THE IMPACT OF THE PAYMENT OF THE NURSING FEE ON THE

QUALITY OF CLINICAL SERVICES AND THE SATISFACTION OF

SERVICE RECIPIENTS

VAHID POURSHAHABI 1*, MOJTABA GHANEI 2 and VALI GOLI 3

1
Assistant Professor, Department of Management, Zahedan Branch, Islamic Azad University, Zahedan, Iran.
Email: [email protected]
2, 3
Department of Management, Zahedan Branch, Islamic Azad University, Zahedan, Iran.
Email: [email protected], [email protected]

Abstract
The first basic step in formulating quality improvement programs is to determine the perceptions and expectations
of the recipients of services or goods regarding their quality. Today, many leading organizations have chosen
service recipient satisfaction as the main indicator of their performance. Services are the delivery of services. In
this study, the effect of paying the fee for nursing examination on the quality of clinical services and satisfaction
of service recipients was investigated with a grounded theory approach using the snowball method on a selected
sample of 10 experts from Mashhad College of Medical Sciences. After in-depth interviews with these experts,
theoretical saturation was achieved. All primary themes were coded and categorized into 10 main categories with
31 subcategories. The results of the research have shown that factors such as referral monitoring, upstream care,
cleanliness, organization of patient expectations and responsiveness as intervening conditions can have an
encouraging aspect in improving the quality of clinical services and the satisfaction of service recipients, and
finally, a combination of the above factors and conditions such as empowerment of staff, revision of goals and
processes, and personalization of services can also be considered as strategies to achieve this model, and finally,
improving the quality of clinical services and increasing the satisfaction of service recipients was identified as a
follow-up category.
Keywords: Service, Clinical, Care Rate, Satisfaction, Background Theory, Coding Process

INTRODUCTION
Quality is a type of policy that fulfills the needs of customers by producing desirable goods
and services. This policy deploys resources to protect the interests of the organization in an
effective and efficient manner and to bring more benefits to the managers and employees of
the organization. Quality does not occur by accident, but is something that the organization
strives for. To achieve quality, it must be planned, strategies, policies, activities and specific
methods must be defined. The quality of health care is one of the most common principles.
Health policy is currently on the agenda of policy makers at national and international level for
a variety of reasons - from public commitment to providing quality health services as a public
good to refocusing on treatment outcomes. From hospital patients to identifying specific issues
raised in the area of quality of health and medical services, it is being discussed (Koulivand,
2012). In 2014 and 2021, the European Commission recognized quality as one of the most
important components of health system performance (i.e. the degree to which health systems
achieve their objectives). At the international level, attention to quality has increased in the
context of the Sustainable Development Goals, as achieving the Sustainable Development

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Goals requires universal health coverage, including protection against financial risks, access to
quality health services and access to safe, effective, high-quality and affordable vaccines and
medicines for all. Clearly, quality is a necessary aspect of value. Indeed, it is the degree to
which the characteristics of the service provided meet the specified standards that determines
the quality of that service. The quality must meet the requirements in terms of performance and
price. This point can be found in two World Health Organization reports published in 2018, in
the booklet on national quality policies and strategies and in another set of guidelines aimed at
facilitating the global understanding of quality as part of the ideals of universal health coverage
(Silos et al., 2021).
In one of the studies conducted by the Organization for the Review of European Health Care
Policies and Systems in the field of health care quality (2008), it is stated that the volume of
articles published in the field of quality of care in health care systems is so large that it was
really difficult to organize them ten years ago. Was. To ensure the improvement of quality of
care, research covers a wide range of approaches or solutions and is often conducted with a
focus on specific organizations, hospitals, medical centers, clinics or specific care areas,
emergency services, maternal and child care, etc.).
Such studies help to better understand the effectiveness of interventions in areas of interest to
specific patient groups. However, existing articles rarely examine the priority of strategies and
generally do not help policy makers determine the priority of using a particular strategy in a
given situation. . Furthermore, despite the numerous articles and public awareness of the
importance of quality in health systems, there is no common understanding of the concept of
quality of care and its scope is still contested. However, as mentioned in the research of Avidis
Donabedian (1980), assessing and improving the quality of the field of inclusion is also crucial
(Reid and Aaj, 2021).

THEORETICAL FOUNDATIONS
 The belief and commitment to the provision of quality medical services as a public good,
raising awareness of the existing gaps in safe, efficient and person-centered care.
 The importance of fundamental changes in standards for the delivery of health and medical
services is raised, re-emphasizing the promotion of performance within the context of
value-based ideas for health care
 The expectations of the media and civil society, coupled with the public's demand for
transparency, increase responsiveness
 Moving towards universal health coverage and recognizing that it is impossible to achieve
the desired outcomes in this area if access is improved without attention to quality.
 Increasing awareness of the need to equalize the performance of health and treatment
services in both the public and private sectors in micro and mixed health markets.
Raising awareness of the importance of providing trusted services to respond

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Effectively to the outbreak and the other complex emergencies
Definitions of quality of healthcare
Early definitions of health care quality were developed almost exclusively by health care
professionals and health services researchers. Although the importance of the attitudes and
opinions of patients, the public and other key stakeholders in the field is now well recognized,
Donabedian (1980) defines quality more generally as "the ability to achieve desirable ends by
legitimate means" This definition reflects the fact that the term "quality" is not exclusive to the
field of health care, but rather is used by different people in different parts of society. People
use the term quality not only when describing a wide range of positive aspects of hospitals and
doctors, but also when talking about food or cars. In fact, this broad use of the term quality is
part of the ambiguity. It is included in the concept of quality of healthcare services when it is
used by policy makers and researchers to express all sorts of positive or desirable
characteristics of healthcare systems. She considers maximizing the patient's well-being to be
the highest priority. The patient's well-being definitely includes their state of health. However,
the concept of patient well-being also corresponds to the approach that pays attention to
important points from the patient's perspective (Boss, 2022).
A decade later, the IOM, a medical institution in the United States, defined the term quality of
care or medical services as the degree of increase in the likelihood of achieving desirable health
outcomes for individuals and society that is consistent with current professional knowledge. At
first glance, it appears that the focus of this definition of achieving desirable health outcomes
is more limited than the concept of patient well-being in Donabedian's definition, but in
explaining this definition, the IOM states that achieving desirable health outcomes means
patient satisfaction and well-being in addition to improving health status or quality of life
criteria. (Carinci et al. 2015)
The HCQI project has chosen the three dimensions of safety and patient-centered effectiveness
as the main dimensions of the quality of medical and health care and believes that other
characteristics such as consistency, availability and acceptability can simply be mentioned in
the three dimensions. Appropriateness, for example, can be interpreted in terms of effectiveness
and continuity, and acceptability in terms of patient-centeredness. Access, efficiency and equity
are also important goals of health and treatment systems (Floodgren et al., 2021).
As already mentioned, the definition of the Council of Europe (1997) serves as a guideline for
the development of quality improvement systems. Therefore, it is natural to include the
evaluation of the medical service process as part of quality, which is superior to other elements
such as accessibility, effectiveness, efficiency and patient satisfaction. Over the last 20 years,
many structures have been developed to enable a better understanding of healthcare systems
and to assess the performance of healthcare systems (Papanikolas 2013 and Fekri Makarian
and Klazinga 2018). Many of these structures implicitly or explicitly include quality as an
important health system objective, but they differ in how they define quality and how they
explain its role in overall health and health system objectives. One of the structures is the
building block structure provided by the WHO. (2006) to strengthen health systems.

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This structure conceptualizes health systems in terms of building blocks, including the
provision of manpower, information, medical equipment, financing and management services.
In addition, this structure defines quality and safety, along with access and care, as intermediate
goals of health systems that will ultimately contribute to the overall health system goals of
improving health, accountability, financial support, and improving efficiency. It is worth noting
that quality and safety are mentioned separately in this structure, while most of the previously
mentioned quality definitions consider safety as a main dimension of quality.
As mentioned earlier, Donabedian (1980) defines quality generally as the ability to achieve
desirable ends by legitimate means. By combining Donabedian's general definition of quality
and the structure of the building blocks provided by the WHO, it can be argued that a health
care system is of quality if it achieves these goals (overall and intermediate) by legitimate
means. When assessing the quality of healthcare, a distinction should be made between
different levels. According to him, these four different levels at which quality can be assessed
are the individual professionals of the care environment, the care received and implemented by
the patient, and the care received by the community (Gravis et al., 2018).
In simpler terms, it can be said that the reasons for the need for quality in medical centers today
are as follows:
The growing demand for adequate and effective health care
The need to standardize and control differences and variations, the need to save costs
The need to use the ideas of others in the field of quality control and standardization.
The need to recognize and meet the needs and expectations of patients
The need to improve services and care
Market pressure, competition and marketing improvement
The desire to showcase the organization and strive for excellence
Ethical considerations
The need to gain financial credit through quality improvement.
Service quality is actually a comparison of service recipients' expectations and perceptions of
service delivery. Quality is a complex concept that changes according to people's mindset
(Borhans and Alligood, 2010).
Service recipients evaluate service quality by comparing their perceptions and expectations of
the service received. (Bahadri et al. 2013) One of the fundamental aspects of service recipients
is quality assurance and improvement. The feedback received from customers helps to identify
and prioritize the dimensions where there is a continuous need for improvement. Indeed, the
key to the success of service organizations is to provide excellent services by maintaining and
improving service quality (Alavi, 2016).

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The problem of service quality occurs mainly in organizations that do not pay attention to
recognizing and meeting the needs and requirements of service recipients (Gholami et al.
2011), also considering the fact that the awareness of service recipients is increasing day by
day and thus they are able to recognize and meet the needs and requirements of service
recipients. To strengthen or weaken organizations, their thoughts and feelings should be at the
top of every organization's work plan. It is complex and completely global, using the economy
and services that have a significant impact on the economy and people's quality of life. In terms
of resources, hospitals account for about 50% of healthcare expenditure as they are the largest
and most expensive operating unit of the healthcare system (Mohammadi et al., 2013), but the
review of the literature shows that the quality of hospital services and patient satisfaction face
many challenges. A study conducted in hospitals in Shiraz shows that the quality of services is
not optimal. In the provision of hospital services, 4379 errors were recorded in one year, with
most errors occurring in large hospitals (Khamarnia et al., 2013). At the same time, most
customers and patients demand high quality services due to increased awareness in the health
sector (Mohammadi Nia et al., 2010). is unfavorable and patient satisfaction is low (Naqvi et
al., 2014). The study by Ezzatabadi et al. conducted in 2013 in different departments of Shahid
Sadouqi Hospital in Yazd showed that there is a gap between the expected quality and the
quality perceived by patients. Bahadri and his colleagues also showed in 2014 in four dialysis
centers in Kerman that patients' average expectations were higher than their perception of the
quality of services provided (Bahadri, 2015). Numerous other domestic and international
studies also came to similar conclusions (Tai, 2014). ).
In nursing sciences, the issue of service quality has been raised since 1980 (Qomari et al.,
2008), so since the 1990s, measuring patient satisfaction has been considered as a method to
obtain patients' opinions and views about their care in most health centers. One of the indicators
of care evaluation is the degree of patient satisfaction with the care received (Zadeh 2020) and
also one of the important aspects of patient satisfaction is nursing care, as nurses are responsible
for most aspects of patient care. The title of patients' opinion about the care received from
nurses is defined (Krambus 2013), moreover, nursing care is introduced as an important part
of health care that affects the overall satisfaction of patients. In general, the importance of
service quality and patient satisfaction and how to increase them as much as possible, especially
in the treatment sector where human lives are at stake, needs to be further investigated. It is
also necessary to identify the gaps in the quality of care and find the right solution to correct
them.
Furthermore, the word "tariff" in the field of medical services is synonymous with the word
price in stock market trading. The reason for using the title tariff is that prices are determined
from the intersection of supply and demand on the market, while the tariff is set for a certain
period of time and in the length of the year is independent of the functioning of the market and
its conditions. The tariff occupies a special position in the healthcare system (Sanehi and
Bennot, 2016). Since the entire financial cycle of the health system is based on it, it can be said
that the tariff system depends on the performance of all elements of the health system (Sadeghi
Fard et al., 2011) and the change affects all these dimensions. Despite the incompatibility of
nurses' wages with their efforts and the perception of injustice on their part, the medical

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tariffization of nursing services has been sought for years by the nursing community and its
affiliated unions, even if the result has not yet been achieved. In this context, the law on
"Tariffization of Nursing Services and Adjustment of Nursing Personnel" of 2006 and "the
"Law on Improving the Productivity of Clinical Personnel of the Health System" of 2008 were
passed by the Islamic Council, which have not been implemented after more than a decade.
They are not on the right track.

BACKGROUND TO THE RESEARCH

Shafiei et al. (2022) conducted a survey to determine the level of patients' satisfaction with
nursing services in Imam Reza Hospital, peace be upon him, in the city of Lar during the Covid-
19 epidemic. The results showed that the majority of patients were fully satisfied with the
services provided by the nurses. It is recommended to improve the quality of care by conducting
written awareness programs and investigating cases of dissatisfaction to increase the level of
patient satisfaction. Also, Bagheri Nekrani et al. (2021 research) entitled "Explanation of the
scenarios of encountering the nursing service rate law based on the triangular model of line
analysis" Mishi" that the research results were categorized into the four dimensions of this
model, i.e. content, process platform and policy makers, which are the scientific and theoretical
foundations required by the existing documents in the field of rate setting, the history and
components of rate setting and the views of key stakeholders. In this edition, it is clarified that
in the conclusions section, the possible scenarios were evaluated, focusing on ensuring the
satisfaction and motivation of nurses while maintaining the quality of healthcare services. In
line with the research process, suggestions were also made for short and medium-term
measures. It is possible to reduce the severity of the current situation and create an opportunity
for fundamental reform. Rafiei and Hosseinzadeh (2014) in their study titled "Evaluation of the
effectiveness of the quality of nurses' work life on patients' satisfaction with nursing services"
showed that there is a relationship between the quality of nurses' work life (with the 7
components of fair and adequate pay, safe and healthy working environment, provision of
opportunities for growth and continuous security, legalism in the organization, social
interdependence in working life, general living atmosphere, unity and social cohesion in the
organization) has a significant relationship with patients' satisfaction with nursing services, i.e.
by improving the quality of working life of nurses, it is possible to improve patients quality of
working life of nurses.i.e. By improving the quality of nurses' working life, services are better
provided to patients and, as a result, patient satisfaction with nursing services also increases.

METHODOLOGY
To achieve the research objective, the method of Fondamental theory, which is one of the most
efficient methods of qualitative research, has been used because the research problem is a
complex, multi-layered and processual problem and Fondamental theory can be an appropriate
method to understand the totality of conditions and effective factors. In the grounded theory
method, the researcher does not begin the work with a theory already in mind, but begins the
work in the field of reality and allows the theory to emerge from the data he or she collects
(Strauss and Corbin 12, 2015). The logic of land theory provides direction for the method of

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data collection and sampling procedures. Presenting a Fondamental theory requires the
collection of textual data from in-depth interviews, as the in-depth interview method is
considered the most important technique for collecting Fondamental data (Morse, 2001). The
in-depth interview is often introduced as a semi-structured interview; because the researcher
retains some control over the direction and content of the interview. While the participants
describe or choose new directions (Boreji, 2017).
One of the disadvantages of the semi-structured interview method is that in this method the
researcher attempts to steer the content of the interview in the direction of his or her objectives,
regardless of the respondents' answers, which can distort the results to a certain extent.
In this study, a semi-structured questionnaire was designed for data collection based on the
literature review. Purposive and non-random sampling method was used to draw the sample,
among the purposive sampling strategies introduced by Gal 14 et al. the snowballing strategy
was used. The selected sample consists of 10 experts from Mashhad University of Medical
Sciences who were selected using the snowballing method and on the suggestion and
recommendation of other respondents. Come.
Table No. 1: Characteristics of the interviewees
No Label Interviewee No Label Interviewee
An expert related to the Chief of Surgery Department of
1 M1 tariff department of the 6 M6 Mashhad University of Medical
Ministry of Health Sciences Hospital
Member of the Faculty of Member of the Faculty of
Medical Information and Medical Information and
2 M2 7 M7
Management, University Management, University of
of Medical Sciences Medical Sciences
3 M3 Nurse 8 M8 Nurse
Head of the Cardiology
Medical assistant specialist
Department of Mashhad
4 M4 of the University of 9 M9
University of Medical Sciences
Medical Sciences
Hospital
Emergency expert at Mashhad
5 M5 Nurse 10 M10 University of Medical Sciences
Hospital
After collecting interview and text data, analysis and coding begins with sampling. In this
study, a systematic approach is used to theorize the baseline data. The systematic approach
emphasizes the use of data analysis steps, including open-axis and selective coding, and the
development of a logical model or visual description of the generated theory. (Creswell, 2002)
in the Mohagheg Foundation data theory, by performing several stages of coding, including
open or primary coding, axial coding, and finally selective or selective coding, he will extract
the main and core subcategories from the data and continue the analysis work (Beheshti, 2016) .
At each of these steps, the attached code or codes must bring the data associated with them to
the saturation level (Strauss and Corbin 2013).

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Open coding is an analytical process through which concepts are identified and their
characteristics and dimensions are discovered in the data. During the process of open coding,
the data is broken down into parts and carefully examined for similarities and differences and
compared with each other. The line- by-line analysis method is used to perform open coding.
This method involves a close examination of the data. It is carried out sentence by sentence
and sometimes word by word (Strauss and Corbin, 2015).
The linking of categories with subcategories is called axial coding because the coding takes
place on the axis of a category and relates the categories to each other at the level of
characteristics and dimensions (Lee, 2015).
In axial coding, the categories are regularly expanded and connected to the subcategories, but
unless the main categories are connected and form a larger theoretical plan, the research
findings will not take the form of a theory. In fact, selective coding serves to integrate and
refine the categories (Strauss and Corbin, 2015). In this phase, the main categories are related
to each other in the form of a paradigm model/territorial model/coding pattern around the core
category. The model drawn describes the core category and analyzes and explains it. They are
reading a resulting theory (Mohammadpour, 2013). Figure 1 shows the phases of analysis in
the grounded theory method.

Diagram 1 of the analysis steps in grounded theory

Finally, it is important to determine whether your theoretical explanation makes sense and is
plausible to the participants and is an accurate representation of the events and their sequence
in the process itself. In data theory, grounding, validation is an active part of the research
process and takes the form of a number of strategies (Crezwell, 2002).
In this study, two strategies were used to validate participants by presenting the research
findings to four participants and considering their viewpoints.

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DISCUSSION AND RESULTS
In order to achieve the aim of determining the impact of payment for care on the quality of
clinical services and the satisfaction of service recipients, the interviews were analyzed using
the field theory method. The text of the interviews is carefully read and according to the
research objective, the analyst extracts the narratives in the text with minimal interference and
categorizes them into categories by compiling categories with similar concepts. In this way, the
most important ones are obtained. In the current study, by reviewing the text of the interviews,
10 main categories were identified, each of which has subcategories. The relationship between
the main categories obtained from the analysis is then examined.
Theory formation
If this phase is not fulfilled, we select the user category of the detailed design from the open
coding phase and place it at the center of the process we are investigating as the central
phenomenon.17 we then relate other categories to it. These other categories are Of the causal
conditions, the factors that influence the central phenomenon, the strategies, the actions that
take place in response to the central phenomenon, the Fondamental and intervening conditions
(specific and general environmental factors that influence the strategies) and the consequences
(results obtained from the application strategies This phase consists of drawing a diagram
called a coding pattern (diagram number (2), the coding pattern represents the relationships
between the conditions, the cause of the strategies, the background conditions and the
intervention and the consequences.

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In this phase of coding, we write a theory of the relations between the categories in the axial
coding model. At a basic level, this theory is an abstract description of the process under
investigation in this study, i.e., the impact of nursing rates on clinical service quality and
satisfaction. The recipients provide services. The process of integrating and improving the
theory consists of selective coding through techniques such as writing a storyline that combines
categories and the process of categorization through personal notes on theoretical ideas. The
following narrative on the impact of the nursing tariff on the quality of clinical services and the
satisfaction of service recipients examines how specific factors influence the phenomenon and
lead to the use of specific strategies with specific outcomes, i.e. in the selective coding phase
of the results. The previous coding steps are carried out, the central category is selected, it is
linked to other categories in a systematic way, these relationships are reviewed and the
categories that need further improvement and development are added. Therefore, the central
category is a very important part of the integration and improvement of the categories. In the
following, the impact of the nursing tariff on the quality of clinical services and beneficiary
satisfaction is explained by writing the storyline, focusing on describing the relationships
between causal conditions, strategies, background conditions and interventions and
consequences.
Causal conditions
Causal or causative conditions are usually the events that influence phenomena (Strauss and
Corbin, 2015). These factors introduce a set of conditions on the basis of which quality of
clinical services and satisfaction of service recipients are introduced as a mandatory core
category. Clinical service quality and service recipient satisfaction are presented in Table No.
2.
Table 2: Conditions of causal categories for the quality of clinical services and
satisfaction of service recipients
Type of
Main categories Subcategories
conditions/categories
Nurses' motivation/Nurses' attitude/Nurses'
Causal conditions Paying the nursing fee financial problems/Nurses' personal
preoccupations
One of the causal categories emphasized by the experts of Mashhad College of Medical
Sciences, which is the subject of our study, is the payment of nursing tariff, because the tariff
of nursing services means the accurate and scientific separation of the components of clinical
services from each other, their relative evaluation in terms of difficulty, time and skills. It is
necessary to do this and determine a fair and transparent fee for each service for the provider,
the recipient organization. The studies conducted in this area show that the correct
implementation of the law on the tariff for nursing services can lead to an improvement and
increase in the quality level of services provided by nurses and a reduction in patient income,
which in turn increases their satisfaction (Shahabi, 2015).

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Fondamental conditions
The conditions of the complex countries are conditions that are influential in the planning
environment, but exist as macro trends in an environment beyond the planning environment
and indirectly influence the desired phenomenon, and hospital managers do not have the power
and authority to intervene in it, and the decision-making levels They are beyond the planning
decisions of the hospital level (Burji 2017). The background conditions of clinical service
quality and service recipient satisfaction are shown in Table 3.
Table 3: Conditions of the categories of clinical service quality domains and service
recipient satisfaction
Type of
Main categories Subcategories
conditions/categories
moment-to-moment control of the patient
Advancement of through new technologies, the use of tools to
technology speed up the delivery of modern care,
physiotherapy and pain relief
The need to deliver medical services on time /
The level of awareness
Fondamental conditions double burden on nursing staff due to staff
of clients in the context
shortages / loss of experienced staff due to their
of the health field
relocation
Unplanned and inexperienced deployment of
The level of knowledge
staff in the emergency department / referral of
and experience of
patients for unnecessary consultations due to
personnel
lack of experience
1. The progress of technology is the first step. Technology with greater efficiency and better
knowledge of nurses to provide strong patient care is expanding the field of nursing in
many ways. This includes devices and programs ranging from handhelds and portable
mobile units to software-equipped command centers. Nurses provide important
perspectives that can be easily accessed and shared with other clinicians. Sue Murphy,
senior director of experience and innovation at the College of Chicago Medicine, believes
technology can continually simplify nursing information and expand nurses' human
connection." Recent research has shown that 82% of nurses worldwide believe that new
technologies help to improve processes. Humanity and the reduction of errors, humanity
will have a positive impact on the quality of patient care.
2. One of the prerequisites for improving the satisfaction and quality of clinical services is
customer awareness in the healthcare sector. Hospitals, as one of the main pillars of health
service delivery, should be an institution that understands and respects the rights of
patients, families, their physicians and other caregivers. In the shadow of appropriate
interaction of providers and recipients of health services regarding their duties and respect
for the rights of others, the health of society will be achievable at the highest possible level,
considering that health, physical, mental, spiritual and social, is one of the most important
aspects of everyone's existence and its provision is one of the most important obligations
of the government in the Islamic Republic based on Article 29 of the Constitution. The
Ministry of Health, Treatment and Medical Education considers itself responsible for the

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 optimal provision of health services, including compliance with the Charter of Patients'
Rights for members of society. In recent decades, the field of medical intervention and
interaction has greatly expanded in line with the breathtaking progress of science,
especially medicine, and the emergence of modern treatment methods and the
advancement of medical scientific technologies, which in turn has led to many ethical
challenges, and patients, as one of the most vulnerable social groups, have been and
continue to be at risk. An efficient healthcare system requires the active participation of
recipients and providers of healthcare services.
3. The level of knowledge and experience of the study staff has shown that nurses who have
based their actions on scientific documents and evidence have been able to make decisions
that reduce the length of hospital stay and costs for patients and bring more effective and
satisfactory results for patients and the organization. The role of education in the
acquisition of decision-making skills, professional independence and growth, and nursing
empowerment is very important. Evidence and research show that it provides an approach
in nursing to support clinical decision making in the context of nursing work. Evidence-
based nursing completes the quality of nursing care through science and nurses'
experiences. If the importance of evidence-based nursing is well taught and developed,
there will be significant growth in the nursing system due to the effectiveness of evidence-
based nursing education. Based on the evidence of nurses' awareness, it is expected that
strengthening this skill will be one of the educational goals in undergraduate and graduate
nursing. The research findings also show that holding a workshop with nursing education
content can increase nurses' awareness. Holding a workshop by creating an environment
where clinical situations are discussed can be the basis for increasing awareness and
professional knowledge, considering the importance of evidence-based nursing to provide
higher quality and more effective care. Managers can also take steps with better planning
for the quantitative and qualitative development of nurses by relying on the recognition of
the functions of evidence-based nursing and time management to promote clinical and
beneficial nursing care, especially in special departments, which was of course the
realization of all cases and led to education. I understand; It requires the relative well-being
of nurses.
Intervening conditions
Intervening conditions are those that mitigate or alter the causal conditions in some way
(Strauss and Corbin, 2015). They are general background conditions that influence strategies
(Danai Fred, 2012). The intervening conditions for the implementation of the diversity-oriented
model are listed in Table No. 4.

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 Table 4: Conditions of the categories of disruptive patterns of clinical service quality
and service recipient satisfaction
Type of
Main categories Subcategories
conditions/categories
Direct monitoring of employee behavior when
Supervision of
dealing with customers / Determination of the
upstream authorities
reward system for off-duty actions
Discharge training / No referral for outside
The beauty of the
preparation of medication / Consolidation and quick
organization
and easy access to medical documents
Respect for convictions / Expected level of care /
Fondamental
Intervening conditions Expected level of quality Prompt presence at the
conditions
patient's bedside
Change of referral date / Giving nursing staff
enough time / Delay in treatment due to referral
Patient expectations
formalities / Waiting for a quick response from
patients to receive services due to staff shortage

1. Supervision of upstream authorities

In order to improve and promote the current methods, it is necessary to focus simultaneously
on emergency situations, patients, design and integration of activities, and in parallel to monitor
and control the above by managers.
2. The beauty of the organization
Implementing organizational beauty involves meaningful change in any organization. As the
research results show, the implementation of the beauty system is seriously effective in the
departments studied, which have significant differences in terms of performance and structural
and process characteristics. The results of the study by Leton and Monaco 18 show that the
implementation of the care system can be used as a tool. Assessment should be used in any
industrial unit or organization to eliminate waste in any form. Furthermore, the research results
show that improving the physical conditions and beauty of the environment has a significant
impact on employee and customer satisfaction. Meanwhile, the results of other studies, such as
the one conducted by Lu 19 and colleagues entitled "Job satisfaction among nurses", have
shown that it was successful in hospital administrative departments and should be taken into
account due to the density of work and especially the need to be careful when recording events.
And its reflection took the form of a regular system that led to employee involvement and
customer satisfaction. Of course, this result in all types of hospital services may not only be the
result of regular and systematic actions to adjust and beautify the work environment, but also
due to the creation of interaction and cooperation between employees to carry out joint actions
with empathy, and the desired results of this cooperation are also somehow It has a rapid
strengthening effect on the growth of motivation and the level of employee participation and
as a result of this, customer satisfaction.

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3. Patients' expectations
Hospitals, all healthcare institutions and their staff, especially nursing staff, must be aware of
and respect the ethical aspects of care. The Bill of Rights of patient Patient aims to defend
human rights in order to preserve the dignity of the patient and to ensure that in situations of
illness, especially in medical emergencies, he or she receives appropriate care without
discrimination on the basis of age and gender and with financial power, and that this care is
provided in an environment of respect and with the desired quality.
The Bill of Rights of the Patient in Iran was drafted in 2013 and promulgated by the Vice
Chancellor for Health of the Ministry of Health, Treatment and Medical Education in the winter
of 2014. Based on this directive, health centers were required to post the provisions of the Bill
of Rights in an appropriate and visible location. Appropriate and honest respect for personal
and professional values and sensitivity to differences are necessary for optimal patient care.
In fact, the importance of behavior is so great that in some cases it overshadows satisfaction
with the quality of care provided. Based on the results of this study, it has been observed many
times that in some cases the quality of service has been assessed as unfavorable from the
customer's point of view, but due to the respectful behavior of the staff, the unfavorable quality
of service has not had a negative impact on patient satisfaction, and customer satisfaction has
also increased.
4. Reaction speed
In order to shorten the admission and treatment processes, the management of the organization
should create conditions under which the patient is immediately admitted and treated by the
hospital and finally, after the emergency situation is resolved and at the time of discharge, the
cost of treatment and all services are provided. Should be collected from him immediately.
Strategies
Strategies are specific actions or interactions that result from the central phenomenon (Danaei
Fard and Emami, 2007). They are the actions that take place in response to the central
phenomenon. Action, interaction or action and interaction are terms we use to refer to strategic
tactics and normal or routine practices and how people deal with situations when confronted
with problems and issues; strategic interactions are purposeful and intentional actions that take
place to solve a problem, and when they take place, a phenomenon emerges.
Have been; That is, empowering employees, revising goals and processes, and personalizing
services can be considered as strategies to achieve this approach (Figure No. 1).

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 Figure 1: Clinical service quality strategies and service recipient satisfaction
Follow-up categories are the categories that reflect the outcome of the event of the central
category. The consequences of the effects of payment of the nursing fee on clinical service
quality and service recipient satisfaction are actually the same negative effects and outcomes
that are expected to occur when they are realized. The effects of paying the nursing rate on the
quality of clinical services and service recipient satisfaction are shown in Table 5.

Table 5: The conditions of the categories of outcome patterns of the impact of the
payment of the nursing care tariff on the quality of clinical services and the satisfaction
of service recipients
Type of
Main categories Subcategories
conditions/categories
Meeting clinical needs during hospitalization and
Improving the quality
outpatient treatment / avoiding medication errors /
of clinical services
Consequential successful CPR
conditions Increasing the Respect for the customer / Managed care and all-
satisfaction of service round caution / Informing the patient and those
recipients accompanying them
Among the positive effects and main consequences of paying the nursing fee, we can mention
the improvement of the quality of clinical services and the increase in the satisfaction of service
recipients, which is one of the main indicators of the success of the health system in the society
based on researches. Clinical solutions should be based on sufficient scientific evidence in
terms of efficiency and cost effectiveness. Department to facilitate the implementation of the
nursing process, providing opportunities for clinical learning, teamwork and improving
communication skills, and should be considered by nursing managers and educational planners.

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CONCLUSION
The present research, by using the method of systematic land theory and collecting textual data
from interviews of informed people in two research and executive fields and data analysis, was
able to identify a wide range of effective factors in the application and realization of this
approach in the form of 10 main categories and Identify 31 sub-categories and the relationships
between them. The identified categories were organized in the form of five categories of
conditions, intervention areas, consequences and strategies, around the core category of clinical
service quality and service recipient satisfaction, emphasizing the undeniable impact of clinical
service quality. And the satisfaction of the service recipients, the factor of paying the nursing
fee was identified as one of the most important conditions for the quality of clinical services
and the satisfaction of the service recipients. The experts and specialists of Mashhad University
of Medical Sciences put forth factors such as the advancement of technology, the level of
awareness of clients in the field of health, and the level of knowledge and experience of
personnel as the background conditions for the realization of this model; Conditions that are
influential in the planning environment, but exist as macro trends in an environment beyond
the program environment and indirectly affect the desired phenomenon. Are introduced as
intervening conditions that can have an encouraging or inhibiting aspect in improving the
quality of clinical services and the satisfaction of service recipients. A combination of the above
factors and conditions, including empowering employees, revising goals and processes, and
personalizing services can also be used as strategies to achieve this to be considered as a model.
Finally, improving the quality of clinical services and increasing the satisfaction of service
recipients was identified as a consequence category.

References
1) Koulivand, Pirhossein Kazemi, head of communication in the field of health, Mirmah Publications 2013
2) Bagheri, Lankarani, Kamran Izadbakhsh, Hamid Najba, Saeed Azadi, Ahmadabadi, Mohammad, and Safari,
Mohammad Saeed (2021) Explaining the scenarios of facing the law on pricing nursing services based on
the triangle model of analysis of Sadra Medical Sciences policy, 39-253 270
3) Shafi'i Mohammad Reza Haqshanas, Hajar, Shafi'i Nasima Bazrafshan Mohammad Rafi, and Bazrafkan,
Leila (2022). Investigating the level of patient satisfaction with nursing services in Imam Reza (AS) hospital
in Lar city during the covid-19 epidemic in 2019, a short report of Rafsanjan University of Medical Sciences
Journal, 21(2), 245-254.
4) Rafiei Marjan and Hosseinzadeh, Ismail (2018) Investigating the effectiveness of nurses' work life quality
on patients' satisfaction with nursing services, a case study: 5 Azar Hospital, Gorgan), the first national
conference on care and treatment, Aliabad
5) Beheshti, S. (٦١٠٢). Tahlil-e Dade-Haye Kei- fi ba Narm Afzar-e Max QDA, Chap-e Avval [Qualitative data
analysis with maxqdall software]. Tehran: Ravesh Shenasan. [in Persian]
6) Strauss, A. & Corbin, J. (°). Mabani-e Pajouhesh-e Kei-fi, Fonoun va Marahel-e Tolid-e Nazarieh-e Zmineh-
ey [Basics of qualitative research: techniques and stages of production of grounded theory], (Ebrahim
Afshar), Tehran: Ney. [in Persian]
7) Tashakkori, A., Johnson, R. B., & Teddlie, C. (٦١٦١). Foundations of mixed methods research: Integrating
quantitative and qualitative approaches in the social and behavioral sciences. Sage publications.

387 | V 1 9 . I 0 1
8) Vahidi Borji, G. Nourian, F., Azizi, M. M. (٦١٠۲). The Obstacles against the Success of Suggested Functions
in Urban Development Projects in Iran. Honar-Ha-Ye-Ziba: Memary Va Shahrsazi, (), °-\. [in Persian]
9) Cylus J, Papanicolas I, Smith P (Y). Health system efficiency: how to make measurement matter for policy
and management. Copenhagen: WHO, on behalf of the European Observatory on Health Systems and
Policies.
10) EC (Y). So What? Strategies across Europe to assess quality of care. Report by the Expert Group on Health
Systems Performance Assessment. European Commission (EC). Brussels: European Commission.
11) Reed JE, Card AJ (Y). The problem with Plan-Do-Study-Act cycles. BMJ Quality & Safety, Yo:1εV_OY.
12) Busse R (Y). High Performing Health Systems: Conceptualizing, Defining,
13) Measuring and Managing. Presentation at the «Value in Health Forum: Standards, Quality and Economics<<.
Edmonton, 19 January ..
14) Flodgren G, Gonçalves-Bradley DC, Pomey MP (Y). External inspection IV. of compliance with standards
for improved healthcare outcomes. Cochrane Database Syst Rev. 1: CD 1997.
15) Sh T, Sadeghifar J, Hamouzadeh P, Afshari S, Foruzanfar F, SM TS. [Quality of educational services from
the viewpoints of students SERVQUAL model]. Education Strategies in Medical Sciences. 11;2(1):1-7.
Persian.
16) Enayati NA, Uosefi M, Siyami L, Javaheri DM. [Evaluation of the quality of education services of Payam
Noor University of Hamedan Based on the SERVQUAL Model]. Quarterly journal of Research and Planning
in Higher Education. ;Y(): o_o). Persian
17) Y.Sahney S, Banwet D, Karunes S. An integrated framework for quality in education: Application of quality
function deployment, interpretive structural modelling and path analysis. Total Quality Management &
Business Excellence. 17;1(): YTO_AO.
18) Burhans LM, Alligood MR. Quality nursing care in the words of nurses. J Adv Nurs. ;77(1):1719-9V.
19) Bahadori M, Mousavi SM, Sadeghifar J, Haghi M. [Reliability and performance of SEVQUAL survey in
evaluating quality of medical education services]. International Journal of Hospital Research. Y.;(1): 79-EE.
Persian
20) Lau PM, Akbar AK, Fie DYG. Service quality: a study of the luxury hotels in Malaysia. Journal of American
Academy of Business. Yo; V(†): ET_
21) Alavi M. [Evaluation of the quality of services of hospitalized patients in surgical wards in private and public
hospitals in Mashhad]. Iran Health Insurance Organization. Mashhad University of Medical Sciences.
Mashhad. Persian
22) Gholami A, Noori A, Khojastepoor M, Asgari M, Sajadi H. [Gaps in the quality of primary health care
services provided by health centers-Care Nishapur city]. Scientific Journal of shahed university. 11;14(94):1-
11. Persian
23) Gohari M. [The relationship between services quality and patient's loyalty in Tehran public and private
hospitals: 9]. Journal of Hospital. Persian
24) Mohammadi A, Eftekharardabili H, Akbarihaghighi F, Mahmudi M, Poorreza A. [mesuring service quality
based on patient's Expectations and perceptions in zanjan hospitals]. Journal of the Faculty of Health and
Medical Research Instute. ;Y(): A-. Persian
25) Khammarnia M, Ravangard R, Jahromi M, Moradi A. [Study on the Medical Errors in Public Hospitals of
Shiraz, ]. Hospital (Rio J). ٦٢-٠۲: )٣(٦١٠٢١٠٣. Persian

388 | V 1 9 . I 0 1
26) Mohammadnia M, Delgoshaei B, Tofighi S, Riahi L, Omrani A. [Survey on nursing service quality by
SERVQUAL at Tehran Social Security Organization hospitals]. Journal of Hospital. ;^(): ^-ˇˇ. Persian
27) Naqavi MR, Refaiee R, Baneshi MR, Nakhaee N. [Analysis of gap in service quality in drug addiction
treatment centers of Kerman, Iran, using SERVQUAL model]. Addiction & health. ;7(-):. Persian
28) Jenaabadi H, Abili K, Nastiezaie N, Yaghubi NM. [The gap between perception and expectations of patients
of quality of treatment centers in Zahedan by using the Servqual model]. Payesh. \\:9_ov. Persian
29) Ranjbarezatabadi M, ZareAhmadabadi H, Arab M, Nasiri S, Hataminasab S, Bahrami M. [Analysis of
SERVQUAL in Shahid Sadoghi hospital, Yazd, Iran]. Bimonthly Journal of Hormozgan University of
Medical Sciences. 1;17(E):-. Persian
30) Bahadori M, Raadabadi M, Jamebozorgi MH, Salesi M, Ravangard R. [Measuring the quality of provided
services for patients with chronic kidney disease]. Nephro-urology monthly. ;7(9):\- V. Persian
31) Taie ES. Emerging of medical tourism in Egyptian hospitals: International patient satisfaction towards nurses
services quality. Global Adv Res J Manag Bus Stud. ;:9-1. Persian
32) Esteki R, Attafar A. [Quality of nursing services (contemporary level of reality and level of expectation)
from nurses' viewpoint on the basis of SERVQUAL Model in Al-Zahra Hospital in Isfahan (ˇ··)]. Modern
Care Journal. ٦١٠٦;(٦):-. Persian
33) Ghamari ZA, Anousheh M, Vanaki Z, Hajizadeh E. [Quality of Nurse's Performance and Patients'satisfaction
in Cardiac Care Units]. Zahedan Journal Of Research In Medical Sciences. ;)(1): V_MT. Persian
34) Schulmeister L, Quiett K, Mayer K, editors. Quality of life, quality of care, and patient satisfaction:
perceptions of patients undergoing outpatient autologous stem cell transplantation. Oncol Nurs Forum;
35) Zadeh H. [The effect of peer review evaluation on quality of nurse's performance and patient's satisfaction].
Iran Journal of Nursing. Y+Y+;YY(TY): A-Y). Persian
36) Samina M, Qadri G, Tabish S, Samiya M, Riyaz R. Patient's perception of nursing care at a large teaching
hospital in India. International Journal of Health Sciences. Y.. ١١۸۰٦ (٦) :۲٦
37) Wagner D, Bear M. Patient satisfaction with nursing care: a concept analysis within a nursing framework. J
Adv Nurs. 9;70():79 _ V .
38) Charalambous A. Variations in patient satisfaction with care for breast, lung, head and neck and prostate
cancers in different cancer care settings. Eur J Oncol Nurs. ;1(0): 0^^_90.

389 | V 1 9 . I 0 1