Iran Occupational Health

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Background and aims

The extensive domains of Nurses' activities and Nursing nature as interdisciplinary science can cause Work pressure and mood disturbance especially depression in Nurses. According to this fact that patient safety was correlated with work place situation and well being of health care providers, this study was aimed to determine Nurses' depression and its associated factors in Namazi Hospital of Shiraz University of Medical Sciences.

Methods

Participants in this descriptive cross sectional study were 311 Nurses who work in Namazi Hospital of Shiraz University of Medical Sciences. In this research, the data collecting tools were Zung Self-Rating Depression Scale and demographic information form. These data were analyzed by SPSS.win 11 software with using descriptive and inferential statistic such as Chi-square and one way ANOVA.

Results

Findings indicate that 41.2% of Nurses are normal and the others suffer from mild (42.4%), moderate (13.8%) and severe depression(2.6%).Analyses using Chi-square showed that depression intensity of Nurses who work in emergency ward and critical care units were more

than depression level of the rest(P=0.001). Also, there was significant statistical relationship between depression severity and Nurses' satisfaction of their sleep (P=0.015).

Conclusion

Current Nursing work place situation can cause emotional strain and depression. Thus researchers suggest that Hospital Nurse Offices should be use the psychiatric mental health nurse for consult services and education to nurses about coping strategies and management of

depressed mood.

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  Background and aims

  Driving is a dangerous and difficult job. In proportion to the other occupational groups, driving has a higher rate of mortality, morbidity and absent due to illness.

  Drivers are susceptible to depression. Depression alters the thought, attitude and operational skills and leads to higher rates of accident. The aim of this study was to determine the prevalence of depression and its related factors among truck drivers.

  Methods

  This was a cross-sectional study that carried out on 400 male truck drivers in Yazd province. Subjects were selected by simple random sampling method from Transport Organization List of truck drivers who live in Yazd province. Presence and severity of depression were assessed by the Beck Depression Inventory Short Form. Data were collected by interview and analyzed with SPSS software.

  Results

 

 Most of drivers(70.3%) had some degrees of depression: major depression was obsereved in 14.8%, moderate depression in 25.4% and mild depression in 30.1%. Only 29.7% of drivers had no depression symptoms. Pearson correlation showed a significant positive relatioship between depression score and the number of cigarettes smoking daily and also the distance of trip.Moreover, negative correlation was found between depression score and the sleep duration in trip.

 Depression score in drivers who had experienced accident during previous year was significantly higher than those with no accident experience.

  Conclusion

our results regarding depression among truck drivers indicate necessity for establishing special committees in order to consulting and guidence of truck drivers as well as further assessing of their problems and finding solutions to help them having a better compatibility with their jobs situations.

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  Background and Aims:
Organophosphate compounds are the most popular insecticides with the widespread application in pest control. These toxic compounds interfere with the blood cholinesterase and inhibit the cholinestarse activity.Measurement of Cholinesterase activity is widely used for diagnosis of poisoning and adverse effects caused by pesticides. Green-house workers are one of the important occupational groups with the high risk of poisoning with organophosphate and karbamat pesticides .The purpose of this study was to assess the exposure of green-house workers with anti-cholinesterase toxic compounds by measuring the blood cholinesterase activity using electrometric method.

  Methods:
This research is a descriptive cross sectional study that carried out on farmers of the cucumber green-houses . In this study, 40 workers were selected and their blood cholinesterase enzyme activity were measured using electrometric method . In electrometric method the reduction of cholinesterase activity can be measured through recording the changes of blood pH induced by anticholinestrase agents . The results were analyzed by version16 of spss software.

  Results:
Based on the obtained results the amount of erythrocyte cholinesterase enzyme inhibition was between 1 / 77% to 35 / 4% and the mean and standard deviation was 23 / 2% ±9 / 68.

  Similarly, the amount of plasma cholinesterase enzyme inhibition was between 1% to 28% and the mean and standard deviation was equal to 16/57 ±7 / 92.

  Following the analysis of results 25% (n=10) of the workers were identified with no poisoning, 17.5% (n = 7) with minor poisoning , 55% (n=22) with moderate poisoning and 2.5% (n=1) with severe poisoning.

 

  Conclusion : Organophosphate poisoning has been reported as the third cause of poisoning and also the leading cause of poisoning deaths in our country.Therefore, considering the results of this research and the importance of the evaluation of workers exposure to organophosphate pesticides it can be stated that the use of electrometric method is a valuable tool for biological monitoring of exposed populations . As this method is simple, portable and not expensive and at the same time provides high precision , it has a potential to be applied for screeningandearlydiagnosisof organophosphate poisonings inlarge-scale studies.

 

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Background and aims: The present study was conducted to assess the role of sleepiness during the day (ESS) and sleep apnea in road accidents in Shahroud drivers.

Methods: In this cross-sectional study, 312 drivers of members of Shahroud's terminals were studied in 1392. Demographic, Pittsburgh Sleep Quality Index (PSQI) standard questionnaire with seven scales, Epworth Sleepiness Scale (ESS) questionnaire with 8 items and STOP BANG questionnaire with 8 questions were used. Data analysis was performed using SPSS statistical software version 18. 

Results: Nearly 16% of drivers had accident history in the past five years. The mean ± SD total score of sleep quality (PSQI) in drivers was 4/5 ± 2/85 and 27/5% of them had poor sleep quality. 5/6% of drivers had Epworth sleepiness scale over 10, which is clinically significant. 11/5% of drivers with STOP BANG> 3 were diagnosed in terms of respiratory disorders. ESS in drivers who had accident history in the past year (p= 0.004) and past five years (p= 0.003) and also perpetrate in accident (p= 0.012) was more than other drivers.

 Conclusion: Significant relationships were observed between ESS and perpetrate in accident and accident history in this study. However, this relationship between ESS and injury or death in accident was not observed. More than 10% of drivers with sleep apnea disorder were candidates for referral to sleep clinic.

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Background and aims: The safety and health performance measurement, designed to provide the necessary information on the concern to progress and the current state of the organization's strategies, processes and activities. The purpose of this study is to present a new model for the development of safety performance indicators using the probability risk assessment model and applying experts' opinions.

Methods: This descriptive-analytic study was carried out in 3 steps: categorize of the construction face activities and its related hazards identification; formation of the accident causal network occurred in the oil and gas refinery construction phase using the Bayesian network and the selection of key performance indicators using AHP method.
Results: The statistical analysis of the recorded accidents showed that 21% of the incidence rate is related to the falling. Among all the construction phase activities, using the WBS analysis of the project, 27 activities with work at height risk of were identified.  18 active performance indicators were extracted the accident causal network  that using SMART criteria and occurrence probability rate  Calculated from the Bayesian network was selected as 5 active key performance indicators.
Conclusion: Determining the leading performance indicators is influenced by various organizational, managerial, operational and other factors. As the project progresses, the nature and level of risk of the operation of construction projects is changing. Therefore, indicators of safety performance measurements in these projects should be sensitive to rapid changes. For this reason, active indicators with a short-term measurement period are more effective in measuring the safety performance of construction operations.

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Background and aims: The circadian rhythm is one the most important biological rhythms that regulates the sleep-wake cycle and repeats every 24 hours roughly. This 24-hour cycle includes physiological and behavioral rhythms like sleep cycle. Any disruptions in the body’s natural rhythms can cause many problems, such as drowsiness, sleep deprivation, reduced physical activity, and mental functions. Working at unusual clocks is one of the main factors that can interfere with the circadian rhythm. It is estimated that almost 25% of employees have experienced some kind of shift around the world. Studies have showed that about 62% of these shift workers suffer from sleep disorder, which is defined as a general or partial deprivation of sleep. Various studies have also shown that in the night shift, the performance of individuals is reduced by 10-5%. If the night shifts when accompanied by sleep deprivation on the next day, the performance of people is reduced by up to 30%. There are several work shift schedules in different industries. These include fixed shift, split shift, irregular shift, rotating shift and so on. Rotating shift follows an especial speed and direction. The speed means the number of times working a particular shift before moving or rotating to a different one. Working in every morning, evening, and night shifts for two consecutive days. It is necessary to consider one or two days off between the shifts. Employees must at least eight hours free from work when the shift is changed. In some factories, there is no rest day between the shifts. It makes the workers deprive sleeping for one night. It is well known that lack of rest can effect on the human health adversely. Cognitive performance is one of the main functions affected in this situation. Memory, accuracy, and attention as well as reaction time are important cognitive functions which are affected in sleep deprivation. Memory is defined as the ability to record, remind, memorize, and retrieve information. One of the functional differences of the memory system is its differentiation into short-term and long-term memory. Short-term memory is responsible for storing information that is instantly used. Recently, short-term memory has found another definition called work memory. Working memory is actually the new and dynamic of memory, which is actively defined when it is necessary to perform a task. In the most conducted studies, this component of memory has been considered to evaluate the effects of sleep. Many laboratory and field studies have been conducted on the long-term effects of sleep deprivation on cognitive functions but a few studies have been focused on short term effects of sleep deprivation on cognitive functions. Considering the known effects of sleep on physical and cognitive performance of individuals, a study in this field is necessary to make suggestions for modifying such unusual work programs. In Iran most of workers in main industries are in a shift work. Shifts in these industries are often forward rotating. In many of these industries, people are resting for one or two nights after night shift, which makes the person adapt to this situation. However, some factory has an irregular shift work which expose workers with many problems. Therefore, this study was aimed at investigating the short-term effects of sleep deprivation due to unusual shift works on cognitive function of workers in a painting industry.
Method: This cross sectional was conducted on the total of workers from painting section of an automotive industry. Considering the inclusion and exclusion criteria 80 persons were selected to the study. The mentioned criteria were alcohol consumption, psychiatric disorders and traumatic brain injury, using psychotropic medications and suffer from epilepsy disorder. Moreover, because the educational status of individuals is one of the factors affecting the cognitive function, all who entered the study had diploma. At first, the baseline and demographic data included age, working experience, quantity of sleep during the previous night shift were asked and recorded. Working shifts were rotating forward from morning to night and night to morning. In this factory, after the night shift, the morning shift began immediately without any rest. In order to investigate the effect of this irregular work shift schedule, cognitive performance was measure in two different conditions. Generally, the study was designed in two phases. Firstly, in the first day of the morning shift following the night shift people who didn’t take any rest in previous night were entered into the first phase of the study. Thus after giving a questionnaire contained some question about quality and quantity of sleep, people with the sleep duration less than two hours were selected for the rest of the study. Cognitive performance was evaluated in three different domains including working memory, selective attention and reaction time by the computerized tests. For assessing the working memory, a validated Persian test of N-Back was applied. STROOP test and Simple Reaction Time Test (SRTT) were also used to measure attention and reaction time status, respectively. In N-Back test, subjects have to react to all of the stimuli so it requires constant control and updating of the information in the working memory and has a very strong reputation for evaluating the working memory. This test has three different levels of complexity. In this study, its first level, N1, was used because studies show that its first level is more sensitive to the effects of sleep deprivation. In this test, 120 stimulants appeared on the screen in 5 minutes. At the first level, the subject had to compare each number with the preceding number and press a certain key on the keyboard. The Persian version of the Stroop computerized test was also used to evaluate the selective attention of individuals. The Stroop color test enables the individual to process related data, thoughts or actions while rejecting unrelated or inaccurate information. In this experiment, four colored circles below the color words are displayed. The person must press the color key word that may not match the color of the circle, regardless of the color displayed on the keyboard. Finally, the error rate and response time are reported as variables in this test. In SRTT, green circles appeared randomly on the screen, which the person had to press a key on the keyboard in the shortest time possible after it appeared. The reaction time was recorded in milliseconds. All tests were carried out in a quiet place where there was no noise, within beginning of morning shift until noon. One week later, the second phase of the study was performed in the afternoon shift when workers got adequate rest in the previous night. It should be noted that in this stage, people were also asked about duration of sleep in the previous night and those who had any sleep deprivation for any reason were temporarily set aside and, at an appropriate time, repeated the tests. The SPSS version 22 was used to stablish the statistical analysis. The tests used included one-way ANOVA, paired t-test and Pearson correlation analysis.
Results: The results of one-way ANOVA showed that there was no significant difference between age and work experience (p-value> 0.05). The amounts of sleep duration of people with adequate rest and without any rest were 7.5± 2.5 and 3.5 ± 1 hour, respectively. The mean and standard deviation (SD) of the working memory (N-Back) in both situations, when workers had adequate rest and without any rest were 100.12 ± 5.79 and 85.23 ± 23.13, respectively. The average of obtained scores for selective attention for both situations was 2.51 ± 1. 3 and 8.27 ± 4.4, respectively. Mean and SD of the reaction time test were also 500.21 ±89 and 445.54 ± 105, respectively. Paired t-test analysis revealed that obtained scores for working memory and selective attention, when workers were in the morning shift and had sleep deprivation, were weaker than the time that they had enough sleep in the previous night (p-value< 0.05). Additionally, the level of error in the test was higher in these subjects. The reaction time was also longer in people who with adequate rest time, although there was not a significant difference between two groups. Pearson's analysis also revealed a strong correlation between the sleeping hours and memory scores, as well as a fairly good correlation between sleep hours and the number of errors in the attention variable (r² = - 0.44).
Conclusion: People working in the painting sections of the major automotive industry need to be in an acceptable cognitive performance due to the nature of their work. In general, unusual shift works and sleep deprivation reduce cognitive function in the memory and selective attention scopes because of inadequate rest time between shifts. It has been shown that brains forehead which is responsible for executive functions, shows a significant decrease in metabolic energy consumption in sleep deprivation. Since working memory and attention are both related to this part of the brain, therefore, they are vulnerable to sleep deprivation and change. The results of this study also showed that work in the night shift can make people fatigue, which reduces the executive and cognitive performance of individuals. Therefore, it seems to be necessary adjusting the work schedule in order to considering adequate time to rest between two shifts in unusual work systems.
 

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Background and aims: Currently, as a result of research on laboratory animals, abundant information has been obtained on the impact of various environmental factors on the occurrence of congenital malformations, but there is still no comprehensive information on the causes of congenital heart malformations (CHD) in human populations. Congenital heart defects (CHDs) constitute the major class of congenital anomalies. Although the incidence of CHDs is close to one percent of live births, its prevalence in the fetus is higher. The prevalence of CHDs is 0.5-0.8% in the live-term neonate, 2% in premature infants and 10-25% in the aborted fetus. The exact causes of CHDs are not clear. About 25% of all CHDs are attributed to the genetic factors. The interaction of genetic and environment is also considered in the etiology of the CHDs. Researchers say occupations such as pharmacy, chemical engineering, dyeing, increase the risk of neonatal eye, heart and intestinal defects and cleft lip and palate. Several studies have shown the effect of non-genetic factors such as environment and lifestyle on the occurrence of CHDs. In the Snijder study, no relationship was found between maternal occupational contact and CHD offspring, whereas fathers' exposure to phthalates increased CHD in neonates. According to the above mentioned content Identify paternal exposure to solvents and its relationship with congenital malformations heart defect can be effective in identifying the factors affecting the incidence of malformations. However, there is no consensus on the role of paternal and maternal exposures and susceptible window of exposure on the CHDs across studies. Additionally, the body of evidence on the association between occupational exposures and congenital malformations especially CHDs are limited. This study aimed to investigate paternal occupational exposure to solvents and congenital heart abnormalities in neonates.
Methods: The study was approved by the Ethics Committee of Shahid Sadoughi University of Medical Sciences (Registration Code: ir.ssu.medicine.rec.1359.37). In this case-control study 200 children with congenital heart defect and 400 matched healthy infants were considered as case and control groups respectively. Cases were randomly selected from the medically diagnosed and registered CHDs newborns during 2015-2017 (1393-1395 Persian year) in Yazd, Afshar referral hospital. Controls were selected from healthy newborns of Yazd province referred to the Yazd city health centers for receiving their routine health care services. Controls were matched case by case with the cases in term of age. A researcher-made questionnaire was used to collect the data by the telephone interview. The questionnaire comprised of three sections including a) general items regarding demographic characteristics b) lifestyle of parents and c) occupational and environmental exposures of the parents. Information on paternal occupation of questionnaires and paternal occupational exposure was performed using job exposure matrix. For this purpose, a matrix of occupational exposure assessment of solvents was prepared in Excel software. Exposure ratings of each job were solved based on the opinions of 10 experienced and well-known occupational health professionals. After completing the job matrix, the mean score of solvent exposure was calculated and the mean scores were used as fathers' exposure to solvents. Outcomes definition was performed according to international Classification of Disease version 10 (ICD 10). All refereed children with maximum three years of age which were diagnosed with at least one of CHDs according to the ICD10 classification were entered into the study.  Data were analyzed using SPSS16 software, descriptive and inferential statistics such as frequency and percentage. STATA14 software was used to evaluate job contact and logistic regression tests were used to estimate odds ratios and odds ratios. 95% confidence interval and 0.05 were considered significant.
Results: Among the analyzed cases, ventricular septal defect with 31.5% (n = 63) and patent ducts arteriosus with 24% (n= 48), had the highest prevalence. Results showed that mothers of case group had lower level of education compared to control group (p-value <0.001). In this study, the sex ratio of girls to boys was 1/1.06. The BMI in mothers in the case group (26.61± 5.74) was significantly higher than the mothers BMI in the control group (25.06± 3.71). Eight percent increase in the risk of CHDs was found per one unit increase in the BMI in the crude model (95% CI: 1.04:1.13). Eight percent increase in the risk of CHDs was found per one unit increase in the BMI in the crude model (95% CI: 1.04:1.13). About 72% (n=144) of mothers in the case group and 83% (n=332) in the control group reported no history of a diagnosed medical problem during their pregnancy. Significant difference was observed between the frequency of heart problems in the newborns of mothers with and without health problems during pregnancy (OR: 1.83; 95% CI: 1.23: 2.74). 26.5% (n=53) of the mothers in the case group and 21.25% (n=85) in the control group were a passive smoker. However, the risk increase due to passive smoking was not statistically significant (OR: 1.34; 95% CI: 0.90: 1.98). Use of folic acid during pregnancy was associated with 41% lower risk of CHDs (95% CI: 0.30: 0.86). Use of Iron supplement during pregnancy was also associated with 40% lower risk of CHDs (95% CI: 0.36: 0.99). Familial history of other congenital anomalies and also CHDs was associated with increase in the odds of CHDs. The prevalent of Paternal occupational exposure to solvents was 66% and 55% in the case and control groups respectively in which relationship was statistically significant (OR = 1.53, 95% CI = 1.06-2.21). After a removing the effect of confounding factors the significant differences was not observed between paternal exposure to solvents and heart defects in child (AOR = 1.28, 95% CI = 0.84-1.6). Investigation of the relationship between patent ducts arteriosus and occupational exposure to solvents showed that fathers' occupational exposure to solvents was higher in the case group (72%) than in the control group (58%), whereas between arterial openness and occupational exposure to solvents. With and without confounding factors, no significant relationship was observed despite high index ratio (OR: 1.94 4- 95% CI: 0.97-94.09 and OR: 64% CI95: 0.76- 3.55 / 1: AOR))
Conclusion: The limitations of the this study were the small number of samples, the limitation of study to a specific timeframe, use of the job evaluation matrix alone and the lack of evaluation of solvent biomarkers in parental and fetal body tissues and fluids. Despite the limitations of the study, the findings of the study showed that one of the environmental factors affecting the fetal health was occupational exposure Father’s with solvents. therefore father's job may affect the child health.  the results of Studies have also shown that exposure to chemicals reduces the quality of semen and can affect epigenetic planning during sperm cell maturation. These changes may lead to abnormal gene transcription in fetal tissue that may later lead to congenital defects. In addition, occupational exposure to chemicals is generally much higher than exposure to such substances in the diet and the environment, which may further impact such exposure. An animal study has also shown that the cardiovascular system in Fetal growth stage is highly sensitive to many environmental contaminants such as dioxins, polycarbonate biphenyls and some pesticides. In this way, training parents about compliance with occupational safety standards can increase the health of next generation. Also, since this study was conducted as a job and solvents are highly diverse, it is recommended to study the effect of each solvent on the biomarkers and the effect of each solvent.
 

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Background and aims: Observance of Health, Safety and Environment (HSE) guidelines is becoming more pervasive in all organizations, and governments and regulators are becoming more strict on it. The onset and prevalence of Coronavirus disease (COVID-19) is an example of a lack of attention or disregard for such standards and guidelines. Adherence to such standards is much more important in all organizations, especially in health-oriented organizations such as hospitals, and they increases safety and improves the efficiency of hospitals and the community (environment). Because health and safety factors are closely related to ergonomic factors (E), attention to this factor has led to the evolution of HSE and the emergence of HSEE. Much research has been done on HSE management, related evaluations, and other related issues, but due to the novelty of HSEE, such models have rarely been researched in HSEE. Also, in previous models, the weight of all factors was considered the same, and the evaluations were practically turned into checklists. While in any organization or in any situation, the importance of observing some factors may be more or less than others, and at the same time the ergonomic factor should be considered in this model. The purpose of this study is to provide a quantitative model for measuring the performance of organizational units based on the observance of the usual HSE criteria and consider the ergonomic factor (HSEE). Numerous studies have shown that ergonomics play a major role in increasing human performance in all areas. Developing such a model can lead to more accurate information to managers and their better decision-making in order to reduce harm in the organization and in the organization environment. It will also provide more accurate feedback to the organization's units for self-assessment and calculation of any points for them, and ultimately ranking the units.
 Methods: Since the result of this research is a model that can be used in practice by organizations (especially hospitals), this research is an applied research. It is also a descriptive study because it explores the current situation and tries to describe and clarify it and present the result in the form of a quantitative model. Finally, because the data in this study is collected through a questionnaire, it is a survey study. In the first phase, studies related to the HSE and HSEE models were reviewed. In each model, the main variables (health, safety, environment and ergonomics) were collected along with the following variables for each. Then, by combining them into one large model, all variables entered the model and overlaps were eliminated. Because this model is made for a hospital, the variables were redefined based on the characteristics of the hospital and the model was modified. Finally, a model including the main variables of safety, health, environment and ergonomics and 12 sub-variables were designed and based on it, a research questionnaire was developed. To calculate the reliability of this questionnaire, Cronbach's alpha method with 11 samples were used. This sample was selected by emphasizing on people's familiarity with HSE and HSEE models. The alpha value was calculated to be greater than 0.8 and the reliability of the questionnaire was confirmed. In order to discover the relationship between the 4 main factors and 12 sub-factors, the DEMATEL method with 8 samples was used. DEMATEL's method is a well-known method used to models whose variables are not independent of each other. Using the initial classification of factors as well as HSE(E), the decision tree was designed based on ANP method and also the weight of the indicators was obtained. The ANP method is a method based on pairwise comparisons and a subset of multi-criteria decision-making (MCDM) techniques used to discover the weight of criteria simultaneously with ranking alternatives. Because each of the ANP and DEMATEL questionnaires requires a lot of patience and concentration, the YungLan method was used to combine DEMATEL and ANP. In this method, the data collection is required only once by the questionnaire and this data is reused in both models. At this stage, the weight of 12 factors was calculated and the research model was completely architectural. The designed model was implemented in ArabNia Hospital in Qom. The goal is to determine how well each of the eight units in the hospital complies with HSEE. Qom ArabNia Hospital is the first hospital in Iran in which patients with COVID-19 were quarantined in February 2020. Because there was no information on how well each of the HSEE components were observed in the hospital, a simple questionnaire using the Likert's spectrum was designed to collect this information. This questionnaire was published in a total of 8 units and 11 questionnaires were completed. This data was entered into the model as input, and after analysis, hospital units were ranked based on compliance with safety, health, environmental and ergonomic criteria.
Results: The most important achievement of this research is a quantitative model including 4 areas of safety, health, environment and ergonomics with 12 sub-variables. The results showed a correlation between the main domains as well as the research variables. Identifying these connections revealed that the decision hierarchy is network type and the model governing the problem is ANP type. However, in some research the AHP model was used for this purpose. The premise of this model is that the variables are sufficiently independent of each other, which was rejected in this study. The results of using this model in ArabNia Hospital in Qom also showed that ergonomic factor has the greatest impact on other macro factors, and employee factor has the greatest impact on other 11 sub-variables of research. This model was used to evaluate all 8 units of the hospital. The goal is to determine how well each of these units complies with HSEE. If there is data related to the observance of each sub-variable by each unit in the hospital documents, the relevant data can be entered into the model and after analysis, the amount of HSEE observance by each unit can be determined. Because many cases are not recorded in organizations, access to the necessary data is not possible through the hospital's databases. Since the organization's staff are the only ones who have a lot of data and metadata in their mental history (albeit to some extent, vague and erroneous), a questionnaire was used to solve this problem. For ease of response, the Likert range was used in qualitative measurements. This questionnaire was distributed in 8 units and 11 questionnaires were completed and received. The required data were analyzed by the research model and 8 hospital units were ranked based on HSEE compliance. The results showed that, firstly, the weight of each of the 12 factors of the HSEE model is not the same, and secondly, there is a relationship between them, and finally, the ranking of the units is not the same.
Conclusion: The findings of using the research model in ArabNia Hospital in Qom proved the power of model differentiation. Using the results obtained in this study, the extent to which each of the components of the HSEE model is affected and different from each other. The use of the model in ArabNia Hospital in Qom showed that the medical, financial and administrative equipment units are ranked first to third in the field of HSEE, respectively. With the development of the HSEE measurement model, including the determination of indicators, sub-indicators, their relationship and the weight of each of them, it was found that the weight of the employee invoice is higher than other sub-factors. This study provides a framework for measuring hospital performance in terms of HSEE compliance. This model can be used in other hospitals as well. The point to keep in mind is that it is necessary to recalculate the weight of the variables and sub-variables, which is very simple. This model can also be used in other organizations. Provided that all sub-variables are redefined in accordance with the same organization and replaced in the model. It should be noted here that the main foundation and architecture of the model is fixed, but due to the difference in the nature of organizations, such a change in the details of the model is necessary. Also, the relationship between the factors and their weight must be recalculated. The results of this study are consistent with many studies conducted in the field of HSE. Including the fact that the human factor is very important in establishing HSE in organizations and complying with the relevant rules and regulations. The difference between the model presented in this study and other research is that the relationship between the factors in this model is considered. Although this is not explicitly stated, the use of AHP in some studies is due to the fact that independent HSE variables have been considered and the relationship between them have not been considered. Some recent research has shown that the combination of  DEMATEL and ANP has been used in the HSE model, which indicates an increase in accuracy in such research. However, ergonomic factors are absent in these studies. In the present study, an attempt has been made to pay attention to all these aspects.

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Introduction:
In the coronavirus (SARS-CoV-2) 2019 (COVID-19) pandemic, the global burden on health care systems increased significantly (1), And led to unprecedented changes in the organization and provision of health care at the national, systemic, and organizational levels. Nurses are recognized worldwide as a focal point for health care in a pandemic field (2). Nurses are at the forefront of care and are more vulnerable. Life-threatening situations during the outbreak of Covid-19 make the nurse's physical and mental condition very stressful (3). A developing body of research highlights deep concerns about the impact of work during the Covid-19 pandemic on this group’s health and well-being. Until today, thousands of healthcare professionals around the world have died from Covid-19 (4). There is also evidence of high levels of psychological stress and burnout due to a sudden increase in demand and the resulting workload (2). On the other hand, during the crisis, people are trying to adapt to the new normal conditions; while health care personnel, including nurses, are still struggling under the heavy burden of the pandemic, many of them become ill themselves due to lack of protective equipment and constant exposure to the virus during hours of daily contact with patients (5).
Nurses face major problems in this situation such as lack of nurses, beds and medical equipment including personal protective equipment and psychological changes and fear of critical infection. Further research is needed to explore the experiences of front-line nurses for further development, preparedness and responsive actions for the future (6). Checking the issues that nurses face during the battle with COVID-19 helps to support them and develops protocols and programs to improve their preparedness. The implications of these findings may help provide support and identify the needs of nurses (5). Nurses have a vital role in providing rapid and creative solutions; since their opinions to determine research priorities are mostly not determined, the need for more information in this regard can be beneficial to patients and their families (2). Determining research priorities is critical to the practice of the nursing profession that uses evidence to provide optimal care (5). Determining research priorities is considered as a key point and the beginning of the research management cycle, so that practical issues are determined according to the limitation of budget allocation (7) and it can make more connection between research topics in nursing with the government and investment institutions and provide services and regulate research and prevent uncoordinated and scattered nursing research (which leads to inefficiency and rework) (8). Using these priorities can be useful in organizing the nurses' response to COVID-19. Also, setting research priorities in Corona nursing can be effective in compiling health policies and innovations. On the other hand, the existing COVID-19 nursing cannot be depicted without information (2). ). Based on the Research Committee overall review of COVID-19 in IRAN, the three main areas of clinical management, health measures and socio-economic responses and eight sub-areas of screening and testing, drug treatment, intensive care, prophylaxis, prognosis, management Clinical effects of pandemic on health, infection prevention and personal protection have been identified (9). However, until today, despite the abundance of research activities, there has been no coordinated approach to attract nursing priorities for research during the Covid-19 pandemic (2), so the present study aims to determine the nursing research priorities in the Covid-19 pandemic in Iran- designed with Delphi technique.
Materials:
This is a descriptive modified classical Delphi study that was conducted to determine Corona nursing research priorities. The Delphi technique is a structured process for predicting and assisting decision-making during survey rounds, gathering information, and ultimately group consensus (10). The purpose of using the Delphi method is to identify one or a limited range of numerical estimates of corona nursing research priorities. The researchers, first by reviewing the related texts extracted a list of research topics and sub-topics (questionnaire design).   Then, a group of 55 experts (considering 25% dropouts)  with at least three years of experience were selected purposefully from people in charge in the field of corona nursing, including members of the nursing board of the Ministry of Health and Medical Education, nursing members in the corona headquarters, heads of all research centers and managers of nursing department, vice chancellors of a number of nursing and midwifery schools in Tehran, Mashhad, Tabriz, Isfahan, Yazd, Sari, Ahvaz, Hamedan, Urmia, hormozgan and Zahedan. The individuals were included in the study with their own consent and agreement after their contact number and postal address were extracted. Subsequently Delphi steps were performed after compiling the initial questionnaire and identifying the group of experts. The questionnaire consisting of three parts: The first part includes personal characteristics including age, gender, educational and clinical background, type of responsibility, education, and place of activity. The second part includes a list of research topics for prioritization with a scale of 1 to 3(low (1) - medium (2) - high (3).The third section includes an open-ended question to prioritize other research topics that, according to participants, were not considered in the suggested list.
 The designed questionnaire was sent to eligible samples to determine the priority of the items in the questionnaire based on the criteria to express their opinions regarding the degree of importance from 1-3. The questionnaires were distributed by e-mail or in person along with a letter in which the objectives of the project, the application of the results and the deadline for submitting the answer were specified. An online questionnaire prepared via WhatsApp was also sent for those who did not respond. The samples were continuously followed up by phone and SMS to answer within the specified time.
After receiving the questionnaires, quantitative data were analyzed by calculating the mean and standard deviation of the response score for each of the topics with SPSS software version 21. Also, after qualitative analysis by content analysis method, new items were set up in different areas and some cases were merged based on participants’ opinions in the open-ended question.  Based on the analysis of the results, the items that were given a score of 2 or higher were identified as a priority and were listed based on a higher mean and less standard deviation. In the second stage, the issues raised in the first stage were submitted to the experts in the form of a questionnaire to determine the degree of their agreement with the priority of each case with a score from 1 to 7. At this stage, the issues were included in the list if they had a degree of agreement higher than 5. At the end of this phase, the final list of COVID-19 nursing research priorities in Iran was extracted.


Results:
Out of 55 invited people, 30 people participated in the first round and 20 people accompanied the study until the end of the second round. 55% of participants were female and 45% were male. The mean age of the samples was 52.2(+_8.37) years. 100% of the participants had a doctorate degree in nursing. In terms of professional work experience, the samples had an average of 8.8(+_ 9.84) years of clinical work experience and 23.1(+_7.78) years of educational work experience.
The initial draft of the research priorities list extracted from documents in six areas included 87 priorities as follows: Emotional psychology (16 items), educational research (16 items), nursing management (18 items), nursing care (13 items), prevention and epidemiology (18 items) and health technology (6 items).
In the first round of the study, 30 out of 55 invited individuals (54% response rate) answered the first round questionnaire .In this way, 19 items were removed, 8 items were merged and 13 items were added and finally 77 research priorities were extracted and formed the basis of the second round structured questionnaire. In the second round of the study, with repeated follow-ups, 20 individuals (67% response rate) completed the questionnaire of this stage of the study .all subjects had a degree of agreement higher than 5 in all items. The results of the Delphi study in response to the first and second round questionnaires led to the completion of priorities from 87 priorities to 77 final priorities. They were finally listed in order of priority in each of the six areas of emotional psychology (8 items), educational research area (16 items), nursing management area (16 items), nursing care area (11 cases), prevention and epidemiology area (21 items), and the field of managerial health technology (6 items) (Table 1-7).











Discussion:
Based on the results of this study, nursing research priorities were determined in six areas .These priorities can be a framework for research in the field of corona nursing in the country. As nurses play a specific and broad role in health care planning and service delivery in response to the level of health service demand and changing patterns, the nursing profession is increasingly at the forefront of research, clinical and Health services policy (11).
This study in line with previous studies (4) showed that mental health is an important area for the sustainability of health and nursing services during the pandemic. Nurses and health visitors are in an ideal position to develop and provide focused psychological interventions to patients and the public. Also, a growing body of evidence of the negative impacts of this pandemic on the mental health of the nursing workforce is emerging, necessitating research to improve long-term resilience and well-being in the context of more optimal staff conditions (12,13,14). On the other hand, the unprecedented psychological problems and social health challenges associated with this terrible pandemic are important issues that require further scientific research and evaluation and scientific solutions to mental health (15). Findings of the study showed that due to the high prevalence of patients' mental problems, even after recovery from COVID-19, a comprehensive study of mental health is needed to improve their quality of life (16).
The development of remote practical plans of nursing care during the pandemic and presenting information technology solutions in nursing education during the Covid-19 pandemic had a high priority in this study. The need for research on technology in nursing has started since 20 years ago and it has been used to support daily care, help patients interact and also educate them (5). Therefore, distance nursing has become an essential component of nursing care. Nursing care has been provided directly or virtually during the Covid-19 pandemic. Today the majority of people use virtual nursing care in the community if possible. Therefore, the concept of virtual care and the model of nursing care with non-verbal communication should be developed and examined. (17).

This study highlighted the priority for focused research on occupational hazards and safety (environment, nurse, and patients) in the field of prevention and epidemiology. The World Health Organization agrees that alternative approaches to reducing the shortage of personal protective equipment should be based on scientific evidence and the principles of safe care (18). This approach is vitally important because concerns about personal protective equipment may arise not only from nurses' personal safety issues, but also from other patients and the transmission of the virus to other people outside the workplace (4). In a study, in order to determine a model for research priorities in the Corona pandemic, the need for research on social psychology to plan preventive measures has been emphasized (19) ,and in this regard, the image of nurses in society and the media can affect the fulfillment of their role(5).
Research related to human resource management and equipment and crisis management had a high priority in this research. Undoubtedly, we must plan for a future with a sufficient number of nurses from now on, and the entire nursing staff must be paid better (20). There is also a generation gap to replace retired nurses. Designing staff models and innovative human resource strategies are essential to replace the new forces. In addition, organizational commitment among nurses needs further consideration due to high workload, low pay, high patient / nurse ratio, and other factors (21). Lack of manpower and medical equipment and resources such as personal protective equipment is the second most important category that nurses stated in the evidence, facing covid-19, which has led to the spread of infection among physicians and nurses and their death (22).
During the Covid-19 pandemic, the training section was one of the most vulnerable (23). To deal with the consequences of the closure of educational centers and the cessation of educational processes, learners and professors in all stages had no choice but to use e-learning in various forms (24). E-learning in nursing education may affect patients' health. There is little consistency between the content, the educational method and the goals of the university (26). Another problem in this section is related to the practical nature of some courses that cannot be presented online (27). Therefore, innovative teaching-learning strategies, utilizing the experience of students and faculty from distance education, educating the patient and their families, and developing an educational guideline are among the priority items that should be considered.
In this study, research in the field of nursing services for patients with COVID-19 at the time of hospitalization and after discharge at home as well as dying patients was given high priority. Families felt a deep sadness for the death of their loved ones who died alone. It is necessary to check and follow up these families and the impact of palliative care (4).
 One of the strengths of this study was the presence of experts and the use of the Delphi method to reach a consensus to determine priorities. The Delphi method was used with the spread of samples in Iran, which strengthens the validity and generalizability of research priorities.This study confirms the pivotal role of nurses in the continuous development of health care services by identifying priority fields that can be the basis for care measures and nursing practices at the national level. It is suggested that the identified research priorities in each of the areas be examined separately and that clinical nurses be used to review future research priorities. Conducting research in the areas identified in this study could guide future nursing research and the allocation of research grants and subsequently lead to the development of nursing knowledge; it could also improve patient outcomes and the quality of nursing care and ultimately lead to maintaining and promoting the health of the individual, family and community. It is recommended that nursing research in the post-corona period be continued due to the effects of this pandemic in the psychological and social fields on nurses and patients.

Conclusion:
In this study, the research-nursing priorities of COVID-19 were determined in Iran, via Delphi method, based on nursing experts' opinion in various fields. Developed research priorities could guide the study audience in selecting topics and focusing on future research activities even in the post-corona period. Also purposefully target the allocation of research resources and budgets. Priority evaluation was done virtually via e-mail, which was difficult and time consuming due to the busy schedule of experts Research priorities with an average score equal to and above 2.5 were listed (table 1).
Acknowledgments:
This study was suggested by the Nursing Research Network, "Corona Research Working Group", Mr. Dr Nejatian,Mr. Dr. Mazloum, especially Mrs. Dr. Leila Valizadeh, who are appreciated. We would also like to thank the Research Vice Chancellor of the University of Medical Sciences and the Midwifery Nursing Research Center of the Shahid Sadoughi School of Nursing and Midwifery in Yazd, and all the valuable experts and professors who helped us in this research.
Ethical considerations:
This study is the result of a research project No. 12085 approved by the Ethics Committee of Shahid Sadoughi University of Medical Sciences of Yazd with the code IR.SSU.RSI.REC.1400.024
Conflict of interest: This study has no conflict of interest.
Funding source: This research did not receive any grant from funding agencies.
Author contributions: khadijeh dehghani: design of the work, methodology, analysis, drafting, editing, revision and Supervision of the work.  danial shadi  : methodology , research review , drafting and editing.