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Professional competence: Factors described by nurses as influencing their

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 Blackwell Science, LtdOxford, UKINRInternational Nursing Review0020-8132International Council of Nurses, 200520065316672Original ArticleFactors influencing nurses’ developmentR. T. Khomeiran et al.

Original Article

Professional competence: factors described by

nurses as influencing their development
R. Tabari Khomeiran1 BS MScN PhD, Z. P. Yekta2 BS MScN PhD,
A. M. Kiger3 RN BA MA MSc PhD & F. Ahmadi4 BS MBcN PhD
1 Nurse lecturer, Nursing School Guilan University of Medical Science, Bandaranzali, Iran, 2 Dean of School of Nursing &
Midwifery,Tehran University of Medical Science,Tehran, Iran, 3 Director of Centre for Advanced Studies in Nursing, University of
Aberdeen, Scotland, 4 Nurse lecturer, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modarres University,
Tehran, Iran

TABARI KHOMEIRAN R., YEKTA Z.P., KIGER A.M. & AHMADI F. (2006) Professional competence: factors
described by nurses as influencing their development. International Nursing Review 53, 66–72

Aim: To discuss the results of a study that explored factors that may influence competence development.
Background: Competence, a controversial issue in health care settings, affects many aspects of the nursing
profession, including education, practice and management. Although a number of research and discussion papers
have explored the issue, in particular the meaning and assessment of nursing competence, to date little research has
explored factors identified by nurses themselves as influencing their development of professional competence.
Methods: A purposive sample of 27 registered nurses was recruited from two university-affiliated hospitals. Data
collection was by tape-recorded semi-structured interviews. Interviews were transcribed verbatim and analysed
according to the qualitative methodology of content analysis.
Findings: Six descriptive categories were identified from the data: experience, opportunities, environment,
personal characteristics, motivation and theoretical knowledge.
Conclusions: The findings suggest that the factors influencing the process of developing professional competence
in nursing extend across personal and extra-personal domains. An understanding of these factors may enhance the
ability of nursing managers and educators to enable student and qualified nurses to pursue effective competency
development pathways to prepare them to provide a high standard of care. These findings, which may have
important implications for nursing practice, management and education, are being further tested in a larger study.

Keywords: Competence Development, Iran, Nursing, Qualitative Content Analysis

Introduction study was conducted as the basis for a larger study that will test the
Competence as a hard-to-definite concept has led to controversy findings that have emerged.
and confusion in nursing as a practice-orientated profession.
Nonetheless, it is important for assuring qualified and cost- Background
effective health care (Meretoja et al. 2002). The qualitative study In today’s world, health care delivery systems are rapidly chang-
described in this paper explored nurses’ own views of factors that ing. Many countries are experiencing nurse shortages (Janis-
influence their development of professional competence. The zewski Goodin 2003), and economic constraints leading to
demands for greater cost-effectiveness are common (Meretoja
et al. 2002). Simultaneously, in the current context of health care
Correspondence address: Rasoul Tabari Khomeiran, Guilan University of Medical
Science,Nursing faculty, Ghazian – Ramazani St. 43157, Bandaranzali, Iran; delivery in Iran, recent changes have made nursing, which was
Tel: +98 181 4223109; Fax: +98 411 4796969; predominantly under the supervision of the medical profession,
E-mail: rtabari@gums.ac.ir, rasooltabary@yahoo.com.
more independent in terms of regulation. The newly established

© 2006 International Council of Nurses 66

Factors influencing nurses’ development
‘Iranian Nursing Organization’ (INO) acts as the exclusive nurs-
ing regulatory body, and this has revolutionized the system of
accountability for nurses. Nurses previously registered just once,
after graduation, but are now required to demonstrate continuing
competence if they are to maintain their registration. At the same
time, communities expect safe and competent health care as a
right (Watkins 2000). To fulfil this expectation, nurses need to be
professionally competent.
These concerns have stimulated measures to enhance compe-
tence development among nursing students and staff. A necessary
step towards this goal is the identification of factors that enco-
urage or discourage competence development. An understanding
of these factors can assist managers and educators to identify
and implement strategies that can effectively boost competence
development.
A search of the literature using the CINAHL and MEDLINE
databases, and the keywords competenc*, nursing, clinical,
develop*, facilitat* and barriers, in various combinations, revealed
numerous articles and accounts of studies focusing on a range of
issues related to competence. Many of the items located address
aspects of assessment. These include accounts of the development
of assessment tools, for example, an article by Fitzpatrick et al.
(1997) about the King’s Nursing Performance Scale. Literature
reviews, such as Girot (1993) focused particularly on continuous
practical assessment and Robb et al. (2002) reviewed tools used to
assess competence in nursing.
Some articles address aspects of competence and its assessment
related to specific types of programmes. Bartlett et al. (2000)
described a quantitative study that compared the competence
achieved by students completing two British diploma and degree
programmes. Utley-Smith (2004) surveyed nurse administrators
in the USA as to their views on the most important competence
factors needed by new baccalaureate graduates.
Occasional articles were found that address measures adopted
to facilitate the development of professional or clinical compe-
tence. Kelly et al. (2002) describe an action research project to
establish the role of ‘clinical practice facilitator’ in a British inner-
city area. However, no articles or reports could be located that
explored factors that facilitate the development of competence, or
factors that act as barriers to that development, from the perspec-
tive of qualified nurses in relation to their own development of
professional competence. These factors formed the focus of the
study reported in this paper, which was a small qualitative study
that is serving as the initial exploratory phase of what will be a
larger study.
‘Competence’ as addressed in the present paper refers primarily
to ‘continuing professional competence’, although there is an
occasional allusion to aspects of basic competence that was
present in the collected data. The working definition of ‘continu-
© 2006 International Council of Nurses, International Nursing Review, 53, 66–72
67
ing professional nursing competence’ has been adopted from that
of the American Nurses Association (ANA 2000): namely, ‘ongo-
ing professional nursing capacity according to level of expertise,
responsibility, and domains of practice’. The basic definition of
‘competence’ is borrowed from the Pennsylvania State Nurses
Association (2001): ‘an individual’s capability to perform to
defined expectations’. This is distinct from the term ‘competency’
that has recently gained favour in countries such as Australia,
Canada and UK, referring to specific learning outcomes defined
for the purposes of standardization, consistency and accredita-
tion (Nelson & Purkis 2004). This study aimed to identify factors
described by nurses as influencing their development of profes-
sional competence.
Methods
Design
The need to capture the personal experiences of participants
prompted consideration of a range of qualitative research meth-
odologies for this study. A descriptive design incorporating quali-
tative content analysis was adopted. This approach allows the
researcher to classify many words of text into considerably fewer
categories (Weber 1985) through a systematic method of reduc-
tion and analysis. According to Priest et al. (2002), content analy-
sis as a widely used method of eliciting meaning from text is
particularly appropriate in exploratory studies. The specific pro-
cedure of qualitative content analysis used in the present study
was inspired by methods described by Kvale (1996), in a step-by-
step process. (See Data analysis below.)
Participants and setting
Registered nurses with more than 1 year of experience were
chosen as participants by purposive sampling. A total of 27 inter-
viewees drawn from the staff of two university-affiliated hospitals
in Iran were selected. The nurses chosen for interview were nom-
inated as ‘competent’ by their line managers and thus provided
‘information-rich cases’ (Patton 1990, p. 169).
Data collection
Following approval by the Local Ethics Committee for Research,
informants were invited to participate in the study. Data were col-
lected through semi-structured interviews carried out in partici-
pants’ workplaces and were conducted by one researcher (RK).
Each interview lasted approximately 1 hour.
The interviews took the form of conversations that began with
a general open-ended question. The interview continued with
supplemental queries that further probed participants’ responses
regarding competence development. These were frequently
related to its bridges and barriers. To ensure that the natural lan-
68 R.T. Khomeiran et al.
guage of nurses was retained and used in the description of the
findings, interviews were tape-recorded and transcribed verbatim
by the first author. This process provided in-depth engagement
with the data and enabled the process of transcribing to become
part of the analysis.
Data analysis
Tapes were listened to and transcripts were read line-by-line at
least twice; each word and sentence was analysed to identify tenta-
tive themes that were compared with each other within and across
transcripts; themes with similar meanings were grouped together;
and finally, categories were formulated from the themes for the
purpose of abstraction.
Ethical considerations
Guidelines specified by the local research ethics committee were
followed. All respondents were given information about the study.
Identifying information was removed and each interviewee was
given a unique code number. Informants gave written consent to
participate in the research and a signed research contract con-
firmed that data would be stored in a secure filing cabinet; that
tape recordings would be erased and transcriptions would be
returned on the completion of study; and that participants could
withdraw at any stage of the process.
Findings
Participants indicated an awareness of the importance of compe-
tence in nursing, and of the need for competence development.
They viewed competence as being on a continuum along which
it may move, increasing or decreasing over time. The informa-
tion they provided related to both pre-registration and post-
registration experiences. Both types were incorporated into the
analysis as being conceptually associated with the process of com-
petence development.
Six categories that influence competence development
emerged from the data: experiences, opportunities, environment,
personal characteristics, motivation and theoretical knowledge.
These categories overlap conceptually, and often several were
described simultaneously.
Experience
Participants saw experience as the most important factor influ-
encing competence development, and described it as ‘touching
the realities’. They recognized direct experience as invaluable for
developing psychomotor skills (e.g. inserting intravenous lines),
putting them in a ‘real examination’ situation with its accompany-
ing challenges, and familiarizing them with actual problems that
may arise. Repeated practice was viewed as a means of gaining
expertise in both technical and non-technical tasks:
© 2006 International Council of Nurses, International Nursing Review, 53, 66–72
Now I know how I should deal with an agitated patient because
I have dealt with them for more than five years in this busy ward
[Emergency Department].
Participants talked about using more experienced colleagues’
experiences, mainly in non-technical skills such as decision mak-
ing, for improving their own competence. They captured these
experiences largely through observing and listening to personnel
who were ‘old hands’: ‘. . . being present at handovers . . . especially
morning handovers, is very useful. When the in-charge nurse is
reporting the last night’s circumstances I learn a lot about how I
should act if those happen to me . . .’
Opportunities
Respondents described learning opportunities that challenged
their abilities and gave them the chance to examine their own per-
formance, being aware of both their limitations and strengths and
ultimately increasing their competence. They believed that these
‘golden chances’ are usually sudden and transient, and should be
seized on promptly and deliberately. Working in different wards
as a ‘relief ’ nurse was described as a precious experience: ‘. . . the
manager’s decision to employ me as a relief nurse disappointed
me at first . . . but later I appreciated it as a worthy chance to
become familiar with different wards . . . medical . . . surgical . . .
paediatrics . . . I learnt a lot from each.’
Some nurses spoke about unexpected circumstances in the
workplace forcing them to rely on their own abilities, such as
when working alone in the evening or night, or on busy shifts.
One interviewee had a similar experience during a study period
when her group had afternoon clinical placements owing to
insufficient availability of placements during the morning shift.
She argued: ‘. . . they [staff] count on you and delegate valuable
tasks . . . not just jobs such as taking vital signs . . . to you
because they were faced nurse shortage on afternoons.’
Environment
Participants described the environment as important in forming
some of their technical competencies. They believed that environ-
mental necessities, which change quickly through the rapid intro-
duction of new technology, require staff to do their best to become
competent: ‘Here [in General ICU] you are up-to-date . . .
because you have to be . . . even if you don’t want it. Encountering
new technology alongside the expectations of doctors and manag-
ers pushes you to learn more and apply your learning in practice.’
Most participants recognized the importance of the ward cli-
mate to their competence development. They believed a good
learning workplace could satisfy their self-actualization needs,
keep the hope of professional improvement alive, provide them a
wholesome and pleasant environment and subsequently inspire
them to a greater readiness for learning and keeping up-to-date
Factors influencing nurses’ development
with professional issues. They argued that this environment could
be best found in university-affiliated hospitals, and in critical units
in particular. A Coronary Care Unit nurse stated: ‘. . . we have phy-
sicians’ and other professionals’ support in our work. They trust
us. This provides me a suitable environment for working.’
Personal characteristics
Data suggest that development of professional competence is
influenced by nurses’ personal characteristics. Many participants
described their curiosity and readiness to know more about any-
thing relating to their work, and involvement in any activities that
could increase their abilities, as important in competence devel-
opment, as this nurse stated: ‘I never reject any suggestion which
seems to be helpful for expanding my abilities . . . continuing
education courses, for example.’
A number of interviewees cited their willingness to ask ques-
tions or to get help as factors that enhance their growth in the
workplace: ‘. . . if I think it’s something that’s really questionable I
always ask somebody . . . doctors . . . any other professional . . .
or even auxiliary nurses. I think the patient is more important
than my conceit.’
Motivation
Being motivated seemed to be an important element of partici-
pants’ success in competence development. Although most
respondents argued that they initially did not have any interest in
studying within nursing, they indicated that they became moti-
vated to be at least a dutiful nurse after entering to work. Patient
satisfaction and the transition from student to staff nurse, which
necessitates accepting accountability and actual workplace
requirements, were the most frequently articulated motivators:
‘. . . their [patients’] satisfaction gives me more energy for being a
better practitioner.’ ‘. . . when I began my job as registered nurse, I
asked myself “what I should do now?” It was like a wake-up signal.’
Negative instances related to this category were also present
in nurses’ descriptions of their experiences. The participants’
descriptions were mainly focused on managers’ unjustified
behaviours, engagement in the same tasks as auxiliary nurses and
non-competitive salary and lack of appropriate social status as
discouraging factors: ‘. . . many patients become surprised when
informed that we have an academic degree. They don’t believe
doing nursing requires studying in university.’
This misunderstanding could extend even to health profession-
als: ‘Some doctors think six months is enough time for learning
nursing.’
Theoretical knowledge
Nurses identified theoretical knowledge as important for compe-
tence development. Arguing that this knowledge is not necessarily
acquired through academic study, they described employees who
© 2006 International Council of Nurses, International Nursing Review, 53, 66–72
69
seem to have poor theoretical knowledge but show excellent per-
formance in some clinical tasks owing to longer exposure to dif-
ferent situations: ‘I know an assistant nurse who can establish an
IV line better than anyone in our ward. I doubt if she has academic
knowledge about vascular anatomy.’
Participants argued that they gain more benefit from theoreti-
cal knowledge when it is tailored to real needs in practice: ‘I enjoy
attending in-service continuing education programmes when
they deal with my workplace issues. They help me provide care
with open eyes.’
Discussion
Many studies have investigated aspects of competence and learn-
ing in clinical placement, but few have illuminated factors that
influence the development of professional competence in regis-
tered nurses. The present study attempts to contribute to current
knowledge by describing such factors as experienced and voiced
by nurses themselves.
Experience was the first category that emerged from the data, and
its presence in the interview data show the importance these nurses
placed on the impact of having sufficient practice for competence
development. Several authors have described the place of experi-
ence in nurses’ development. According to Benner (1984), by expe-
rience, preconceived notions and theory are refined through
encounters with many actual practical situations. Arbon (2004),
referring to the assumption that experience adds to knowledge and
skill cumulatively in a linear process, argues that nurses experience
their development in more complex ways. He suggests that under-
standing is developed during a process he calls meaning-making,
through which existing meaning is re-formulated in the midst of
new experience. From both perspectives, experience is viewed as
needing to be active if it is to lead to learning. This implies that
experience is not the mere passage of time (Benner 1984) and
cannot result in the development of competence on its own if the
individual does not reflect on and learn from it (Rolfe 1997).
In our study, it emerged that the nurses learned mainly through
their own experiences. Arbon (2004) points to primary and vicar-
ious experiences as powerful forms of experience for nurses. He
notes that primary experience, in which the nurse is a principal
actor, is more immediate and often more challenging, and inter-
pretation and reaction are required. Arbon (2004) describes
vicarious experience as using scenarios, video, observation and
other forms of secondary experience. In our study, vicarious expe-
rience primarily took the form of listening to more experienced
nurses’ accounts of their experience and/or seeing their actions.
The feasibility of these modes of experience transmission can
make them more favoured, especially in developing countries,
which often suffer lack of modern teaching equipment. However,
as such transmission may often come from nurses who have had
70 R.T. Khomeiran et al.
no academic study, the validity of this form of experience must be
treated cautiously.
Findings in the opportunities category indicate that these nurses
have confronted some awkward working situations. Although
these sometimes challenged their current knowledge and skills,
appearing at first glance to be threats, the nurses had eventually
perceived them as useful stimuli to learning. In different work set-
tings these situations, which may provide, or even impose on
nurses, the opportunity to develop their professional compe-
tence, may have a different nature. For example, as Segesten et al.
(1998) indicate, budget cuts and staff shortages in many countries
have forced managers to initiate changes in staffing. One of these
changes, which could expand nurses’ competence, is enhancing
their versatility. A closer scrutiny of our study participants’
expression in this category revealed that the circumstances they
pointed to as opportunities for learning were mostly related to
their pre-registration or early career. It seems they used these
opportunities to compensate for shortcomings they had experi-
enced in their initial training and/or in-service programmes,
mainly caused by lack of appropriate planning, which is common
in developing countries. The need to provide opportunities for
students to gain appropriate depth and breadth of theoretical
knowledge as well as clinical experience has been emphasized
(Chapman 1999). Studies undertaken in various countries have
shown that these opportunities can be negatively influenced by
circumstances such as insufficient time for releasing nurses owing
to staff shortage (Scholes & Endacott 2003), lack of accessible and
relevant in-service programmes (Prater & Neatherlin 2001),
supernumerary status (Cope et al. 2000), working in an environ-
ment in which learning opportunities are limited (Ballard &
Trowbridge 2004) and inappropriate clinical placement length
during pre-registration education (Crawford & Kiger 1998). Data
from the present study suggest that during their pre-registration
period, these nurses enjoyed rotating to different wards and work-
ing full-time shifts without the restrictions of clinical placement.
In a study undertaken by Pedley & Arber (1997) it was apparent
that students enjoyed choice, autonomy and relevance as impor-
tant motivators for learning. It seems these opportunities could
increase the student’s confidence (Cope et al. 2000) and promote
the characteristics of a professional nurse such as being self-
directed, responsible, autonomous and able to identify one’s own
learning needs (Chan & Wai-Tong 2000).
Although interviewees in the present study found that such
opportunities promoted competence development, apparently
they could also cause problems. Firstly, as such opportunities
often occur in circumstances where the main aim is not learning
(e.g. night shifts in areas with staff shortages), novice practi-
tioners have no specific learning plan for these situations. As a
result they have to learn through doing, and despite its usefulness,
© 2006 International Council of Nurses, International Nursing Review, 53, 66–72
the incident-based acquisition of this type of understanding may
lead the practitioner in the wrong direction in competence devel-
opment. On the other hand, increased workload on staff owing to
the need to supervise these unskilled workers (The British Associ-
ation of Critical Care Nurses 2003) may result in a decreased qual-
ity of care or may even endanger patient safety.
Results related to the environment category suggest the impor-
tance of being in an appropriate setting, in both physical and emo-
tional terms, for competence development. This topic is well
documented by authors (Abruzzese 1996; Watkins 2000; Ballard &
Trowbridge 2004). Participants indicated that working in some
clinical areas such as critical care units gave them a sense of being in
a good learning environment. A high quality learning environment
is one with mutual respect, partnership, support and trust, where
staff are valued, highly motivated and provide supportive relation-
ships (An Bord Altranais 2003). In such an environment, profes-
sionals are nurtured with appropriate support at the right time,
work alongside a preceptor/mentor or another member of staff,
receive guidance and receive constructive feedback on perfor-
mance (Miller & Blackman 2004). Working in such environments
not only helps develop further competencies (Watkins 2000) but
can also provide the stimulus for discussion and promote critical
thinking (Ballard & Trowbridge 2004), producing work content
which leads to motivation and satisfaction (Suominen et al. 2001).
Personal characteristics is the fourth category of participants’
experience that emerged from the data. Participants expressed
their self-satisfaction in becoming more competent despite prob-
lems described in other categories. Eraut et al. (2004) acknowl-
edged the importance of the learner’s wish to learn and his or her
accountability and continuing endeavour to expand his or her
knowledge in the workplace. Eustace (2001) notes that ‘lifelong
learning requires nurses to depend on themselves to learn what is
needed to enhance their competence after graduation’ (p. 135).
Data suggest that the nurses in this study prioritized patients’
benefits over their own self-interest, which could be interpreted as
their commitment to the job. This in turn increased their eager-
ness to improve their competence. According to Eraut et al.
(2004), commitment to the importance of the work is a primary
factor that affects the extent to which professionals are proactive
in taking advantage of available learning opportunities. Lee-
Hsieh et al. (2003) found that some students who held status in
their full-time jobs hesitated to ask questions of younger nurses
because that would cause them to lose face.
Results in the motivation category indicate that these nurses
recognized motivation as an influential factor in competence
development. Lee-Hsieh et al. (2003) similarly found motivation
to be an important factor in effective nursing performance.
In our study, participants’ motivation was influenced mainly by
patient satisfaction, which seems to satisfy the nurses themselves.
Factors influencing nurses’ development
Sellman (2000) notes, ‘it is reasonable to suggest that the activity
of nursing is perceived as having internal rewards related directly
to the satisfaction of helping others’ (p. 28). In our study, partici-
pants reported that they became primarily motivated after begin-
ning to work as registered nurses. It seems work environment
requirements alongside an increase in accountability and respon-
sibility, which come with qualification (Miller & Blackman 2004)
play important roles in motivating the nurses to learn. In a study
undertaken by Pedley & Arber (1997), participants pointed out
that taking some degree of responsibility had given them the
opportunity to acquire skills of self-motivation, time manage-
ment and assertiveness. Chiu (2005), based on a study undertaken
with Malaysian graduate nurses, introduced work-related stimu-
lation and self-growth, compliance with management require-
ments, professional advancement and keeping up with the
profession, and availability and accessibility as motivation for for-
mal learning. Abruzzese (1996) argues, ‘professional people are
more likely to seek learning because of intrinsic motivation such
as self-fulfilment, responsibility, achievement, or a desire to better
perform their tasks’ (p. 34).
Nurses in this study expressed frustration in some job-related
circumstances that prevented them from being more proactive in
competence development. The poor image of the nursing profes-
sion within their society, as in many other developing countries,
and existing even among other health care professionals, was an
important factor influencing participants’ desire to promote pro-
fessional competencies. Eraut et al. (2004) note the value of the
work (both for clients and to the individual) as a significant moti-
vating factor to learning. In our study, participants pointed to
managers’ unjustified behaviours, engagement in the same tasks
as auxiliary nurses, and non-competitive salary ranges which are
common in this context, as the main other job-related complica-
tions that hinder them in improving their competence. These
constitute serious problems that can cause nurses to leave the job
in developed countries (Janiszewski Goodin 2003).
The final category to emerge was theoretical knowledge. Knowl-
edge as the foundation of nursing practice (Cope et al. 2000) has
been cited as a component of competence in most definitions and
has received considerable attention in the professional literature.
This knowledge does not transfer directly to competent behav-
iours, and the appropriate use, rather than the amount of stored
knowledge in one’s memory, is the key factor in differentiating an
expert from a novice nurse (Nojima et al. 2003). As has been
pointed out in our study findings, sometimes auxiliary nurses
without academic knowledge could perform certain practical
skills better than the nurses themselves could. Rolfe (1997) states
that the experienced nursing assistant might have plenty of know-
how but no academic knowledge base. This argument attributes
to the role a kind of knowledge-in-practice which auxiliary nurses
© 2006 International Council of Nurses, International Nursing Review, 53, 66–72
71
acquire through experience with multiple cases. As this time-
consuming process, normally accompanied by frequent trial and
error, could put patients’ safety in danger, it can be argued that
having prior theoretical knowledge is a ‘catalyst’ for competence
development in a safer way.
Conclusions
From the results of our study, it is suggested that the development
of competence is dependent on both the context and the individ-
ual. More importantly, although organizations gain most benefit
from improving employees’ competence, participants described
relying mainly on their own actions, perhaps owing to the absence
of coherent work-based plans for competence development in
many developing countries, or limiting these programmes to
mandatory continued education programmes in developed-
world countries. In this way, if the findings of this study are con-
firmed through further research, organizations could adopt strat-
egies to help nurses to pursue a competence development
pathway more efficiently. All of these activities could lead to high
quality care delivery, achieving more cost-effectiveness in health
care systems and, more importantly, improved patient outcomes.
Moreover, although this study targeted registered nurses, the find-
ings may contribute to improving the quality of initial nursing
education programmes as well as being relevant to other health-
related professionals such as midwives and physicians.
Limitation
This was a small qualitative study, carried out in one national con-
text with its specific educational and care delivery attributes.
Thus, as is common with most such qualitative studies, caution is
needed in generalizing from the findings. This implies that apply-
ing the findings of the five categories identified in the study should
only be done after adjusting to the specific context to which they
will be applied. Attributing greater strength to the findings will
only be justified if/when they are confirmed in the larger study.
Acknowledgements
The present work was supported by funding from Tabriz University
of Medical Science. The authors acknowledge the cooperation of
nursing managers and staff at the two hospitals involved in recruiting
the sample and participating in interviews. The contributions of Mrs
Arax and Mrs Adyib in facilitating access to research fields are also
gratefully acknowledged.
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