BackgroundThe rising prevalence of diabetes necessitates continuous monitoring and treatment, especially for type 2 diabetes. Patient education plays a crucial role in enabling self-management, and web-based educational portals can support patients effectively. While the literature highlights various issues impacting self-management system design, few studies explore the usability aspects that either facilitate or hinder such systems for this patient group. ObjectiveThis study aimed to investigate usability issues related to a web-based educational portal for patients with diabetes in Razavi-Khorasan Province, Iran. Additionally, it sought to develop a framework of design principles to address critical usability concerns for diabetes self-management. MethodsThe literature on diabetes self-management was analyzed. The analysis focused on design and usability issues affecting self-management. A think-aloud study was carried out with 10 patients using a web-based educational portal designed for patients with diabetes. The portal comprises 9 sections, with patients performing tasks related to each one. Participants’ task completion times were measured, and severity ratings of usability problems were calculated. ResultsFive design principles were proposed that cover (1) understanding and learning about one’s condition, (2) motivation and fostering sustained practices, (3) autonomy and confidence, (4) interaction and collaboration, and (5) privacy and security. The study identified 111 usability problems related to the portal’s 9 sections. Feedback from participants was considered to refine the principles, and participants’ considerations were recorded for any issues that worked against the principles. A total of 16 suggestions for improvement were extrapolated from the data. ConclusionsThis study highlights critical usability and design aspects to consider when developing web-based educational portals to support self-management in type 2 diabetes.

Introduction: Midwifery education is a part of the medical education system that deals with human life. This study was conducted with aim to evaluate the quality of approved midwifery curricula in the clinical education program of medical students with the job needs of physicians working in the health centers of South Khorasan Province. Methods: In this descriptive-analytical study, 86 general practitioners of South Khorasan Province were selected using convenience sampling and examined in 2023. The data collection tool was a researcher-made questionnaire with 33 questions that assessed the quality of approved midwifery training topics in the clinical training program of medical students with the job needs of practicing physicians. Data analysis was performed using SPSS statistical software (version 16) and one-sample t-test, independent t-test, and analysis of variance statistical tests. P<0.05 was considered significant. Results: Based on the results of the study, the mean score of the topics of prenatal care, labor physiology, labor course, postpartum care, preterm labor, and post-term pregnancy was less than the theoretical mean of 1.5; therefore, it can be said that these topics correspond slightly to the job needs of general practitioners and were statistically significant. Other midwifery topics were highly consistent with the job needs of general practitioners (p=0.0001). Conclusion: Given that in deprived and remote areas, access to specialist doctors and sufficient treatment facilities is not easily possible, general practitioners in the health service system must be able to diagnose emergency diseases of pregnant women, therefore, the homogeneity of midwifery topics in the general medicine course with the job needs of physicians is of great importance.

Introduction:: Among the characteristics of an instructor, his communication skills with students are much stronger than other skills. Class management is also one of the most important educational challenges in educational centers. The purpose of this study was to investigate the relationship between communication skills and classroom management styles in Behvarzi instructors.Materials & Methods: : It is a descriptive analytical study that was conducted in 1401 on 124 instructors in 12 Behvarzi education centers. Through Google form and messengers to complete checklists of demographic characteristics and communication skills of Queendom which was confirmed by Hossein Chari (1384) its validity and reliability (Cronbach's alpha = 0.69) and Wolfgang's class management styles which was conducted by Aali and Amin Yazdi (1384) in the community Iranian validity and reliability were confirmed (Cronbach's alpha = 0.68). The data was analyzed with SPSS26.Results: The study included 124 instructors with an average age of 45.3 ± 6.3 years (31.5% male, 68.5% female). Classroom management styles were predominantly interactive (83.1%) compared to interventionist (16.9%). Communication skills were high in 75% of instructors, with a notable 25% at an average level. Significantly, listening skill scores differed between interventionist (19.1 ± 2.3) and interactionist (20.4 ± 2.1) groups (p=0.032). The Spearman correlation test showed a weak, negative correlation (r=-0.18, p=0.038) between communication skills and years of service. However, no significant relationships were observed between other communication skills and classroom management stylesConclusion: Based on the findings, classroom management style (interactive and interventionist) had no significant relationship with other communication skills, except for listening skills. Considering the importance of communication skills of instructors in the training process, it is necessary to pay attention to this in the training programs of instructors teachers.

Introduction: The review of published articles shows that medical schools in Iran use similar methods and formats for assessment. While assessment is considered an important pillar in educational planning and a valuable step for the training of expert and committed doctors. The aim of the study is to examine the assessment methods in terms of evaluation formats, Miller's evaluation levels and implementation capability.Materials & Methods: The required information was started by searching in Persian and international databases, magazines, curriculum of prestigious universities in the world in the last 20 years alongside with virtual conferences AMEE international virtual conferences in August 2021 and the summary booklet of medical education articles of Shahid Motahari 2021 (the 22nd national conference of medical education) were reviewed. Data analysis was done by Beredy's adaptive model. The results were provided to assessment experts during a focused group meeting for further reviewResults: According to the extracted data, the approach of assessment is towards formative assessment format and improvement of traditional methods along with modern methods, which was clearly observed in the study of the curriculum of Harvard University in America and Oxford University in England. Opinions of experts were collected about the appropriateness of assessment methods with evaluation formats and levels of Miller's pyramid, the solution and the implementation conditions. The majority of opinions and suggestions of experts were related to the change in the way of executive policies of universities and providing a context for the emergence of new idea.Conclusion: The data analysis led to the identification of the evolution of suitable methods, formats of assessment and providing educational-executive solutions. It is suggested that the obtained results be used to develop assessment models according to Miller's assessment levels.

Podcasts have become increasingly prominent as tools for health communication, offering flexible and accessible formats for patient education. While widely used in professional training, their role in supporting patient-centered learning remains underexplored. This systematic review synthesized studies published from 2010 to 2024 concerning podcast use in patient education. Five databases—PubMed, Scopus, Web of Science, Google Scholar, and Embase—were searched using defined keywords. Studies were selected based on relevance to patient education through podcasts, and outcomes such as knowledge retention, comprehension, and engagement. Data extraction was performed independently by two reviewers. Quality assessment was conducted using the Cochrane Risk of Bias Tool, the Newcastle-Ottawa Scale, and the CASP checklist. A thematic synthesis approach was employed to analyze qualitative and quantitative findings. Of the twenty-one included studies, seven demonstrated improved patient knowledge retention, comprehension, and engagement through podcast use. Five studies emphasized accessibility and learner autonomy, highlighting the benefits of asynchronous and flexible delivery. Three studies explored the integration of podcasts with traditional teaching methods, showing positive outcomes when used as complementary tools. However, three studies identified challenges including content quality variability, limited production standards, and digital access disparities. Thematic synthesis categorized findings into four domains: educational effectiveness, integration with traditional education, accessibility and learner autonomy, and implementation challenges. Podcasts represent a promising adjunct to patient education. Their effectiveness depends on thoughtful design, contextual relevance, and equitable delivery. Standardization, blended learning models, and ongoing evaluation are essential for maximizing their impact. Not applicable.

BACKGROUND:Bridging the gap between theoretical instruction and practical competence remains a central challenge in nursing education. Nursing students often struggle to transfer classroom-acquired knowledge into real-world clinical environments, resulting in decreased confidence, impaired decision-making, and compromised patient care. Clinical simulation has emerged as a promising pedagogical tool to address this longstanding theory-practice gap by recreating realistic scenarios in a controlled setting. METHOD:This systematic review synthesized studies published from 2010 to 2025 concerning the use of clinical simulation in nursing education. Five databases were searched using defined keywords to identify relevant studies. Eligible studies focused on simulation-based interventions aimed at enhancing nursing students' clinical competence, decision-making, confidence, and knowledge transfer. Data extraction was independently performed by reviewers, and methodological quality was assessed using the Cochrane RoB 2, CASP, and Newcastle-Ottawa Scale (NOS) checklists. A thematic synthesis approach was employed to analyze both qualitative and quantitative findings. RESULTS:Of the fifteen included studies, twelve reported significant improvements in nursing students' clinical decision-making, judgment, or self-confidence, involving over 1,100 participants. High-fidelity simulation and structured scenario-based interventions were particularly effective in enhancing core competencies such as cardiopulmonary resuscitation (CPR), infection control, and diagnostic reasoning. Thematic synthesis categorized findings into six domains: clinical decision-making, clinical judgment, learner self-confidence, empathy development, experiential learning, and learner satisfaction. Reported challenges included limited technological access, inconsistent debriefing, and insufficient faculty training. No adverse outcomes were noted, although potential publication bias and short follow-up durations were identified as limitations. CONCLUSION:Simulation-based education can serve as an effective and scalable strategy to reduce the theory-practice gap in nursing education. Its success depends on sustained implementation, institutional support, and pedagogical integration. Future research should emphasize long-term effectiveness and explore context-specific barriers.

BACKGROUND:Talented students are among the key human resources in society, and educational and university authorities bear the responsibility of addressing the potential challenges they face. Therefore, identifying these challenges is essential. Objective: This research aimed to identify the challenges experienced by talented students and to propose possible solutions to help managers and planners design effective interventions. METHODS:The participants were 50 talented students from healthcare sciences. A phenomenological approach was employed using Colaizzi's seven steps method for data collection and analysis. Structured interviews were conducted with the students selected through purposive sampling. RESULTS:Data analysis revealed the central theme of the "narrow alley of talents" accompanied by six main themes: "motivational slope", "striving for improvement", "uneven university path", "social lens", "family umbrella", and "the bright side of talents", each comprising several subthemes. CONCLUSION:The challenges faced by talented students can be mitigated and their competencies enhanced through tailored educational opportunities and services, counseling, and engagement of external motivational and support resources.

Introduction: Educational procrastination is a pervasive issue among students, influenced by a range of demographic, psychological, and behavioral factors. This study aimed to assessthe prevalence and determinants of educational procrastination among medical students at Shahid Beheshti University of Medical Sciences, focusing on the unique challenges posed by remote learning and Internet use.Methods: A quantitative, cross-sectional study was conducted involving 200 medical students who had completed the basic sciences courses. Data were collected using a demographicquestionnaire, Solomon and Rothbloom’s academic procrastination questionnaire, and a researcher-made questionnaire assessing the factors contributing to procrastination. Statistical analyses, including t-tests, chi-square tests, and regression analyses, were performed using SPSS version 24.Results: The study found a high prevalence of severe procrastination among medical students. Age, gender, and Internet addiction emerged as significant predictors of procrastination,with younger students, females, and those with higher levels of Internet addiction exhibiting greater procrastination tendencies. Other factors, including educational status, second job, workexperience, marital status, living arrangements, socioeconomic status, GPA, psychological issues, self-confidence, stress during tests, and motivation, did not significantly predict procrastination.These findings underscore the complexity of academic procrastination and its multifaceted determinants. Conclusion: Interventions to reduce procrastination should consider key demographic and psychological factors, especially focusing on younger students, females, and those with high levelsof Internet addiction. Further research is required to explore causal relationships and develop targeted strategies for addressing procrastination in medical education.

Impairments in social cognition are recognized as a key factor contributing to functional disabilities in individuals with schizophrenia. This study aims to understand the essence of how functioning is subjectively experienced within the context of social cognition. A descriptive phenomenological approach was employed. Ten discharged patients from the largest psychiatric hospital in Khorasan Razavi Province, Iran, were selected using purposive sampling. Data were collected through in-depth, semi-structured interviews and analyzed based on Amedeo Giorgi’s phenomenological method. The COREQ checklist was utilized to guarantee transparency and methodological rigor. The analysis identified five overarching themes and 21 subthemes: (1) Restoring Identity through Employment; (2) The Struggle between Motivation and Functional Barriers; (3 Living on the Margins of Social Engagement: Cognitive–Emotional Isolation; (4) Dysfunctional Engagement with the Social Environment; and (5) The Family’s Role in Psychosocial Rehabilitation and Identity Reconstruction. Functioning within the domain of social cognition was revealed to be a multifaceted and dynamic process, marked by internal struggles, fluctuating motivation, and sustained social withdrawal. Employment emerged as a vital avenue for rebuilding a sense of self, while the family context acted as both a facilitating and constraining force in the psychosocial recovery journey. Functioning in schizophrenia is a dynamic process of identity reconstruction shaped by psychological vulnerability, cognitive-emotional detachment, and disrupted social engagement. Social cognition—particularly intention recognition, emotional regulation, and attributional tendencies—plays a central role in how individuals relate to themselves and others. Employment and family offer key contexts for meaning-making, self-renewal, and belonging. A nuanced understanding of functioning requires a biopsychosocial perspective that integrates cultural, interpersonal, and intrapsychic dimensions.

Background: Epidermolysis bullosa (EB) is a rare, inherited disease characterized by mucocutaneousfragility. It requires continuous family support and caregiving. However, insights into the complexrealities of daily caregiving roles for parents remain limited. This study aimed to explore the livedexperiences of Iranian family caregivers caring for their children with EB.Methods: This phenomenological study was carried out from February to November 2023 at MashhadAkbar Hospital or participants’ homes. Purposeful maximum variation sampling was used to recruit10 parents (3 fathers, 7 mothers) who met the inclusion criteria. Data were gathered through in-person,semi-structured interviews and analyzed using Van Manen method in MAXQDA software version 2020.Results: Caregivers’ experiences elucidate the profound adversity endured by parents raising childrenwith EB. Four themes emerged from the data: “lost and confused about care and treatment”; “trapped inendless cycle of hardship caring”; “inevitable self-isolation”; and “bitter and deteriorating family life”.Conclusion: Family caregivers who provide care for children with EB face numerous difficulties,leading to significant stress and heavy responsibilities. Their lived experiences provide a comprehensivepicture of the physical, psychological, and social difficulties related to this rare disease.

Background: A review of the available literature shows that preoperative care primarily focuses on the physical preparation of patients, with limited attention given to their psychological and spiritual concerns. The predominant focus has been on stress caused by the fear of surgery, while patients’ perceptions of the surgical process and their presence in the operating room remain unexplored. Accordingly, this study aimed to investigate the lived experiences of patients in the operating room. Methods: This qualitative study was conducted using a descriptive-interpretive phenomenological approach from 2019 to 2020 in Iran. Data were collected via in-depth interviews with 20 participants, who were selected through purposive sampling, supplemented by observational notes taken during and after the interviews. Data were analyzed using Van Manen’s approach. Results: Data analysis revealed that patients’ lived experiences of being in the operating room could be categorized into two main themes and six subthemes. The main themes included emotional immersion and the duality of support. Emotional immersion was further divided into several subthemes including stress and fear, internal suffering, and psychological distress. The duality of support was subcategorized into perceived support, self-help, and unfulfilled support needs. Conclusion: The experience of being in the operating room is predominantly psychological. Patients place significant value on communication with the operating room staff and have critical informational and emotional support needs that they expect the surgical team to address in accordance with their individual needs and expectations.

Background: Parents of children with cancer, especially leukemia, face many emotional and physical challenges, which can lead to chronic stress, anxiety, and depression. The online interventions have been recognized as an effective way to support parents in difficult situations.Aim: The present study was conducted with aim to evaluate the effects of an online supportive program on the care burden of parents of children with leukemia.Method: This randomized controlled trial study was conducted in 2020 on 76 parents of children with leukemia hospitalized in the oncology department of Dr. Sheikh Hospital in Mashhad, Iran. The parents were randomly divided into two groups: intervention and control (n=38 per group). The parents in the intervention group had access to an online support program via WhatsApp for one month. The parental caregiving burden was measured using the Zarit Caregiver Burden Scale. The data were analyzed using SPSS software (version 20) and descriptive statistics, Kolmogorov-Smirnov, independent t, paired t, and chi-square tests. p<0.05 was considered significant.Results: The mean care burden scores before the intervention did not differ significantly between the two groups (p=0.061). The mean parental care burden score in the intervention group before the intervention was 45.63±4.44, which decreased significantly to 42.81±5.07 after the intervention (p<0.015). However, the mean care burden score for the control group before the intervention was 43.94±3.17 and after the intervention was 45.13±4.50, showing no statistically significant difference (p<0.164). After the intervention, the care burden decreased significantly in the intervention group compared to the control group (p<0.05).Implications for Practice: Regular supportive programs can be developed and implemented for the main caregivers of patients with other chronic diseases and integrated into the health system.

Background: Higher education institutions have maintained a longstanding commitment to the education and development of academically talented students, consistently seeking to identify, attract, empower, and support this population. Objectives: The current research has developed a holistic framework intended to mitigate the available obstacles for academically talented students’ success and facilitate favorable outcomes. Methods: This phenomenological study explored the experiences of 50 talented students, specifically examining the challenges they encountered. Through in-depth interviews, focus groups with experts, and a comprehensive literature review, a practical guide was developed, grounded in Keller's motivational model, to identify and manage challenges and empower gifted learners. Results: The research identified a central theme, "the narrow alley of talented students," and six sub-themes. Through the information and concepts extracted from interviews, expert focus group discussions, and a comprehensive literature review, the study developed a conceptual model comprising four key categories: Attention, relevance, confidence, and satisfaction. This model effectively transformed abstract explanatory concepts into practical guidelines and actionable solutions. Conclusion: The proposed strategies within this study offer remarkably beneficial. Overlooking the unique needs of these individuals can culminate in decreased motivation and misallocation of financial resources. The findings of this research can be leveraged by students, professors, and educational administrators to empower these invaluable assets to the academic system.

Background: Heart valve replacement (HVR) surgery represents a significant life event that can potentially impact the well-being (WB) of patients; however, there is a shortage of research on the understanding of WB in HVR patients. This study aims to elucidate the WB experiences of patients who have undergone HVR surgery.Methods: A qualitative directed content analysis approach was employed, focusing on patients who had undergone HVR surgery at hospitals affiliated with Mashhad University of Medical Sciences in Iran from March 2021 to June 2022. Data collection involved conducting 23 face-to-face, semi-structured, in-depth interviews with HVR patients until data saturation was reached. Data analysis was performed using the Elo and Kyngäs approach in MAXQDA software version 10.Results: The analysis revealed 11 generic categories based on the Biopsychosocial-Spiritual (BPSS) model, encompassing the WB experiences of HVR patients. These categories included physical improvements, facilitated treatment compliance, personal and environmental mastery, optimism in life, resilience, healing therapeutic communication of medical staff, a positive supportive atmosphere, job and financial assurance, faith in a higher power, optimism regarding a purposeful future, and gratitude mixed with generosity.Conclusion: The findings of the current study revealed that the experience of WB in HVR patients was influenced by various conditions. By recognizing these conditions, healthcare providers can develop targeted interventions to improve the WB experience in these patients. Also, the findings provide a foundation for future research on WB in medical contexts.

Background: In health care, the well-being and flexibility of the operating room staff are of great importance due to the hard and stressful nature of their work. Therefore, this study was conducted to determine the effect of Stoic resilience training on the resilience of operating room staff. Methods: The present study was a semi-experimental pre-test-post-test intervention study with a control group. A study was conducted among 67 people operating room staff working in Imam Ali and Imam Hassan hospitals in Bojnord city in September 2023 In this research, the demographic check list and the Connor and Davidson standard resilience questionnaire were used to collect information. The educational intervention was also implemented using the “SeRenE” Stoic education package. This training package includes 4 exercises, which were used only 3 exercises per day and for 6 consecutive days (45 minutes per day) due to the resilience variable. Statistical analysis was done using SPSS version 24 and at a significance level of 0.05. Results: Based on the results, the total resilience score increased after the Stoic training (72.03±8.31) and showed a statistically significant difference with the control group (65.03±11.16) (P>0.05). The results showed that after Stoic training, mean of subscales of competence, trust in one’s instincts, tolerance of negative affect, positive acceptance of change and secure relationships, control as well as the total score of resilience increased in the training group. Although the mean score of spiritual influences dimension increased after the training, this increase was not statistically significant (P=0.097). Conclusion: The findings show that Stoic training had a positive effect on various aspects of resilience among operating room staff, whose effects are more obvious in some subscales such as trusting individual instincts, tolerance of negative emotions, and positive acceptance of change. In general, the results showed that people's resilience increased after Stoic training. It is recommended to include Stoic training programs in the training of health personnel and caregivers.

Background: Spirituality helps family caregivers of vegetative state patients to overcome the stressful conditions of patient care. However, the illness and caregiver burden may also negatively affect the caregiver’s spirituality. Accordingly, this study aimed to investigate the challenges of family caregivers of patients in a vegetative state.Methods: The present qualitative study was conducted through conventional content analysis from August 2020 to September 2021 in two provinces of Iran (Sistan and Baluchestan and Khorasan Razavi). A total of 20 family caregivers of patients in a vegetative state were included in the study. Semi-structured interviews were employed to collect data. Data were analyzed using the method proposed by Graneheim and Lundman via MAXQDA2020 software. Data collection continued until data saturation and identification of main categories.Results: Based on data analysis, spiritual disintegration and spiritual coherence were identified as the two main categories to describe the spiritual challenges of family caregivers of patients in a vegetative state. The experiences of family caregivers showed that spirituality is effective in accepting the conditions and adapting to the role of the patient caregiver. However, illness and caregiver burden lead to spiritual damage and the turning away of family caregivers from performing religious rites and rituals.Conclusion: Considering the undeniable role of spirituality in dealing with the stressful situation of caring for a patient in a vegetative state, the spiritual needs of family caregivers and the implementation of nursing interventions to enhance the spiritual health of caregivers should be given more attention.

Background: Clinical failures are considered as a serious problem in the health system and a threat for patients’ safety. The nurses' performance was poor during the blood products transfusion for children. One of the main obstacles to implement a national blood policy in developing countries is the lack of trained staff.Aim: To determine the effect of a designed training program based on the ADDIE model (analysis, design, development, implementation, evaluation) on nurses’ performance regarding blood transfusion for children.Method: This randomized clinical trial (RCT) study was performed in Bint Al-Huda teaching hospital at Al- Nasiriya City in Iraq. The study started from July 2021 to March 2021 and involved 60 nurses. Data was collected using a demographic data questionnaire and the observational checklist of nurses’ performance regarding transfusion of blood and blood products. At first, nurses’ performance regarding transfusion of blood and blood products to a child was checked. Then, the intervention group received a designed training program based on the ADDIE model. Again, nurses’ performance was assessed. Finally, data were analyzed with SPSS 25 software. P<0.05 was considered statistically significant. Results: The scores of nurses’ performance in pretest stage in the intervention and control groups was relatively similar (M=10.23±1.07 versus M=10.83±4.49; P>0.05), but in post-test stage, the scores of the intervention group were higher (M=36.40±3.08 versus M=10.85±4.53; P<0.001).Implications for Practice: According to the results, the designed training program based on ADDIE model can be used in pediatric setting to improve the nurses’ knowledge and practices about blood transfusion.

AIM:To develop and validate a set of OSCEs for use as a nationally applicable final exam of undergraduate nursing students' clinical and professional competencies.BACKGROUND:Tertiary recommendations for nursing registration require student achievement of a prerequisite level of both nursing knowledge and skill. Assessment of nursing skills prior to provision of nursing registration is an increasingly important focus of university nursing education. Objective Structured Clinical Examinations (OSCEs) are an appropriate tool for assessing the competencies of nursing students, but the mode and content of OSCEs varies widely. Thus, for nationally-based registration, development of a standardized set of OSCEs to determine the clinical competence of nursing students is important.DESIGN:A modified Delphi study, informed by a systematic scoping review of relevant literature.METHODS:A two-phase study was conducted. Initially, a scoping review was conducted to establish internationally agreed competences for graduating nursing students. These were included in an online questionnaire send to national experts to develop a validated and accepted nursing competency framework and associated implementation strategies. This was round 1 of a three-round modified Delphi study. A Content Validity Index (CVI) was calculated and thematic analysis was used to analyze the experts' opinions.RESULTS:Details of a set of OSCEs for final exam of undergraduate nursing students were developed and validated. These OSCEs included nine competencies addressed in eight 10-minute stations.CONCLUSION:A 'best-practice' OSCE evaluation system, designed from both international literature and the opinions of nation-wide experts was achieved. This well-designed OSCE was shown to be a reliable and valid method for assessing the clinical competence of nursing students. It reflected global procedures as well as the local conditions and Iranian expectations. The results of this study can be used by nursing schools across the country. They can also be used to model equivalent development of locally relevant OSCEs in countries around the world.

BACKGROUND:Heart failure (HF) is becoming one of the important health care problems around the world. Physical activity as the foundation of the cardiac rehabilitation program is poorly adhered by patients with HF. This study aimed to understand the experiences of patients with HF in terms of adherence to physical activity. MATERIALS AND METHODS:This study was conducted using conventional qualitative content analysis. Data were collected by semistructured telephone interviews with 25 patients with HF through open-ended questions. Data were collected from patients with HF in Birjand and Mashhad hospitals and heart departments from December 2021 to March 2022. Data were analyzed using Max-QDA10 and data analysis was continuous, comparative, and simultaneous with data collection. RESULTS:After data analysis, three main categories were identified: (1) patient-related barriers and facilitators, (2) support system-related barriers and facilitators, and (3) environmental barriers and facilitators. These categories were subdivided into two main themes: (1) threatening disease and (2) challenging disease. CONCLUSION:The results showed that beyond patient-related, support system-related, and environmental categories, perceiving the disease as a challenge or a threat is crucial in the activity of patients with HF. Nurses and other health care providers can train problem-solving behaviors to patients with HF to improve their physical and mental well-being. It is suggested that theoretical-behavioral approaches can be used in future clinical trials to improve adherence to physical activity.

Background: Despite the importance of physical activity in heart failure treatment, physical activity adherence in heart failure patients is low. The purpose of this umbrella review was to obtain the best strategies for enhancing physical activity adherence among HF patients. Methods: Databases were investigated from 2010 to Jan 2022. The full text of the papers was investigated in terms of inclusion and exclusion criteria. Eventually, out of 74 relevant papers, 7-review study with 20977 patients were eligible and included in the study. Results: Five key effective approaches were identified in two subsets for enhancing physical activity adherence as follows: 1) exercise-based approaches including 1.1) Exergames, whereby the extent of adherence to exergames was between 84 and 98%. 1.2) Tele-rehabilitation with 70%-100% adherence the intervention groups 1.3) Tai chi and Qigong practices (TQPs), whereby the exercise adherence in TQP groups was 67-100%, 2. Theoretical-behavioral approaches 2.1) approaches based on behavioral and psychological theories, which were a combination of an exercise program alongside a behavior modification intervention, 2.2) Self-efficacy. Conclusion: Approaches that are based on exercise alongside behavioral and theoretical interventions could enhance physical activity adherence among HF patients. It is suggested to evaluate mix methods of exercise-based approaches and theoretical-behavioral approaches mentioned in this study in future clinical trial studies. Use of capacity of TR programs improve to physical activity adherence should receive more attention.