairs can play a major role in providing services to patients. Reducing challenges and bureaucracy in nursing affairs will lead to satisfaction and reduce burnout fatigue. After revising the AP according to the country's governance conditions and available equipment, the MOHME should take steps toward training other personnel besides nurses and announce the AP appropriate to the country's health structure for implementation by all employees.

Accreditation in Iran is being implemented simultaneously with other countries; however, it has created problems for patients and nurses due to being in its infancy. While some participants acknowledged organizational benefits of accreditation such as transparency and reduced personal preferences in management decisions (reported in the Negative Case Analysis), the dominant experience was one of challenge and barrier. Discovering and disseminating the experiences of individuals involved in this process, especially nurses, can inform the relevant authorities and managers about these challenges. Consequently, a step can be taken to solve the problems. More studies are needed to identify existing problems in implementing accreditation and the factors affecting them in different hospitals.

6. Conclusions

HN has a profound effect on the quality of services and community health. The results of this study showed that the implementation of accreditation also had a great impact on the quality of HN. Therefore, identifying more factors affecting the accreditation process can significantly help solve existing problems in HN.

The accreditation system is a new way of evaluating hospitals in Iran, which has undergone reforms after years of implementation. The results of this study showed that there are various challenges in the policymaking, structure, implementation process, knowledge and attitudes of managers and nurses in the implementation of the AP. This study indicated that accreditation is inherently ideal; however, various challenges in its implementation hinder the achievement of goals. While some participants acknowledged organizational benefits such as transparency and reduced personal preferences in management decisions (reported in the Negative Case Analysis), the dominant experience was one of challenge and barrier to HN.

The AP can be used as a guide map for managers to achieve an organization with balanced, safe and quality results. The results of this study can provide deep insight for HA authorities in Iran and other countries and help to develop a suitable HA system. The results highlighted the need for providing necessary context, training and motivation for the staff before programme implementation. Therefore, it is recommended that the officials identify the existing problems and challenges before taking any action and take the necessary measures to solve them.

It is preferable to focus on issues such as revision of standards, result‐oriented standards, provision of sufficient workforce and localization of standards, and take more time to implement standards. Holding training courses to increase the level of employee knowledge in the field of AP seems necessary. One of the main factors for successful implementation and achieving good hospital scores is having human resources with proper knowledge and positive attitudes at all levels, including managers, nursing staff and administrative staff. Therefore, the positive attitude of the managers toward providing employee welfare and solving the existing challenges creates a positive attitude among personnel toward accreditation. The results of this study can be considered an evidence‐based approach for managers and policymakers. However, similar studies in other parts of the country are necessary. Generally, all conducted studies, particularly those conducted in Iran, indicate numerous challenges and strengths during the implementation of the accreditation process in hospitals. Obtaining more knowledge about these factors can help improve the quality of services and HN. It should be noted that the present study was conducted only in one city; hence, due to the novelty of the AP in Iran and the lack of studies in this field, the researchers are recommended to conduct this study in other cities to gain nurses' experiences from all cities.

The results can effectively improve the AP, thus promote HN. It is also recommended to conduct more studies on the effect of the AP on nurse and patient satisfaction and on the quality of nursing services. Conducting longitudinal studies to monitor the impact of the AP on the quality of health services can be effective for health policies. Studies on the design of different AP models and their effect on service quality are also recommended. HA is still in its infancy in Iran; accordingly, we cannot expect the same results from well‐established APs as in, for instance, the United States, Canada and Australia, with 65, 57 and 42 years of experience (Yousefinezhadi et al. 2017).

7. Strengths and Limitations

First, the main limitation of this study was the lack of access to similar studies due to the limited research conducted in this field in the country. This may affect comparison of our findings with other studies and the richness of the discussion section. Also, this limitation can affect our knowledge about the AP and the quality of nursing care. To overcome this limitation, as much as possible, comprehensive internet searches were performed in different periods.

Second, nurses' experiences are context‐dependent; therefore, the results of this study, like all qualitative studies, are not directly transferable and generalizable. Decisions about policies and AP implementation processes cannot be based solely on the findings of this study. Extensive studies in all provinces of the country are necessary.

Third, as with all qualitative studies, researcher bias in data collection and analysis may have influenced the findings. However, attempts were made to ask all participants questions in the same context, and the analyses were confirmed by another researcher who was not involved in the original coding.

The main strength of this study was the excellent cooperation of managers and nurses of Iranian hospitals with the researchers. The cooperation of the managers created a suitable setting for better interviews. Also, the sincere and fearless cooperation of the nursing staff in disclosing information helped us to obtain richer and deeper information. We are grateful to all participants.

Author Contributions

The conception and design of the study: Mahnaz Atapour and Nahid Dehghan Nayeri. Methodology: Mahnaz Atapour and Nahid Dehghan Nayeri. Acquisition of data: Mahnaz Atapour. Formal Analysis: Mahnaz Atapour and Nahid Dehghan Nayeri. Writing – original draft preparation: Mahnaz Atapour. Writing – review and editing: Mahnaz Atapour and Nahid Dehghan Nayeri. Validation: Mahnaz Atapour and Nahid Dehghan Nayeri. All authors read and approved the final manuscript and had full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis.

Funding

The present study was conducted with the financial support of the Nursing and Midwifery Care Research Center of the School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran (ID: IR.TUMS.FNM.REC.1398.216). The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Disclosure

Transparency statement: The corresponding author, Nahid Dehghan Nayeri, affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Ethics Statement

The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences (ID: IR.TUMS.FNM.REC.1398.216). Informed consent was obtained from all participants. All methods were performed in accordance with relevant guidelines and regulations for human research.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Consolidated criteria for reporting qualitative studies (COREQ): 32‐item checklist.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.