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Volume 11, Issue 4 (2023)
Health Educ Health Promot 2023, 11(4): 569-579 |
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Received: 2023/09/11 | Accepted: 2023/11/4 | Published: 2023/11/15
Received: 2023/09/11 | Accepted: 2023/11/4 | Published: 2023/11/15
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Mansoori S, Mahdavi F, Behjati Ardakani F, Bagheri F, Niroumand Sarvandani M. Empowering Healthcare Workers: Insight from an Interpretive Structural Model for Educational Needs in Iran. Health Educ Health Promot 2023; 11 (4) :569-579
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Authors
S. Mansoori *1 
, F. Mahdavi2 , F. Behjati Ardakani3 , F. Bagheri4 , M. Niroumand Sarvandani5
, F. Mahdavi2 , F. Behjati Ardakani3 , F. Bagheri4 , M. Niroumand Sarvandani5
1- Department of Education, Faculty of Humanities, Arak University, Arak, Iran
2- The Health of Plant and Livestock Products Research Center, Mazandaran University of Medical Sciences, Sari, Iran
3- Department of Counseling, Faculty of Humanities, Ardakan University, Ardakan, Iran
4- Department of Education, Yazd Branch, Islamic Azad University, Yazd, Iran
5- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
2- The Health of Plant and Livestock Products Research Center, Mazandaran University of Medical Sciences, Sari, Iran
3- Department of Counseling, Faculty of Humanities, Ardakan University, Ardakan, Iran
4- Department of Education, Yazd Branch, Islamic Azad University, Yazd, Iran
5- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
Keywords:
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Introduction
Iran's higher education system has made significant strides in the realm of health and treatment, aiming to cater to the evolving needs of society. Health and medical indices have significantly grown in the past two decades [1-3]. However, it is imperative to continue enhancing the system, particularly in terms of training healthcare professionals with a social-oriented health approach [4]. Several developed countries that prioritize community-oriented medical education have successfully implemented key features to achieve this goal. These features encompass establishing a robust connection between medical education and the future work environment, tailoring professional training based on society's actual needs, fostering a reciprocal relationship between medical education and the healthcare system, imparting knowledge on the management of chronic and prevalent regional diseases, and nurturing essential skills in the learning process. These essential skills include problem identification, problem-solving, decision-making, research, and evaluation. These countries have effectively developed and integrated these features into their educational systems, ensuring that physicians consider the social, economic, cultural, and other pertinent aspects that profoundly influence patient care [5]. Nevertheless, experts have raised concerns regarding the insufficient knowledge of medical graduates in critical areas that are fundamental for general practitioners, regional health team managers, or family physicians [6]. As a result, it becomes paramount to identify and prioritize the requisite training requirements for healthcare providers, particularly in underdeveloped regions. In-service training is widely acknowledged as a pivotal intervention for augmenting healthcare services and competencies. It plays a significant role in enhancing health outcomes and is regarded as an indispensable tool for addressing the educational needs of healthcare workers [7].
Research in various countries has demonstrated the positive impact of needs assessments and on-the-job training on the performance of healthcare providers. Needs assessment increases readiness for timely action, and leads to efficient services in the field of health and healthcare [8, 9]. In a study conducted in Jordan, approximately 60% of family physicians who did not integrate evidence-based medicine into their daily practice, expressed the need for guidance and on-the-job training to effectively utilize evidence-based medicine and ensure its efficacy [10]. Likewise, a training program targeting the enhancement of children's mental health care was implemented for family physicians in England. The outcomes of this program indicated notable improvements in various aspects. Family physicians exhibited enhanced diagnostic skills for mental disorders in children and adolescents, reported increased clinical confidence, and demonstrated improvements in their diagnosis and treatment practices. These findings serve as compelling evidence of the positive impact of targeted training programs on healthcare providers' performance in specific domains [11, 12].
Numerous studies have been conducted to investigate the educational needs of healthcare professionals, specifically physicians and nurses, in Iran. For example, Kabir et al. [5] conducted a study on the educational needs of family physicians and healthcare workers participating in an urban family physician program. Their findings revealed that physicians had relatively low educational needs, while healthcare workers had higher educational needs. Shahmahdi et al. [13] demonstrated that the educational needs of specialists in the field of health and the environment include general needs (education, assessment, research, and communication, as well as personal development) and specialized needs (pollution, waste management, wastewater treatment, and soil and water pollution). Baghaei et al. [14] showed that general practitioners exhibited the highest level of interest in refresher courses and continuous medical education programs related to dermatology in Ahvaz, while they displayed the lowest interest in occupational medicine programs. Asadi et al. [15] demonstrated that the educational needs of hospital emergency department staff encompass five areas: management, communication, assessment skills, equipment, and operational skills.
Among healthcare workers, specialized skills, such as ultrasound interpretation, screening for fetal abnormalities, ECG preparation and interpretation, identification of physically and mentally disabled individuals, and assisting in labor were identified as the highest educational needs. Modiri et al. [16] found that management skills (planning, leadership, and supervision) and specialized skills (specialized knowledge and skills in healthcare) were the most important educational needs among physicians working in health and treatment departments covered by the Ministry of Health, Treatment, and Medical Education. Abbaszadeh et al. [17] investigated the educational needs of nursing managers in state hospitals and emphasized the importance of teamwork, decision-making, and problem-solving abilities, understanding and implementing legal and ethical issues in healthcare, and access to internet-based information. Dehghani et al. [18] explored the primary needs of nurses working in hospitals affiliated with the Shahid Sadoughi University of Medical Sciences in Yazd. They identified legal and ethical issues in healthcare as well as specialized skills, such as cardiopulmonary resuscitation, special care, and proficiency with medical devices and equipment as primary needs. Dehghani et al. [18] reported communication skills, responsibility and conscientiousness, decision-making and problem-solving abilities, and teamwork as the main needs among hospital executive managers. Avijgan et al. [19] investigated the educational needs of clinical faculty members at the Isfahan Universities of Medical Sciences, which encompassed education, research, personal development, executive and managerial activities, time management, medical services, and health promotion, recording patient information, specialized activities outside the university, and providing education and counseling to society through mass media. Barati et al. [20] focused on the needs of service providers in the outpatient departments of Motahari and Imam Reza Clinics in Shiraz. They identified communication skills, problem-solving skills, and management skills (stress and time management) as crucial areas for improvement [21]. Hojat [22] highlighted the importance of communication skills and familiarity with healthcare regulations and guidelines among nurses. Yusefi and Sadeghi [23] identified the training needs of hospital managers, including budgeting, planning, coordination, guidance, organization, recruitment, and reporting. Jannati et al. [24] found that nurses had the greatest needs in research and investigation, managerial and supervisory duties, communication, and teamwork, respectively. Zeraatchi et al. [25] reported that nurses at the Zanjan University of Medical Sciences had the highest training needs in areas, such as adult resuscitation, mechanical ventilation, ECG interpretation, maternal resuscitation, and preeclampsia. Raispour et al. [26] conducted a study to identify the primary educational needs of nursing managers, prioritizing safety and infection control as the highest priority. This was followed by communication, ethics, and professional rules. Hosseini [27] conducted a study on the educational needs of nurses in the neurology department of hospitals affiliated with the Ahvaz Jandishapur University of Medical Sciences. The identified needs included acquiring knowledge of relevant diseases, pharmaceutical and non-pharmacological care, and providing proper nursing care. Sadrizadeh and Malekafzali [28] assessed weaknesses in Iran's primary healthcare system. These weaknesses included inadequate intra- and inter-departmental coordination, patient and provider dissatisfaction, limited resources, and centralized decision-making. In addition, Malekafzali [29] outlined several challenges faced by the Iranian healthcare system. These challenges encompassed insufficient emphasis on primary healthcare in medical education, outdated health information collection systems, absence of a culture of evidence-based decision-making, lack of organization, and limited community participation in decision-making processes.
However, a comprehensive examination of the research background reveals two notable research gaps. Firstly, the existing studies in the field of educational needs assessment have primarily focused on nurses and physicians, neglecting other essential healthcare workers. Considering the vital role played by healthcare workers, particularly in developing countries and low-income areas, it is imperative to address their educational needs as well. Therefore, future research should emphasize the educational needs assessment of various categories of healthcare workers, ensuring a comprehensive approach to workforce development. Secondly, although several studies have identified educational needs, there is a lack of prioritization and stratification of these needs. Understanding the relative importance and impact of different educational needs is crucial for effective resource allocation and planning. Hence, future research should aim to prioritize and categorize the identified educational needs based on their significance and influence. This will enable policymakers, educational institutions, and healthcare organizations to concentrate their efforts and resources on addressing the most critical educational needs first, thereby maximizing the impact of training and development initiatives. The aim of this study was to develop a comprehensive framework to identify and prioritize the educational prerequisites of healthcare workers in Iran using interpretive structural modeling.
Participants & Methods
The case study was done on experts in health and treatment issues, including academic staff of the University of Medical Sciences and senior managers from the Iran health and treatment network. A purposive sampling method was employed, with 27 individuals deliberately selected as desirable cases. The inclusion criteria were familiarity with healthcare workers' competencies and skills. The research tool utilized was a self-interactive questionnaire known as the ISM (Interactive Self-Report Measure). To develop and validate the tool, the first step involved extracting the educational needs of healthcare workers through an extensive review of research documents and relevant literature. The selection of primary needs was based on theoretical literature related to the research topic. To gather relevant information, databases and search engines, such as MagIran SID, Google Scholar, and ScienceDirect were utilized. The search terms used included educational needs of healthcare workers, educational needs of nurses, educational needs of physicians, educational needs of science managers in medicine, needs assessment in medical sciences, etc. Persian sources covering the period between 2007 and 2022 and English sources from 2007 to 2022 were considered.
Next, the factors were combined and compiled, removing any duplicates, and resulting in the final factors (Table 1). To validate these final factors, the Laoshi content validity index was employed. Experts were asked to assess the comprehensiveness and hindrances of the factors, based on the factors extracted from the literature. The tool demonstrated a CVR of 98%, indicating its reliability. Additionally, the interpretive structural modeling technique was utilized to analyze and present a model of the factors influencing in-service course quality. The different stages of the ISM are as follows:
1. Formation of the Structural Self-Interaction Matrix (SSIM): The identified factors are incorporated into the structural self-interaction matrix (SSIM). Within this matrix, the presence or absence of relationships between row i and column j is indicated by the placement of specific letters. If the element of row i leads to column j, the letter V is assigned. Conversely, if the element of column j leads to row i, the letter A is assigned. In cases where the relationship is bilateral, the letter X is assigned, and if no relationship exists, the letter O is assigned. Given that this research involved the input of multiple experts who completed the questionnaires, the mode method based on the maximum frequency within each domain was employed to construct the structural self-interaction matrix [30].
2. To construct the initial access matrix (RM), the symbols within the SSIM matrices are converted to binary values of zero and one. Specifically, i,j=1 and j,i=0 are represented by V, while i,j=0 and j,i=1 are denoted as X. Additionally, i,j,j,i=1 is replaced with A, and i,j,j,i=0 is represented by O.
3. The final achievement matrix is formed by establishing internal consistency within the initial access matrix. It is important to ensure that if factor 1 leads to factor 2 and factor 2 leads to factor 3, then factor 1 should also lead to factor 3. In cases where this condition is not initially met in the achievement matrix, appropriate modifications are made by replacing the relationships to establish the required consistency.
4. Determining the level and priority of variables.
5. Drawing an interpretive structural model: Based on the determined levels and the final achievement matrix, the model is drawn.
6. Penetration power analysis, dependence, and MICMAC graph drawing.
Findings
To address the initial inquiry regarding the educational needs of healthcare workers in Iran, a comprehensive examination was conducted. This examination encompassed a review of relevant literature and documents, which allowed for the identification and categorization of the educational needs pertinent to healthcare workers. By collating and refining these needs through consultation with health and treatment experts, a final set of nine educational needs was determined as the key factors. Table 1 presents a detailed specification of these factors, based on the gathered information and analysis. Healthcare providers were determined in Table 1.
Table 1. Educational needs of healthcare workers extracted from the literature
![src=./files/hehp/images/HTML_Publish/71522/71522-T_1A.png]()
![src=./files/hehp/images/HTML_Publish/71522/71522-T_1B.png]()
In this stage, the identified critical needs of healthcare workers in Iran underwent structural modeling for leveling. Thus, a set of finalized questionnaires was administered to experts, enabling the analysis of the interpretive structural modeling method and the stratification of the factors. The nine selected factors were arranged in the form of rows and columns within a table. Respondents were then requested to indicate the type of two-way communication between these factors using the symbols X, A, V, and O. By following the prescribed rules and converting the symbols representing the relationships into binary values of zero and one in the SSIM, the initial matrix (RM matrix) was derived. Then, the internal consistency of the factors was established (Table 2). In this table, the numbers zero and one indicate the type of relationship between the variables and each other.
Table 2. Final achievement matrix
![src=./files/hehp/images/HTML_Publish/71522/71522-T_2.png]()
In the subsequent step, the level and priority of the variables were determined by establishing the achievement set and prerequisite set for each factor. The achievement set represented the factors that needed to be attained before a particular factor could be achieved, while the prerequisite set denoted the factors required for the attainment of a specific factor. By identifying the common set between these two sets, a consolidated set of factors was obtained. If the factors in the common set matched those in the access set (initial factors), they were assigned the highest priority level. Subsequently, these factors were removed, and the process was repeated for the remaining factors. Through this iterative procedure, the level of all factors was determined. The results of this step are presented in Tables 3-5, which provide a comprehensive overview of the identified levels and priorities of the factors within the research context.
Table 3. Determining the level of factors (first level)
![src=./files/hehp/images/HTML_Publish/71522/71522-T_3.png]()
Factors 1, 2, and 3, namely communication skills, ability to access information in the Internet environment, and responsibility/work conscience, had an equal level of importance. The achievement set and prerequisite set for these factors were exactly the same, indicating that the factors in the achievement set were also present in the prerequisite set. As a result, these three indicators or educational needs formed the first level of the model, given their shared characteristics and significance.
Table 4. Determining the level of factors (second level)
![src=./files/hehp/images/HTML_Publish/71522/71522-T_4.png]()
Factors 2, 5, and 6, specifically familiarity with rules and regulations, ability to make decisions and solve problems, and teamwork, possessed an equivalent level of importance. The achievement set and prerequisite set for these factors were identical, meaning that all factors in the achievement set were also present in the prerequisite set. Consequently, these three indicators or educational needs constituted the second level of the model, given their mutual dependencies and significance.
Table 5. Determining the level of factors (third level)
![src=./files/hehp/images/HTML_Publish/71522/71522-T_5.png]()
Factors 7, 8, and 9, which included understanding and implementation of legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (knowledge and specialized skills in the field of health and treatment), had an equal level of importance. The prerequisite set for these factors matched the achievement set, indicating that the factors in the prerequisite set were also present in the achievement set. As a result, these three indicators or educational needs formed the third level of the model. Considering the interrelationships between these educational needs and their influence on each other, a comprehensive model could be presented to depict the hierarchical structure and dependencies among the identified educational needs.
The educational needs of healthcare workers in Iran had three levels that influenced each other in different ways. Within these nine levels, they interacted with each other, as explained across the three levels. Below, the MICMAC graph can be found (Figure 1).
![src=./files/hehp/images/HTML_Publish/71522/71522-F_1.png]()
Figure 1. Leveling the training needs of healthcare workers
According to Figure 2, educational need number 4 was identified as a key independent variable with high influence power and low dependence. In contrast, educational needs 1-9 exhibited high power as linked variables, indicating that they possessed significant influence power and dependence. The most prominent form of power was dependence, signifying the strength of influence. Furthermore, the graph illustrated that none of the variables functioned solely as independent variables (low penetration power and low dependence power) or dependent variables (strong dependence power and low penetration power). This suggested that most variables had a robust interactive relationship, characterized by mutual action and reaction.
![src=./files/hehp/images/HTML_Publish/71522/71522-F_2.png]()
Figure 2. MICMAC analysis graph
Discussion
In this research, an examination of theoretical literature was conducted to identify the fundamental educational needs of healthcare workers. Through a process of combining and consolidating the identified needs, eliminating duplications, and considering expert opinions, a final set of nine educational needs was determined as the most influential and crucial. These factors encompassed various areas, including communication skills, familiarity with laws and regulations, responsibility and work conscience, the ability to access information in the Internet environment, the ability to make decisions and solve problems, teamwork, and understanding and implementing legal and ethical issues in healthcare. Additionally, management skills (planning, leadership, and supervision) and specialized skills (knowledge and specialized skills in healthcare) were identified as essential components of the educational needs of healthcare workers.
Based on the inputs from experts, an appropriate model was developed using the ISM technique to address the educational needs of healthcare workers. Among the nine identified factors, three factors, namely communication skills, the ability to access information in the internet environment, and responsibility and conscientiousness, emerged as the most influential factors in determining the educational needs of healthcare workers. These factors were placed at the highest level in the model, indicating their significance. At the second and intermediate levels, healthcare workers required familiarity with laws and regulations, the ability to make decisions and solve problems, and teamwork. These factors were categorized as interface needs, serving as important links in the educational framework for healthcare workers. At the third and foundational level, three factors, including the need to understand and implement legal and ethical issues in health and treatment, management skills (planning, leadership, and supervision), and specialized skills (knowledge and specialized skills in health and treatment) were identified. These factors were considered decoration needs, representing essential pillars for comprehensive education in the healthcare field. In addition to illustrating the relationships between these factors, the model classified them into four distinct categories, providing a structured framework for understanding and addressing the educational needs of healthcare workers.
The model developed in this research categorized the factors into four distinct groups. The first category comprised linked variables that exhibited both high influence and high dependence. These factors were dynamic in nature, as any changes in them could affect the system, potentially leading to further changes in these factors. Also, factors, such as communication skills, responsibility, work conscience, familiarity with laws and regulations, ability to make decisions and solve problems, teamwork, understanding and implementation of legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (specialized knowledge and skills in the field of healthcare) fell under this category. The second category consisted of key independent variables that possessed strong influence but weak dependence. These variables formed the foundation of the model and required significant emphasis in their development. In this research, the ability to access information on the Internet was identified as a key independent variable. The third category encompassed independent variables characterized by weak influence and dependence. None of the identified educational needs in this research fell into this category, indicating a strong interplay among all factors. The final category comprised dependent variables that had low influence but strong dependence. These variables were typically the outcome of multiple contributing factors and rarely served as the basis for other variables. None of the factors or educational needs in the present study were classified as dependent variables. The model’s levels were further explained in the subsequent analysis.
As mentioned above, this model had three levels: the third level (the most basic) was the educational needs of healthcare providers, including the three educational needs of understanding and implementing legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (specialized knowledge and skills in the field of health and treatment).
Understanding and implementing legal and ethical issues in the healthcare field were identified as one of the fundamental educational needs for healthcare workers. This result aligned with previous studies conducted by Khoshbaten et al. [31], Dehghani et al. [18], and Abbaszadeh et al. [17], highlighting the importance of familiarity of healthcare staff with legal and ethical considerations. The significance of measuring healthcare workers' performance based on their adherence to professional and ethical principles was crucial. It not only contributed to improving employee productivity but also affected patients' attitudes toward healthcare. Ethics plays a vital role in professions that directly interacts with clients, and its importance was amplified in the healthcare sector, particularly for healthcare workers. Being one of the largest groups of service providers in the healthcare system, healthcare workers significantly influence the quality of healthcare. Compliance with ethical standards has become an effective factor in enhancing nurses' performance in delivering quality care. Providing ethical care is a primary goal in healthcare systems worldwide. The healthcare system has various departments, with healthcare workers serving as a vital pillar. Thus, the services provided by this group directly influence health-related indicators and outcomes. Healthcare providers spend a significant amount of time at patients' bedside, experiencing close contact with patients' diverse situations. Consequently, they are frequently confronted with ethical dilemmas. Furthermore, advancements in healthcare technology introduced complexities in ethical aspects, leading to transformation, diversity in ethical problems, and increased occurrence of ethical challenges among the care team members. Compared to other healthcare service providers, healthcare workers face a higher magnitude and scope of ethical issues within their work environment. As integral components of the healthcare system, healthcare workers encounter ethical decisions due to their key role in patient care. Making these decisions without adequate knowledge results in failure to meet service recipients' needs and could lead to stress and moral conflicts among healthcare providers. Efforts to strengthen the ethical foundations of the healthcare system should prioritize the needs and expectations of the stakeholders involved in this field.
At the third level, healthcare workers required management skills, including planning, leadership, and supervision. These findings were consistent with the studies conducted by Yusefi and Sadeghi [23], Avijgan et al. [19], Abbaszadeh et al. [17], and Barati et al. [20], which emphasized the importance of management skills for healthcare providers. It is important to highlight that healthcare workers, as representatives of the Ministry of Health in underserved areas, not only fulfill their specialized roles but also require management capabilities. They need to possess
Iran's higher education system has made significant strides in the realm of health and treatment, aiming to cater to the evolving needs of society. Health and medical indices have significantly grown in the past two decades [1-3]. However, it is imperative to continue enhancing the system, particularly in terms of training healthcare professionals with a social-oriented health approach [4]. Several developed countries that prioritize community-oriented medical education have successfully implemented key features to achieve this goal. These features encompass establishing a robust connection between medical education and the future work environment, tailoring professional training based on society's actual needs, fostering a reciprocal relationship between medical education and the healthcare system, imparting knowledge on the management of chronic and prevalent regional diseases, and nurturing essential skills in the learning process. These essential skills include problem identification, problem-solving, decision-making, research, and evaluation. These countries have effectively developed and integrated these features into their educational systems, ensuring that physicians consider the social, economic, cultural, and other pertinent aspects that profoundly influence patient care [5]. Nevertheless, experts have raised concerns regarding the insufficient knowledge of medical graduates in critical areas that are fundamental for general practitioners, regional health team managers, or family physicians [6]. As a result, it becomes paramount to identify and prioritize the requisite training requirements for healthcare providers, particularly in underdeveloped regions. In-service training is widely acknowledged as a pivotal intervention for augmenting healthcare services and competencies. It plays a significant role in enhancing health outcomes and is regarded as an indispensable tool for addressing the educational needs of healthcare workers [7].
Research in various countries has demonstrated the positive impact of needs assessments and on-the-job training on the performance of healthcare providers. Needs assessment increases readiness for timely action, and leads to efficient services in the field of health and healthcare [8, 9]. In a study conducted in Jordan, approximately 60% of family physicians who did not integrate evidence-based medicine into their daily practice, expressed the need for guidance and on-the-job training to effectively utilize evidence-based medicine and ensure its efficacy [10]. Likewise, a training program targeting the enhancement of children's mental health care was implemented for family physicians in England. The outcomes of this program indicated notable improvements in various aspects. Family physicians exhibited enhanced diagnostic skills for mental disorders in children and adolescents, reported increased clinical confidence, and demonstrated improvements in their diagnosis and treatment practices. These findings serve as compelling evidence of the positive impact of targeted training programs on healthcare providers' performance in specific domains [11, 12].
Numerous studies have been conducted to investigate the educational needs of healthcare professionals, specifically physicians and nurses, in Iran. For example, Kabir et al. [5] conducted a study on the educational needs of family physicians and healthcare workers participating in an urban family physician program. Their findings revealed that physicians had relatively low educational needs, while healthcare workers had higher educational needs. Shahmahdi et al. [13] demonstrated that the educational needs of specialists in the field of health and the environment include general needs (education, assessment, research, and communication, as well as personal development) and specialized needs (pollution, waste management, wastewater treatment, and soil and water pollution). Baghaei et al. [14] showed that general practitioners exhibited the highest level of interest in refresher courses and continuous medical education programs related to dermatology in Ahvaz, while they displayed the lowest interest in occupational medicine programs. Asadi et al. [15] demonstrated that the educational needs of hospital emergency department staff encompass five areas: management, communication, assessment skills, equipment, and operational skills.
Among healthcare workers, specialized skills, such as ultrasound interpretation, screening for fetal abnormalities, ECG preparation and interpretation, identification of physically and mentally disabled individuals, and assisting in labor were identified as the highest educational needs. Modiri et al. [16] found that management skills (planning, leadership, and supervision) and specialized skills (specialized knowledge and skills in healthcare) were the most important educational needs among physicians working in health and treatment departments covered by the Ministry of Health, Treatment, and Medical Education. Abbaszadeh et al. [17] investigated the educational needs of nursing managers in state hospitals and emphasized the importance of teamwork, decision-making, and problem-solving abilities, understanding and implementing legal and ethical issues in healthcare, and access to internet-based information. Dehghani et al. [18] explored the primary needs of nurses working in hospitals affiliated with the Shahid Sadoughi University of Medical Sciences in Yazd. They identified legal and ethical issues in healthcare as well as specialized skills, such as cardiopulmonary resuscitation, special care, and proficiency with medical devices and equipment as primary needs. Dehghani et al. [18] reported communication skills, responsibility and conscientiousness, decision-making and problem-solving abilities, and teamwork as the main needs among hospital executive managers. Avijgan et al. [19] investigated the educational needs of clinical faculty members at the Isfahan Universities of Medical Sciences, which encompassed education, research, personal development, executive and managerial activities, time management, medical services, and health promotion, recording patient information, specialized activities outside the university, and providing education and counseling to society through mass media. Barati et al. [20] focused on the needs of service providers in the outpatient departments of Motahari and Imam Reza Clinics in Shiraz. They identified communication skills, problem-solving skills, and management skills (stress and time management) as crucial areas for improvement [21]. Hojat [22] highlighted the importance of communication skills and familiarity with healthcare regulations and guidelines among nurses. Yusefi and Sadeghi [23] identified the training needs of hospital managers, including budgeting, planning, coordination, guidance, organization, recruitment, and reporting. Jannati et al. [24] found that nurses had the greatest needs in research and investigation, managerial and supervisory duties, communication, and teamwork, respectively. Zeraatchi et al. [25] reported that nurses at the Zanjan University of Medical Sciences had the highest training needs in areas, such as adult resuscitation, mechanical ventilation, ECG interpretation, maternal resuscitation, and preeclampsia. Raispour et al. [26] conducted a study to identify the primary educational needs of nursing managers, prioritizing safety and infection control as the highest priority. This was followed by communication, ethics, and professional rules. Hosseini [27] conducted a study on the educational needs of nurses in the neurology department of hospitals affiliated with the Ahvaz Jandishapur University of Medical Sciences. The identified needs included acquiring knowledge of relevant diseases, pharmaceutical and non-pharmacological care, and providing proper nursing care. Sadrizadeh and Malekafzali [28] assessed weaknesses in Iran's primary healthcare system. These weaknesses included inadequate intra- and inter-departmental coordination, patient and provider dissatisfaction, limited resources, and centralized decision-making. In addition, Malekafzali [29] outlined several challenges faced by the Iranian healthcare system. These challenges encompassed insufficient emphasis on primary healthcare in medical education, outdated health information collection systems, absence of a culture of evidence-based decision-making, lack of organization, and limited community participation in decision-making processes.
However, a comprehensive examination of the research background reveals two notable research gaps. Firstly, the existing studies in the field of educational needs assessment have primarily focused on nurses and physicians, neglecting other essential healthcare workers. Considering the vital role played by healthcare workers, particularly in developing countries and low-income areas, it is imperative to address their educational needs as well. Therefore, future research should emphasize the educational needs assessment of various categories of healthcare workers, ensuring a comprehensive approach to workforce development. Secondly, although several studies have identified educational needs, there is a lack of prioritization and stratification of these needs. Understanding the relative importance and impact of different educational needs is crucial for effective resource allocation and planning. Hence, future research should aim to prioritize and categorize the identified educational needs based on their significance and influence. This will enable policymakers, educational institutions, and healthcare organizations to concentrate their efforts and resources on addressing the most critical educational needs first, thereby maximizing the impact of training and development initiatives. The aim of this study was to develop a comprehensive framework to identify and prioritize the educational prerequisites of healthcare workers in Iran using interpretive structural modeling.
Participants & Methods
The case study was done on experts in health and treatment issues, including academic staff of the University of Medical Sciences and senior managers from the Iran health and treatment network. A purposive sampling method was employed, with 27 individuals deliberately selected as desirable cases. The inclusion criteria were familiarity with healthcare workers' competencies and skills. The research tool utilized was a self-interactive questionnaire known as the ISM (Interactive Self-Report Measure). To develop and validate the tool, the first step involved extracting the educational needs of healthcare workers through an extensive review of research documents and relevant literature. The selection of primary needs was based on theoretical literature related to the research topic. To gather relevant information, databases and search engines, such as MagIran SID, Google Scholar, and ScienceDirect were utilized. The search terms used included educational needs of healthcare workers, educational needs of nurses, educational needs of physicians, educational needs of science managers in medicine, needs assessment in medical sciences, etc. Persian sources covering the period between 2007 and 2022 and English sources from 2007 to 2022 were considered.
Next, the factors were combined and compiled, removing any duplicates, and resulting in the final factors (Table 1). To validate these final factors, the Laoshi content validity index was employed. Experts were asked to assess the comprehensiveness and hindrances of the factors, based on the factors extracted from the literature. The tool demonstrated a CVR of 98%, indicating its reliability. Additionally, the interpretive structural modeling technique was utilized to analyze and present a model of the factors influencing in-service course quality. The different stages of the ISM are as follows:
1. Formation of the Structural Self-Interaction Matrix (SSIM): The identified factors are incorporated into the structural self-interaction matrix (SSIM). Within this matrix, the presence or absence of relationships between row i and column j is indicated by the placement of specific letters. If the element of row i leads to column j, the letter V is assigned. Conversely, if the element of column j leads to row i, the letter A is assigned. In cases where the relationship is bilateral, the letter X is assigned, and if no relationship exists, the letter O is assigned. Given that this research involved the input of multiple experts who completed the questionnaires, the mode method based on the maximum frequency within each domain was employed to construct the structural self-interaction matrix [30].
2. To construct the initial access matrix (RM), the symbols within the SSIM matrices are converted to binary values of zero and one. Specifically, i,j=1 and j,i=0 are represented by V, while i,j=0 and j,i=1 are denoted as X. Additionally, i,j,j,i=1 is replaced with A, and i,j,j,i=0 is represented by O.
3. The final achievement matrix is formed by establishing internal consistency within the initial access matrix. It is important to ensure that if factor 1 leads to factor 2 and factor 2 leads to factor 3, then factor 1 should also lead to factor 3. In cases where this condition is not initially met in the achievement matrix, appropriate modifications are made by replacing the relationships to establish the required consistency.
4. Determining the level and priority of variables.
5. Drawing an interpretive structural model: Based on the determined levels and the final achievement matrix, the model is drawn.
6. Penetration power analysis, dependence, and MICMAC graph drawing.
Findings
To address the initial inquiry regarding the educational needs of healthcare workers in Iran, a comprehensive examination was conducted. This examination encompassed a review of relevant literature and documents, which allowed for the identification and categorization of the educational needs pertinent to healthcare workers. By collating and refining these needs through consultation with health and treatment experts, a final set of nine educational needs was determined as the key factors. Table 1 presents a detailed specification of these factors, based on the gathered information and analysis. Healthcare providers were determined in Table 1.
Table 1. Educational needs of healthcare workers extracted from the literature
In this stage, the identified critical needs of healthcare workers in Iran underwent structural modeling for leveling. Thus, a set of finalized questionnaires was administered to experts, enabling the analysis of the interpretive structural modeling method and the stratification of the factors. The nine selected factors were arranged in the form of rows and columns within a table. Respondents were then requested to indicate the type of two-way communication between these factors using the symbols X, A, V, and O. By following the prescribed rules and converting the symbols representing the relationships into binary values of zero and one in the SSIM, the initial matrix (RM matrix) was derived. Then, the internal consistency of the factors was established (Table 2). In this table, the numbers zero and one indicate the type of relationship between the variables and each other.
Table 2. Final achievement matrix
In the subsequent step, the level and priority of the variables were determined by establishing the achievement set and prerequisite set for each factor. The achievement set represented the factors that needed to be attained before a particular factor could be achieved, while the prerequisite set denoted the factors required for the attainment of a specific factor. By identifying the common set between these two sets, a consolidated set of factors was obtained. If the factors in the common set matched those in the access set (initial factors), they were assigned the highest priority level. Subsequently, these factors were removed, and the process was repeated for the remaining factors. Through this iterative procedure, the level of all factors was determined. The results of this step are presented in Tables 3-5, which provide a comprehensive overview of the identified levels and priorities of the factors within the research context.
Table 3. Determining the level of factors (first level)
Factors 1, 2, and 3, namely communication skills, ability to access information in the Internet environment, and responsibility/work conscience, had an equal level of importance. The achievement set and prerequisite set for these factors were exactly the same, indicating that the factors in the achievement set were also present in the prerequisite set. As a result, these three indicators or educational needs formed the first level of the model, given their shared characteristics and significance.
Table 4. Determining the level of factors (second level)
Factors 2, 5, and 6, specifically familiarity with rules and regulations, ability to make decisions and solve problems, and teamwork, possessed an equivalent level of importance. The achievement set and prerequisite set for these factors were identical, meaning that all factors in the achievement set were also present in the prerequisite set. Consequently, these three indicators or educational needs constituted the second level of the model, given their mutual dependencies and significance.
Table 5. Determining the level of factors (third level)
Factors 7, 8, and 9, which included understanding and implementation of legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (knowledge and specialized skills in the field of health and treatment), had an equal level of importance. The prerequisite set for these factors matched the achievement set, indicating that the factors in the prerequisite set were also present in the achievement set. As a result, these three indicators or educational needs formed the third level of the model. Considering the interrelationships between these educational needs and their influence on each other, a comprehensive model could be presented to depict the hierarchical structure and dependencies among the identified educational needs.
The educational needs of healthcare workers in Iran had three levels that influenced each other in different ways. Within these nine levels, they interacted with each other, as explained across the three levels. Below, the MICMAC graph can be found (Figure 1).
Figure 1. Leveling the training needs of healthcare workers
According to Figure 2, educational need number 4 was identified as a key independent variable with high influence power and low dependence. In contrast, educational needs 1-9 exhibited high power as linked variables, indicating that they possessed significant influence power and dependence. The most prominent form of power was dependence, signifying the strength of influence. Furthermore, the graph illustrated that none of the variables functioned solely as independent variables (low penetration power and low dependence power) or dependent variables (strong dependence power and low penetration power). This suggested that most variables had a robust interactive relationship, characterized by mutual action and reaction.
Figure 2. MICMAC analysis graph
Discussion
In this research, an examination of theoretical literature was conducted to identify the fundamental educational needs of healthcare workers. Through a process of combining and consolidating the identified needs, eliminating duplications, and considering expert opinions, a final set of nine educational needs was determined as the most influential and crucial. These factors encompassed various areas, including communication skills, familiarity with laws and regulations, responsibility and work conscience, the ability to access information in the Internet environment, the ability to make decisions and solve problems, teamwork, and understanding and implementing legal and ethical issues in healthcare. Additionally, management skills (planning, leadership, and supervision) and specialized skills (knowledge and specialized skills in healthcare) were identified as essential components of the educational needs of healthcare workers.
Based on the inputs from experts, an appropriate model was developed using the ISM technique to address the educational needs of healthcare workers. Among the nine identified factors, three factors, namely communication skills, the ability to access information in the internet environment, and responsibility and conscientiousness, emerged as the most influential factors in determining the educational needs of healthcare workers. These factors were placed at the highest level in the model, indicating their significance. At the second and intermediate levels, healthcare workers required familiarity with laws and regulations, the ability to make decisions and solve problems, and teamwork. These factors were categorized as interface needs, serving as important links in the educational framework for healthcare workers. At the third and foundational level, three factors, including the need to understand and implement legal and ethical issues in health and treatment, management skills (planning, leadership, and supervision), and specialized skills (knowledge and specialized skills in health and treatment) were identified. These factors were considered decoration needs, representing essential pillars for comprehensive education in the healthcare field. In addition to illustrating the relationships between these factors, the model classified them into four distinct categories, providing a structured framework for understanding and addressing the educational needs of healthcare workers.
The model developed in this research categorized the factors into four distinct groups. The first category comprised linked variables that exhibited both high influence and high dependence. These factors were dynamic in nature, as any changes in them could affect the system, potentially leading to further changes in these factors. Also, factors, such as communication skills, responsibility, work conscience, familiarity with laws and regulations, ability to make decisions and solve problems, teamwork, understanding and implementation of legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (specialized knowledge and skills in the field of healthcare) fell under this category. The second category consisted of key independent variables that possessed strong influence but weak dependence. These variables formed the foundation of the model and required significant emphasis in their development. In this research, the ability to access information on the Internet was identified as a key independent variable. The third category encompassed independent variables characterized by weak influence and dependence. None of the identified educational needs in this research fell into this category, indicating a strong interplay among all factors. The final category comprised dependent variables that had low influence but strong dependence. These variables were typically the outcome of multiple contributing factors and rarely served as the basis for other variables. None of the factors or educational needs in the present study were classified as dependent variables. The model’s levels were further explained in the subsequent analysis.
As mentioned above, this model had three levels: the third level (the most basic) was the educational needs of healthcare providers, including the three educational needs of understanding and implementing legal and ethical issues in the field of health and treatment, management skills (planning, leadership, and supervision), and specialized skills (specialized knowledge and skills in the field of health and treatment).
Understanding and implementing legal and ethical issues in the healthcare field were identified as one of the fundamental educational needs for healthcare workers. This result aligned with previous studies conducted by Khoshbaten et al. [31], Dehghani et al. [18], and Abbaszadeh et al. [17], highlighting the importance of familiarity of healthcare staff with legal and ethical considerations. The significance of measuring healthcare workers' performance based on their adherence to professional and ethical principles was crucial. It not only contributed to improving employee productivity but also affected patients' attitudes toward healthcare. Ethics plays a vital role in professions that directly interacts with clients, and its importance was amplified in the healthcare sector, particularly for healthcare workers. Being one of the largest groups of service providers in the healthcare system, healthcare workers significantly influence the quality of healthcare. Compliance with ethical standards has become an effective factor in enhancing nurses' performance in delivering quality care. Providing ethical care is a primary goal in healthcare systems worldwide. The healthcare system has various departments, with healthcare workers serving as a vital pillar. Thus, the services provided by this group directly influence health-related indicators and outcomes. Healthcare providers spend a significant amount of time at patients' bedside, experiencing close contact with patients' diverse situations. Consequently, they are frequently confronted with ethical dilemmas. Furthermore, advancements in healthcare technology introduced complexities in ethical aspects, leading to transformation, diversity in ethical problems, and increased occurrence of ethical challenges among the care team members. Compared to other healthcare service providers, healthcare workers face a higher magnitude and scope of ethical issues within their work environment. As integral components of the healthcare system, healthcare workers encounter ethical decisions due to their key role in patient care. Making these decisions without adequate knowledge results in failure to meet service recipients' needs and could lead to stress and moral conflicts among healthcare providers. Efforts to strengthen the ethical foundations of the healthcare system should prioritize the needs and expectations of the stakeholders involved in this field.
At the third level, healthcare workers required management skills, including planning, leadership, and supervision. These findings were consistent with the studies conducted by Yusefi and Sadeghi [23], Avijgan et al. [19], Abbaszadeh et al. [17], and Barati et al. [20], which emphasized the importance of management skills for healthcare providers. It is important to highlight that healthcare workers, as representatives of the Ministry of Health in underserved areas, not only fulfill their specialized roles but also require management capabilities. They need to possess