Exploring the challenges and executive strategies of nursing services tariff setting in Islamic Republic of Iran :A qualitative study

Exploring the challenges and executive strategies of nursing services tariff setting in Islamic Republic of Iran :A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the challenges and executive strategies of nursing services tariff setting in Islamic Republic of Iran :A qualitative study Shima safazadeh, Shahla abolhasani, Somayeh Azimpour This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7105927/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Nurses are a cornerstone of the healthcare system and play a key role in improving public health. Ensuring their well-being and satisfaction, particularly through fair compensation mechanisms, is crucial for policymakers. One such mechanism is the Nursing Services Tariff Law, which, despite its emphasis on justice, efficiency, quality, and accountability, remains in the early stages of implementation in Iran. This study aimed to explore the challenges and suggest corrective strategies for its effective execution. Methods: This qualitative study was conducted in 2025 using inductive content analysis based on Graneheim and Lundman’s seven-step approach. Data were collected through 27 in-depth semi-structured interviews with nurses and nursing managers, selected purposively from various levels within the healthcare system affiliated with Isfahan University of Medical Sciences. Results: Data analysis led to the emergence of three main themes: “Preparation for Birth,” “Infant Care,” and “Growth and Development,” encompassing six main categories and 32 subcategories. The theme “Preparation for Birth” included the categories of eager parents and a secure cradle. “Infant Care” comprised the categories of care experience and perception of pain. The theme “Growth and Development” referred to attention to vital signs and efforts toward maturity. Conclusion: The implementation of the nursing service tariff law in Iran is hindered by challenges such as a lack of transparency, inadequate training, calculation flaws, delayed payments, and unfair tariff distribution, affecting both nurse satisfaction and care quality. Addressing these issues requires revising guidelines, providing accurate implementation training, ensuring timely budgeting, and simplifying tariff calculations. Nursing Tariffing Qualitative Study Nursing Services Introduction Human resources are recognized as the most critical driver of development in any organization or country, with heightened importance in healthcare settings due to their direct impact on community health. Nurses, as the largest and most vital workforce in healthcare systems, play a key role in delivering safe, effective, and high-quality care[ 1 ]. One major factor influencing nurses’ professional performance is a fair compensation system[ 2 ]. Equitable payment not only enhances job motivation and satisfaction but also improves service quality and patient outcomes[ 3 , 4 ]. Consequently, global efforts have focused on developing fair, performance-based payment models for nursing professionals. Despite global recognition of the importance of nursing compensation, limited data exist on precise payment mechanisms based on actual nursing services. Most countries have adapted compensation systems to their local contexts rather than adopting a uniform model[ 5 ]. For instance, in the United States, nursing costs are calculated for each DRG category using nursing intensity weights that reflect patient complexity and direct care needs[ 6 ]. Payment structures vary globally: the U.S. follows an organizational-level approach, the U.K. relies on an independent pay review body, Australia emphasizes state-level negotiations, and Japan uses a decentralized hospital-based system[ 7 ]. In Iran, the Nursing Services Tariff Plan emerged in recent years as a key demand of the nursing community and professional organizations6. Although it was ratified by the Iranian Parliament and approved by the Guardian Council in 2007, the law has faced persistent implementation challenges and remains largely unrealized after more than 15 years[ 7 ]. Among domestic research efforts, Bagheri-Lankarani et al. (2021) conducted a qualitative study using the Policy Triangle Framework, identifying challenges of nursing service tariffs across four dimensions: content, context, process, and actors. They proposed both short-term (e.g., tariff formula clarification, service documentation improvement) and long-term (e.g., regulatory reforms, institutional coordination) solutions[ 8 ]. Similarly, Deshmangir et al. (2011) highlighted structural fragmentation and lack of cost evaluation standards in the tariff system[ 9 ]. While these studies contributed to structural and policy-level insights, a comprehensive qualitative investigation focusing on stakeholders’ perspectives and practical solutions for implementing the Nursing Services Tariff Law remains absent. In other words, there is a noticeable research gap due to the lack of contextual analysis, stakeholder perspectives, and evidence-based operational solutions derived from real-world experiences. Addressing these challenges and developing practical strategies could significantly enhance the effective implementation of the Nursing Services Tariff Law, thereby improving nurses’ job satisfaction and the quality of patient care. Given this research gap, the present qualitative study was designed to explore the challenges and propose actionable strategies for the effective implementation of the Nursing Services Tariff Law in Iran. A qualitative approach enables a deeper understanding of stakeholder experiences and barriers, ultimately supporting more informed and equitable policymaking[ 10 ]. Methods To explore the nature and dimensions of the challenges in implementing the Nursing Services Tariff Law, a descriptive qualitative approach using inductive content analysis was employed. Qualitative research enables a deeper understanding of individuals' experiences and interpretations of their social reality[ 11 ]. The study was conducted in selected teaching hospitals affiliated with Isfahan University of Medical Sciences and administrative departments such as the Deputy of Treatment, Insurance Coordination Office, and the Nursing Organization. Participants were purposefully selected and included nurses at various levels—from frontline staff to senior administrators, such as hospital directors, experts in insurance, tariffs, and standards, nursing managers, Head nurses, supervisors, and clinical nurses. Inclusion criteria for the study included having work experience as a bedside nurse or a nurse in a managerial role, as well as being a specialist or senior administrator with at least one year of experience since the implementation of the productivity and performance-based payment law. Participants were also required to be employed in hospitals affiliated with the university. Exclusion criteria included voluntary withdrawal, extended leave, exit from the public healthcare system, or discontinuation of receiving nursing service tariffs. Data collection Data were collected through in-depth semi-structured interviews conducted between November 2024 and January 2025. Participants were selected using purposive sampling. The researcher, equipped with an introduction letter from the university’s research deputy, visited teaching hospitals affiliated with Isfahan University of Medical Sciences. After explaining the study's objectives, ensuring confidentiality, and obtaining informed consent (Appendix 1), interviews were scheduled and conducted at the participants’ workplaces. Interviews began with open-ended questions and were audio-recorded with participants’ permission. The interview guide was developed based on a review of related literature, and its content validity was confirmed by five faculty members with expertise in nursing management, qualitative research, and familiarity with the nursing service tariff law. Two pilot interviews were conducted to ensure question clarity, after which final modifications were made. Key interview questions included: “In your opinion, what are the challenges in implementing the nursing service tariff law?” and “What solutions do you suggest for improving its implementation?” During the interviews, participants were encouraged to share their experiences freely and in detail, while the researcher (S.A.) maintained an active listening role. To enhance data richness and achieve relative generalizability, participants were selected with diversity in age, gender, education, and work experience. Each interview lasted an average of 55 minutes. All interviews were transcribed verbatim by the researcher (S.A.) and returned to participants for accuracy verification. The transcripts were then reviewed and initially coded by two researchers (Sh.S. and Sh.A.). This process was iterative and conducted concurrently with data collection until data saturation was achieved after 27 interviews, with no new information emerging. Data analysis In this study, qualitative content analysis using the conventional (inductive) approach was conducted concurrently with data collection, based on Graneheim and Lundman’s seven-step method (2004)[ 12 ]. After transcription, each interview text was read multiple times by the researcher to achieve immersion and a comprehensive understanding of the content. Each full interview was considered a unit of analysis. Meaning units were identified, coded, condensed, and then grouped into subcategories and main categories. Through continuous comparison, latent themes were extracted. The data analysis was conducted using MAXQDA software (version 2020). To ensure the credibility of findings, various strategies were employed, including conducting in-depth interviews at different times and settings, triangulation through combining interviews and document review, purposeful sampling with maximum variation, and member checking by both participants and faculty experts. The researchers explicitly stated their assumptions to minimize bias in the analysis process. Further strategies to enhance dependability included detailed documentation of the research process, data analysis, and coding. Participants were fully informed about the study's purpose and procedures, and confidentiality and anonymity were assured. To enhance transferability, the study design, implementation steps, and participant characteristics were clearly described, allowing others to assess the applicability of findings. All research documentation was preserved to support confirmability and transparency throughout the study. Results In this study, participants included 10 men and 17 women aged between 34 and 60 years (Table 1 ). They represented a diverse group of individuals working in both clinical and administrative sectors, such as hospital directors, heads of insurance coordination and tariff offices, officials from the Nursing Organization, head nurses, supervisors, nursing service managers, and frontline clinical nurses. Table 1 provides an overview of their demographic characteristics. Data analysis yielded a total of 1,553 initial codes, which were organized into 32 subcategories, 6 main categories, and 3 overarching themes: "Preparation for Birth," "Infant Care," and "Growth and Nurturing" (Table 2 ). These themes and their associated categories are further detailed in the subsequent sections. Table 1 Participant Characteristics (n = 27) Participant Code Age Gender Education Organizational Position Work Experience (Years) 1 43 Female M.Sc. Nursing Services Manager 21 2 52 Male B.Sc. Nursing Services Manager 28 3 50 Female B.Sc. Nursing Services Manager 28 4 42 Male M.Sc. Hospital manager 20 5 41 Female M.Sc. Hospital manager 20 6 46 Female M.Sc. Nursing Management Expert 22 7 42 Male B.Sc. Hospital Supervisor 17 8 45 Female B.Sc. Hospital Supervisor 23 9 43 Female M.Sc. Hospital Supervisor 17 10 42 Male PhD in Nursing Hospital Supervisor 18 11 45 Female PhD in Nursing Hospital Supervisor 20 12 51 Female M.Sc. Head Nurse 27 13 45 Male B.Sc. Head Nurse 23 14 42 Female B.Sc. Head Nurse 21 15 44 Female B.Sc. Head Nurse 22 16 49 Male B.Sc. Head Nurse 23 17 45 Female B.Sc. Head Nurse 23 18 42 Female B.Sc. Nurse 18 19 35 Female B.Sc. Nurse 13 20 34 Female B.Sc. Nurse 12.5 21 48 Male B.Sc. Nurse 22 22 28 Female B.Sc. Nurse 10 23 38 Male B.Sc. Nurse 14 24 40 Female B.Sc. Nurse 16 25 60 Male PhD in Nursing senior male official from the Nursing Organization 34 26 42 Female B.Sc. a senior female from the Insurance, Tariff, and Standards Coordination Office 20 27 45 Male PhD in Health Policy senior male official from the Nursing Organization 34 Table 2 Themes, Main Categories, and Subcategories of Challenges and Strategies Related to the Implementation of the Nursing Tariff Law Subcategory Main Category Theme Awareness-raising Enthusiastic Parents Preparing for Birth Cultural Promotion Empowerment Increased Perception Safe Infrastructure A Safe Cradle Provision of Facilities Support Delivery Justice and Non-discrimination Caregiving Experience Infant Care Complexity in Legal Compliance Understanding Barriers to Proper Implementation Punishment vs. Recognition Challenges in Formulation Perception of Pain Challenges in Implementation Response to Payment Meeting Expectations Ensuring Satisfaction Interprofessional Collaboration Growth Indicators Recognizing Signs of Life Growth and Development Symptoms of Illness Compensation for Survival Meaning of Life Addressing Root Causes Striving for Maturity Service Quality Improvement Professional Development Need for Policy Revision Theme: Preparation for Birth The theme of Birth Preparedness encompasses two main categories: Eager Parents and Safe Cradle, reflecting the emphasis on human capital. Participants, viewed as the hospital’s human resources, highlighted the necessity of increasing awareness and fostering a culture of understanding among nurses, ensuring clarity in guidelines, integrating nursing tariff education into academic curricula, improving computational infrastructure, providing necessary equipment, involving nursing representatives in decision-making bodies, and establishing organizational support to ensure the fair and accurate implementation of the Nursing Services Tariff Law. Eager Parents : The analysis revealed that although nurses were considered vital human capital and showed enthusiasm for learning about the Nursing Service Tariff Law, there remained significant gaps in their awareness, understanding, and the overall cultural groundwork surrounding the law. A female nursing services manager at a specialized hospital emphasized the importance of educating staff about differences in hospital revenues, as a means to reduce comparisons among nurses regarding received tariffs. She stated: "They constantly compare themselves with nurses from other hospitals. In various meetings, I explain that our fund is not the same as others. Imagine having a pot to divide among 1,400 people with high outflow, versus a pot for 200 people. Some hospitals have better revenue tracking and fewer deductions." (Participant 2) A male general hospital director attributed nurses’ lack of awareness to the absence of tariff-related education in nursing curricula. He said: "Our nursing schools do not provide any training on this subject. Nurses should learn about tariffing during their education—what services are eligible, what amounts are assigned, what a professional unit is, and how it’s calculated—so that they’re familiar with it before entering clinical practice." (Participant 4) A female surgical ward nurse pointed to the complexity of the calculation methods as a barrier to understanding, stating: "They say it’s based on formulas that are so complicated, you can’t understand them. You get a code based on the service you provided, and you receive money for it instead of a fixed bonus, but it’s not clear how." (Participant 23) Safe Cradle : Through this theme, participants emphasized the importance of creating a secure foundation, providing adequate facilities, and receiving support from nursing-related organizations to ensure effective implementation of the Nursing Tariff Law. The findings indicated that successful enforcement of the law requires proper infrastructure, sufficient training, efficient equipment, and both financial and organizational support to function effectively within the healthcare system and meet nurses' expectations. For example, a female head nurse in an internal medicine ward attributed payment delays to inefficiencies in the HIS system, stating: "Even two years after the implementation of the tariff law, the HIS system still hasn’t been updated. It lacks complete item listings, and some calculations are incorrect. There are several challenges in the calculation process." (Participant 13) A female nursing services manager in a general hospital noted that equipment shortages due to sanctions negatively affected tariff payments: "Given the current sanctions, many surgical supplies can’t be procured or are worn out. When operating rooms can't function fully, the number of surgeries drops, and this directly reduces the tariff income for OR staff, even though they show up for work as usual." (Participant 3) Another issue raised was the absence of a representative from the Nursing Organization in the High Council of Insurance. A female internal ward nurse stated: "If the Nursing Organization had a representative on the High Council of Insurance, they could advocate for the inclusion of all nursing services under insurance coverage, which would greatly help in implementing the tariff system more effectively." (Participant 24) Infant Care The theme of infant Care comprised two main categories: Care Experience and Perception of Pain. Within this theme, participants identified several challenges in implementing the Nursing Tariff Law, including inequity in payments, inconsistencies in defining levels of care, data entry errors, a lack of a unified definition of tariffs, and insufficient transparency regarding the calculation and explanation of nurses’ compensation. These issues collectively led to dissatisfaction and a decrease in motivation among nurses. Care Experience : Following the implementation of the nursing tariff law, participants reported several challenges, including a lack of fairness, senior managers’ non-compliance with proper implementation, organizational obstacles, insufficient clarification of payment calculations, and a general disregard for nurses' concerns. For instance, a senior male official from the Nursing Organization attributed payment inequity to the subjective allocation of care levels: “An ICU head nurse might classify a patient as Level 3 care, while the same patient is classified as Level 2 in another ward. This leads to score discrepancies, and over a month, the difference becomes significant, which undermines fairness in payment.” (Participant 25) Additionally, a senior female from the Insurance, Tariff, and Standards Coordination Office emphasized that failure to adhere to proper implementation—particularly errors in data entry—affects tariff calculations: “Ward managers enter patient data into the system within 7 to 10 days, but it’s unlikely to be 100% accurate. Some cases may be missed, and nurses may have provided services that are not recorded.” (Participant 26) A female nurse from the neurology ward highlighted the lack of clear communication regarding tariff payments and punitive responses to complaints as major sources of dissatisfaction: “ I objected to the amount I received and asked how it was calculated. They gave no explanation, showed no concern, and some of our colleagues were suspended due to their protests and strikes over the implementation of the tariff.” (Participant 18) Perception of Pain : Findings revealed that deficiencies in the developed guidelines, shortcomings in the implementation of the nursing tariff law, and weak interprofessional collaboration were among the most significant challenges, resulting in dissatisfaction, negative reactions, and unmet expectations among nursing staff. Participants highlighted the undervaluation of critical specialty areas such as endoscopy, dialysis, and triage units. For example, a male emergency ward head nurse stated: “Triage nurses receive low scores and therefore receive low tariffs.” (Participant 16) Some participants also identified the time-consuming nature of tariff calculations as a challenge. A female nursing services manager in a general hospital stated : “I think they’ve made it too complicated. These calculation formulas are very time-consuming, and our nursing center manager spends all her time just on tariff calculations.” (Participant 5) Moreover, the financial expectations of nursing staff were not met after the implementation of the tariff law. A female nurse from the cardiology ward shared: “Since the beginning of the tariff implementation until now, it has unfortunately led to the discontinuation of performance-based bonuses. Nurses gained practically nothing despite all the expectations they’ve had over the years—it hasn't brought any real financial benefit.” (Participant 24) Findings also indicated that improper implementation and resulting dissatisfaction have led to a decline in collaboration among nursing staff in delivering patient care under the current payment system. A male ICU nurse expressed this issue: “Assistants and nurses are constantly arguing. When I ask the assistant to connect the oxygen manometer, they respond, ‘That’s not my job; the nurse is getting paid for it.’ There’s no respect anymore.” (Participant 23) Growth and Development The theme of "growth and development" encompasses two main categories: "attention to vital signs" and "striving for maturity." Participants emphasized that improving the implementation process of the nursing service tariff law requires revising existing guidelines, involving qualified professionals in tariff formulation, addressing operational flaws, ensuring fairness in payment, enhancing care quality, strengthening nurses’ professional identity, and providing adequate financial support to reduce turnover and migration while increasing motivation. Attention to Vital Signs : Accurate tariffing of nursing services plays a significant role in enhancing professional identity, promoting autonomy, and improving nurse-patient interactions. Addressing existing challenges can lead to increased motivation, hope, and encouragement for continued service, foster interprofessional collaboration among nursing staff, and ultimately improve the quality of care. A male supervisor in a general hospital highlighted how the proper implementation of the tariff system could enhance teamwork among nursing units and departments: "This evening, I faced a challenge. I arranged for a nurse from the ICU to cover the gynecological surgery ward. She asked, ‘What happens to my tariff?’ She was right—it’s like she worked a whole shift for free because her tariff isn’t defined for that ward. Addressing such issues could improve cooperation among staff." (Participant 7) Participants also emphasized the importance of financial reassurance to retain nursing staff and reduce attrition. A female nursing management officer from the university explained: "We’re currently facing a high rate of migration. If our colleagues had greater job satisfaction, motivation, and financial support, the number of nurses leaving the system would likely decrease." (Participant 6) Striving for Maturity : Participants identified revising contextual factors and reviewing existing guidelines as essential strategies for improving the implementation of the nursing services tariff law, viewing these reforms as crucial for professional growth and enhancing service quality. One key factor in revising contextual elements is selecting knowledgeable and specialized individuals to develop or amend the guidelines. A male supervisor expressed his view as follows: "I think a professional working group should be formed from all departments. For example, the ICU provides specific services, and someone with years of experience should document these services, define them, assign codes, and determine their tariffs." (Participant 7) A male manager in a general hospital stated that addressing issues in the tariff system would lead to positive outcomes: "I believe that by resolving its problems, nursing tariffs can become more equitable in the future." (Participant 4) This category also highlighted satisfaction, improved nursing care quality, and professional development resulting from receiving fair compensation. A male supervisor remarked: "When a nurse knows that they will receive payment for the care provided, they perform their duties wholeheartedly and strive for professional growth. For instance, if a patient has phlebitis, the nurse won’t just cover it with a bandage, leading to necrosis; instead, they will change the IV site, receive compensation for this care, and even seek additional knowledge to solve the problem." (Participant 7) Discussion This study aimed to explore the challenges and solutions related to the implementation of the nursing services tariff law in Iran through a qualitative analysis of the perspectives of frontline and administrative nursing participants. The findings revealed that the execution of this law faced multiple barriers, including insufficient education and awareness, lack of clarity in guidelines, infrastructural deficiencies, payment inequities, and delays in tariff disbursement. These challenges were categorized into three main themes: “Preparation for Birth,” “Infant Care,” and “Growth and Development,” which collectively represent the conceptual progression of the law’s implementation from inception to maturity. The theme "Preparation for Birth" highlights the need for education and clarification regarding the nursing services tariff law. A major challenge in implementing the law was the lack of formal training and awareness among nurses. Findings revealed that nursing schools do not provide official education on tariff calculation, and many nurses have an unclear understanding of the process. Proposed solutions include integrating tariff-related content into nursing curricula and offering in-service training with simplified, practical instructions. Similar challenges have been reported internationally; for instance, Akinyemi et al. (2022) found that clear education on wages and benefits reduces nurse dissatisfaction[ 13 ]. Likewise, Bagheri Lankarani et al. (2021) emphasized that the lack of nurse education on tariff calculation is a key barrier to effective implementation in Iran[ 8 ]. The theme "Infant Care" addresses the operational challenges and systemic issues affecting the implementation of the nursing tariff law and its impacts. Findings revealed that nurses face payment inequities, data entry errors, a lack of standardized tariff definition, and payment delays. Such problems have been reported in other studies, with unequal payment systems contributing to job dissatisfaction, turnover, and reduced care quality [ 14 , 15 ]. For example, Gautam et al. (2020) found that dissatisfaction with unfair pay structures and unclear tariffs decreases job satisfaction and increases nurses’ intention to leave. These findings align with domestic studies highlighting similar issues[ 16 ]. Furthermore, Callaghan (2025) reported that over 38% of Irish nurses plan to leave their jobs within two years due to dissatisfaction with work schedules, payment inequities, poor workplace relationships, and limited career advancement opportunities[ 17 ]. In the present study, nurses’ dissatisfaction with the lack of an integrated payment system for nursing tariffs emerged as a significant challenge in implementing the nursing tariff law. This dissatisfaction is heightened when nurses performing similar duties receive different payments across hospitals. The absence of uniformity in payments fosters feelings of injustice, unfair comparison, and ultimately decreases motivation among nurses. Similarly, Imam et al. (2023) reported that nurses working in lower-income hospitals receive fewer benefits, leading to job dissatisfaction and perceived inequality[ 18 ]. The study also highlighted issues with tariff calculation and payment delays due to inefficiencies in hospital HIS systems. Rahayudi et al. (2021) confirmed that optimizing hospital information systems can reduce payment calculation errors[ 19 ]. Regarding equipment shortages and the impact of sanctions, Moyimane et al. (2017) found a direct effect of medical equipment scarcity on nurses’ wages[ 20 ]. In Iran, multiple studies have confirmed that sanctions exacerbate equipment shortages, worsening nurses’ financial challenges[ 21 ]. Proposed solutions included ensuring essential medical equipment to maintain clinical services, establishing transparent monitoring systems for defining care levels and tariff payments, optimizing HIS to reduce calculation errors, and expediting payments through government funding and insurance support. The theme of "growth and development" highlights strategies to address the challenges in implementing the nursing tariff law. Central to this theme is the emphasis on fair compensation and its impact on nurses’ professional identity. The partial or flawed implementation of the law has led to demotivation, reduced intra-professional collaboration, and even increased intentions to migrate among nurses. Proper implementation of the law is thus seen as a key driver of motivation and interprofessional cooperation. These findings align with previous research. Motie et al. (2024) identified low wages and lack of payment equity as major drivers of nurse migration in Iran[ 22 ]. Similarly, Konlan et al. (2023) found that countries with equitable payment systems report lower migration rates among nurses[ 23 ]. According to the present study, payment injustice has weakened intra-professional collaboration, as nurses feel their efforts are undervalued. Muench et al. (2015) also reported that inequitable pay contributes to unhealthy competition and diminished cooperation among nursing staff[ 24 ]. Based on the findings of this study, the proper implementation of the nursing tariff law has the potential to enhance nurses’ professional autonomy and improve the quality of care, an outcome also supported by previous research. Salahat et al. (2022) demonstrated that fair compensation strengthens professional identity and improves patient care quality[ 25 ]. Accordingly, the present study recommends the establishment of a transparent and equitable payment system, increased financial support to reduce nurse migration, enhanced motivation, and improved interprofessional collaboration among healthcare providers. A comparative analysis with international experiences revealed that Iran’s challenges in implementing the nursing tariff law mirror those of other countries during the early phases of developing nursing payment systems. However, nations that have adopted payment reforms, enhanced transparency, upgraded information systems, and secured sustainable funding have reported improvements in nursing conditions and job satisfaction. Therefore, revising tariff guidelines, institutionalizing financial equity, developing practical training, addressing operational barriers, and ensuring adequate funding are essential for the successful implementation of the nursing tariff law in Iran. One limitation of this study was the reluctance of some participants to engage due to privacy concerns. To address this challenge, the researcher made efforts to build trust by providing clear explanations about data confidentiality, obtaining informed consent, and ensuring the anonymity of participants. This approach helped encourage participation and improved the credibility of the data. Conclusion The implementation of the Nursing Tariff Law in Iran resembles a vulnerable Infant, requiring careful, continuous, and strategic attention. Despite its potential to elevate the professional status of nurses and improve the quality of healthcare services, the law’s execution faces numerous obstacles. These include ambiguous guidelines, lack of specialized training in nursing curricula, inadequate software infrastructure, delays in payment, and equipment shortages. These challenges not only undermine the quality of nursing care but also diminish nurses’ job satisfaction and professional motivation. To achieve the intended goals of this legislation, a revision of its implementation policies is essential. Recommended measures include developing clear and practical guidelines, updating nursing curricula to include tariff-related education, strengthening software and financial infrastructure, and enhancing nurses’ professional involvement in decision-making processes. Such reforms could significantly improve the operationalization of the law and contribute to the overall enhancement of nursing services within the healthcare system. Abbreviations DRG: Diagnosis related group; FFS: Fee-For-Service; NIW: Nursing Intensity Weights; HIS: Hospital information system Declarations Acknowledgements The authors would like to express their sincere appreciation to all individuals who contributed meaningfully to the completion of this research. Author Contributions Dr. Shima Safazadeh and Dr. Shahla Abolhasani were involved in the study design, framework development, and coding. Somayeh Azimpour conducted the interviews and transcribed the interview content. The first draft of the manuscript was written by Somayeh Azimpour, and the final version was reviewed and approved by all authors. Funding This study is based on a research proposal entitled “Identifying the Challenges and Strategies for Implementing the Nursing Tariff Law in Isfahan”, funded by the Research Committee of the School of Nursing and Midwifery, Isfahan University of Medical Sciences under grant number 140344. Data Availability Data are available in handwritten notes or supplementary files. All data supporting the findings of this study are available from the corresponding author upon reasonable request. Ethics Approval and Consent to Participate This study was approved by the Ethics Committee of Isfahan University of Medical Sciences with the ethics code IR.MUI.NUREMA.REC.1403.042. All research procedures were conducted under Helsinki ethical standards, and participant confidentiality was rigorously maintained. Written informed consent was obtained from all participants after a comprehensive explanation of the study objectives and procedures. Clinical trial number Not applicable. Competing Interests The authors declare that they have no competing interests. References Benhelal A, Gerry S, Mahmoodi M: The knowledge and satisfaction of nurses about performance pay (Qasedak plan) and its relationship with the quality of nursing care . Quarterly Journal of Nursing Management 2018, 7 (2):37-48. Toulideh Z, Sadeghifar J, Nasiripour A, Roshani M: Relationship between mechanisms of servicescompensation and job performance among nurses . 2016. 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Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7105927","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494633275,"identity":"79dde113-7519-496d-8794-275b435d2215","order_by":0,"name":"Shima safazadeh","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shima","middleName":"","lastName":"safazadeh","suffix":""},{"id":494633276,"identity":"4bf11beb-2ea5-4568-bcdd-cc25a6e16d3d","order_by":1,"name":"Shahla abolhasani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shahla","middleName":"","lastName":"abolhasani","suffix":""},{"id":494633277,"identity":"e459f216-54ba-41a7-9546-1eea8222a6ea","order_by":2,"name":"Somayeh Azimpour","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie2PsQrCMBCGTwJxOXVVRPsKJwGfJ9krCC6OnewivoKvoEtcC67FWagIOjjHRRAcrG0VHBodBfMNSQj/x38H4HD8IF5QCUBmTxZlF89OKlcoSpO5wuWXyjMJgJbYu4LCHPxdl5L4ctyCVjNgBwPDfaniBUik9EnQZrASPiRqAlw0gUblNRGSVHqtFnFNt3MF+mm7tCgNE+UKngqlevmgYC8oFF4oaG+hNQp47NKKeb/tUyImDEdNaVG8cCrOV73r1mOWDjZOOvMwXBpzswzG8vGepcWPRXht9DnicDgc/8sd2aNQptz32dEAAAAASUVORK5CYII=","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Azimpour","suffix":""}],"badges":[],"createdAt":"2025-07-12 05:53:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7105927/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7105927/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95226904,"identity":"4fa182e9-b14f-415a-bbb9-d35a3128b9a9","added_by":"auto","created_at":"2025-11-05 16:31:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1833027,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7105927/v1/78213f63-fb74-4fb2-8eaa-82bd74a9fbb5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the challenges and executive strategies of nursing services tariff setting in Islamic Republic of Iran :A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHuman resources are recognized as the most critical driver of development in any organization or country, with heightened importance in healthcare settings due to their direct impact on community health. Nurses, as the largest and most vital workforce in healthcare systems, play a key role in delivering safe, effective, and high-quality care[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. One major factor influencing nurses’ professional performance is a fair compensation system[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Equitable payment not only enhances job motivation and satisfaction but also improves service quality and patient outcomes[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, global efforts have focused on developing fair, performance-based payment models for nursing professionals.\u003c/p\u003e\u003cp\u003eDespite global recognition of the importance of nursing compensation, limited data exist on precise payment mechanisms based on actual nursing services. Most countries have adapted compensation systems to their local contexts rather than adopting a uniform model[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For instance, in the United States, nursing costs are calculated for each DRG category using nursing intensity weights that reflect patient complexity and direct care needs[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Payment structures vary globally: the U.S. follows an organizational-level approach, the U.K. relies on an independent pay review body, Australia emphasizes state-level negotiations, and Japan uses a decentralized hospital-based system[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Iran, the Nursing Services Tariff Plan emerged in recent years as a key demand of the nursing community and professional organizations6. Although it was ratified by the Iranian Parliament and approved by the Guardian Council in 2007, the law has faced persistent implementation challenges and remains largely unrealized after more than 15 years[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong domestic research efforts, Bagheri-Lankarani et al. (2021) conducted a qualitative study using the Policy Triangle Framework, identifying challenges of nursing service tariffs across four dimensions: content, context, process, and actors. They proposed both short-term (e.g., tariff formula clarification, service documentation improvement) and long-term (e.g., regulatory reforms, institutional coordination) solutions[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, Deshmangir et al. (2011) highlighted structural fragmentation and lack of cost evaluation standards in the tariff system[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While these studies contributed to structural and policy-level insights, a comprehensive qualitative investigation focusing on stakeholders’ perspectives and practical solutions for implementing the Nursing Services Tariff Law remains absent.\u003c/p\u003e\u003cp\u003eIn other words, there is a noticeable research gap due to the lack of contextual analysis, stakeholder perspectives, and evidence-based operational solutions derived from real-world experiences. Addressing these challenges and developing practical strategies could significantly enhance the effective implementation of the Nursing Services Tariff Law, thereby improving nurses’ job satisfaction and the quality of patient care.\u003c/p\u003e\u003cp\u003e Given this research gap, the present qualitative study was designed to explore the challenges and propose actionable strategies for the effective implementation of the Nursing Services Tariff Law in Iran. A qualitative approach enables a deeper understanding of stakeholder experiences and barriers, ultimately supporting more informed and equitable policymaking[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo explore the nature and dimensions of the challenges in implementing the Nursing Services Tariff Law, a descriptive qualitative approach using inductive content analysis was employed. Qualitative research enables a deeper understanding of individuals' experiences and interpretations of their social reality[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study was conducted in selected teaching hospitals affiliated with Isfahan University of Medical Sciences and administrative departments such as the Deputy of Treatment, Insurance Coordination Office, and the Nursing Organization. Participants were purposefully selected and included nurses at various levels—from frontline staff to senior administrators, such as hospital directors, experts in insurance, tariffs, and standards, nursing managers, Head nurses, supervisors, and clinical nurses.\u003c/p\u003e\u003cp\u003eInclusion criteria for the study included having work experience as a bedside nurse or a nurse in a managerial role, as well as being a specialist or senior administrator with at least one year of experience since the implementation of the productivity and performance-based payment law. Participants were also required to be employed in hospitals affiliated with the university. Exclusion criteria included voluntary withdrawal, extended leave, exit from the public healthcare system, or discontinuation of receiving nursing service tariffs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData were collected through in-depth semi-structured interviews conducted between November 2024 and January 2025. Participants were selected using purposive sampling. The researcher, equipped with an introduction letter from the university’s research deputy, visited teaching hospitals affiliated with Isfahan University of Medical Sciences. After explaining the study's objectives, ensuring confidentiality, and obtaining informed consent (Appendix 1), interviews were scheduled and conducted at the participants’ workplaces.\u003c/p\u003e\u003cp\u003e Interviews began with open-ended questions and were audio-recorded with participants’ permission. The interview guide was developed based on a review of related literature, and its content validity was confirmed by five faculty members with expertise in nursing management, qualitative research, and familiarity with the nursing service tariff law. Two pilot interviews were conducted to ensure question clarity, after which final modifications were made.\u003c/p\u003e\u003cp\u003eKey interview questions included: “In your opinion, what are the challenges in implementing the nursing service tariff law?” and “What solutions do you suggest for improving its implementation?”\u003c/p\u003e\u003cp\u003e During the interviews, participants were encouraged to share their experiences freely and in detail, while the researcher (S.A.) maintained an active listening role. To enhance data richness and achieve relative generalizability, participants were selected with diversity in age, gender, education, and work experience. Each interview lasted an average of 55 minutes. All interviews were transcribed verbatim by the researcher (S.A.) and returned to participants for accuracy verification. The transcripts were then reviewed and initially coded by two researchers (Sh.S. and Sh.A.). This process was iterative and conducted concurrently with data collection until data saturation was achieved after 27 interviews, with no new information emerging.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eIn this study, qualitative content analysis using the conventional (inductive) approach was conducted concurrently with data collection, based on Graneheim and Lundman’s seven-step method (2004)[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. After transcription, each interview text was read multiple times by the researcher to achieve immersion and a comprehensive understanding of the content. Each full interview was considered a unit of analysis. Meaning units were identified, coded, condensed, and then grouped into subcategories and main categories. Through continuous comparison, latent themes were extracted. The data analysis was conducted using MAXQDA software (version 2020).\u003c/p\u003e\u003cp\u003eTo ensure the credibility of findings, various strategies were employed, including conducting in-depth interviews at different times and settings, triangulation through combining interviews and document review, purposeful sampling with maximum variation, and member checking by both participants and faculty experts. The researchers explicitly stated their assumptions to minimize bias in the analysis process.\u003c/p\u003e\u003cp\u003eFurther strategies to enhance dependability included detailed documentation of the research process, data analysis, and coding. Participants were fully informed about the study's purpose and procedures, and confidentiality and anonymity were assured. To enhance transferability, the study design, implementation steps, and participant characteristics were clearly described, allowing others to assess the applicability of findings. All research documentation was preserved to support confirmability and transparency throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, participants included 10 men and 17 women aged between 34 and 60 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). They represented a diverse group of individuals working in both clinical and administrative sectors, such as hospital directors, heads of insurance coordination and tariff offices, officials from the Nursing Organization, head nurses, supervisors, nursing service managers, and frontline clinical nurses. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of their demographic characteristics. Data analysis yielded a total of 1,553 initial codes, which were organized into 32 subcategories, 6 main categories, and 3 overarching themes: \"Preparation for Birth,\" \"Infant Care,\" and \"Growth and Nurturing\" (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These themes and their associated categories are further detailed in the subsequent sections.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant Code\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOrganizational Position\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWork Experience (Years)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNursing Services Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNursing Services Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNursing Services Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNursing Management Expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital Supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital Supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital Supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhD in Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital Supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhD in Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital Supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eM.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhD in Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003esenior male official from the Nursing Organization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB.Sc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ea senior female from the Insurance, Tariff, and Standards Coordination Office\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhD in Health Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003esenior male official from the Nursing Organization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes, Main Categories, and Subcategories of Challenges and Strategies Related to the Implementation of the Nursing Tariff Law\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubcategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAwareness-raising\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEnthusiastic Parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003ePreparing for Birth\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCultural Promotion\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmpowerment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncreased Perception\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSafe Infrastructure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eA Safe Cradle\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProvision of Facilities\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport Delivery\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJustice and Non-discrimination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eCaregiving Experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eInfant Care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplexity in Legal Compliance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstanding Barriers to Proper Implementation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePunishment vs. Recognition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChallenges in Formulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003ePerception of Pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChallenges in Implementation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResponse to Payment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeeting Expectations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnsuring Satisfaction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterprofessional Collaboration\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrowth Indicators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eRecognizing Signs of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eGrowth and Development\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptoms of Illness\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompensation for Survival\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeaning of Life\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAddressing Root Causes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eStriving for Maturity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eService Quality Improvement\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional Development\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeed for Policy Revision\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme: Preparation for Birth\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe theme of Birth Preparedness encompasses two main categories: Eager Parents and Safe Cradle, reflecting the emphasis on human capital. Participants, viewed as the hospital\u0026rsquo;s human resources, highlighted the necessity of increasing awareness and fostering a culture of understanding among nurses, ensuring clarity in guidelines, integrating nursing tariff education into academic curricula, improving computational infrastructure, providing necessary equipment, involving nursing representatives in decision-making bodies, and establishing organizational support to ensure the fair and accurate implementation of the Nursing Services Tariff Law.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEager Parents\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe analysis revealed that although nurses were considered vital human capital and showed enthusiasm for learning about the Nursing Service Tariff Law, there remained significant gaps in their awareness, understanding, and the overall cultural groundwork surrounding the law.\u003c/p\u003e\u003cp\u003eA female nursing services manager at a specialized hospital emphasized the importance of educating staff about differences in hospital revenues, as a means to reduce comparisons among nurses regarding received tariffs. She stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"They constantly compare themselves with nurses from other hospitals. In various meetings, I explain that our fund is not the same as others. Imagine having a pot to divide among 1,400 people with high outflow, versus a pot for 200 people. Some hospitals have better revenue tracking and fewer deductions.\" (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA male general hospital director attributed nurses\u0026rsquo; lack of awareness to the absence of tariff-related education in nursing curricula. He said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Our nursing schools do not provide any training on this subject. Nurses should learn about tariffing during their education\u0026mdash;what services are eligible, what amounts are assigned, what a professional unit is, and how it\u0026rsquo;s calculated\u0026mdash;so that they\u0026rsquo;re familiar with it before entering clinical practice.\" (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA female surgical ward nurse pointed to the complexity of the calculation methods as a barrier to understanding, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"They say it\u0026rsquo;s based on formulas that are so complicated, you can\u0026rsquo;t understand them. You get a code based on the service you provided, and you receive money for it instead of a fixed bonus, but it\u0026rsquo;s not clear how.\" (Participant 23)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSafe Cradle\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThrough this theme, participants emphasized the importance of creating a secure foundation, providing adequate facilities, and receiving support from nursing-related organizations to ensure effective implementation of the Nursing Tariff Law. The findings indicated that successful enforcement of the law requires proper infrastructure, sufficient training, efficient equipment, and both financial and organizational support to function effectively within the healthcare system and meet nurses' expectations.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor example, a female head nurse in an internal medicine ward attributed payment delays to inefficiencies in the HIS system, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Even two years after the implementation of the tariff law, the HIS system still hasn\u0026rsquo;t been updated. It lacks complete item listings, and some calculations are incorrect. There are several challenges in the calculation process.\" (Participant 13)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA female nursing services manager in a general hospital noted that equipment shortages due to sanctions negatively affected tariff payments:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Given the current sanctions, many surgical supplies can\u0026rsquo;t be procured or are worn out. When operating rooms can't function fully, the number of surgeries drops, and this directly reduces the tariff income for OR staff, even though they show up for work as usual.\" (Participant 3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother issue raised was the absence of a representative from the Nursing Organization in the High Council of Insurance. A female internal ward nurse stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"If the Nursing Organization had a representative on the High Council of Insurance, they could advocate for the inclusion of all nursing services under insurance coverage, which would greatly help in implementing the tariff system more effectively.\" (Participant 24)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInfant Care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe theme of infant Care comprised two main categories: Care Experience and Perception of Pain. Within this theme, participants identified several challenges in implementing the Nursing Tariff Law, including inequity in payments, inconsistencies in defining levels of care, data entry errors, a lack of a unified definition of tariffs, and insufficient transparency regarding the calculation and explanation of nurses\u0026rsquo; compensation. These issues collectively led to dissatisfaction and a decrease in motivation among nurses.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCare Experience\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eFollowing the implementation of the nursing tariff law, participants reported several challenges, including a lack of fairness, senior managers\u0026rsquo; non-compliance with proper implementation, organizational obstacles, insufficient clarification of payment calculations, and a general disregard for nurses' concerns.\u003c/p\u003e\u003cp\u003eFor instance, a senior male official from the Nursing Organization attributed payment inequity to the subjective allocation of care levels:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;An ICU head nurse might classify a patient as Level 3 care, while the same patient is classified as Level 2 in another ward. This leads to score discrepancies, and over a month, the difference becomes significant, which undermines fairness in payment.\u0026rdquo; (Participant 25)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdditionally, a senior female from the Insurance, Tariff, and Standards Coordination Office emphasized that failure to adhere to proper implementation\u0026mdash;particularly errors in data entry\u0026mdash;affects tariff calculations:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Ward managers enter patient data into the system within 7 to 10 days, but it\u0026rsquo;s unlikely to be 100% accurate. Some cases may be missed, and nurses may have provided services that are not recorded.\u0026rdquo; (Participant 26)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA female nurse from the neurology ward highlighted the lack of clear communication regarding tariff payments and punitive responses to complaints as major sources of dissatisfaction:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI objected to the amount I received and asked how it was calculated. They gave no explanation, showed no concern, and some of our colleagues were suspended due to their protests and strikes over the implementation of the tariff.\u0026rdquo; (Participant 18)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerception of Pain\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e Findings revealed that deficiencies in the developed guidelines, shortcomings in the implementation of the nursing tariff law, and weak interprofessional collaboration were among the most significant challenges, resulting in dissatisfaction, negative reactions, and unmet expectations among nursing staff.\u003c/p\u003e\u003cp\u003eParticipants highlighted the undervaluation of critical specialty areas such as endoscopy, dialysis, and triage units. For example, a male emergency ward head nurse stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Triage nurses receive low scores and therefore receive low tariffs.\u0026rdquo; (Participant 16)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome participants also identified the time-consuming nature of tariff calculations as a challenge. A female nursing services manager in a general hospital stated :\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they\u0026rsquo;ve made it too complicated. These calculation formulas are very time-consuming, and our nursing center manager spends all her time just on tariff calculations.\u0026rdquo; (Participant 5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMoreover, the financial expectations of nursing staff were not met after the implementation of the tariff law. A female nurse from the cardiology ward shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Since the beginning of the tariff implementation until now, it has unfortunately led to the discontinuation of performance-based bonuses. Nurses gained practically nothing despite all the expectations they\u0026rsquo;ve had over the years\u0026mdash;it hasn't brought any real financial benefit.\u0026rdquo; (Participant 24)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFindings also indicated that improper implementation and resulting dissatisfaction have led to a decline in collaboration among nursing staff in delivering patient care under the current payment system. A male ICU nurse expressed this issue:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Assistants and nurses are constantly arguing. When I ask the assistant to connect the oxygen manometer, they respond, \u0026lsquo;That\u0026rsquo;s not my job; the nurse is getting paid for it.\u0026rsquo; There\u0026rsquo;s no respect anymore.\u0026rdquo; (Participant 23)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGrowth and Development\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe theme of \"growth and development\" encompasses two main categories: \"attention to vital signs\" and \"striving for maturity.\" Participants emphasized that improving the implementation process of the nursing service tariff law requires revising existing guidelines, involving qualified professionals in tariff formulation, addressing operational flaws, ensuring fairness in payment, enhancing care quality, strengthening nurses\u0026rsquo; professional identity, and providing adequate financial support to reduce turnover and migration while increasing motivation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAttention to Vital Signs\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAccurate tariffing of nursing services plays a significant role in enhancing professional identity, promoting autonomy, and improving nurse-patient interactions. Addressing existing challenges can lead to increased motivation, hope, and encouragement for continued service, foster interprofessional collaboration among nursing staff, and ultimately improve the quality of care.\u003c/p\u003e\u003cp\u003eA male supervisor in a general hospital highlighted how the proper implementation of the tariff system could enhance teamwork among nursing units and departments:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"This evening, I faced a challenge. I arranged for a nurse from the ICU to cover the gynecological surgery ward. She asked, \u0026lsquo;What happens to my tariff?\u0026rsquo; She was right\u0026mdash;it\u0026rsquo;s like she worked a whole shift for free because her tariff isn\u0026rsquo;t defined for that ward. Addressing such issues could improve cooperation among staff.\" (Participant 7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants also emphasized the importance of financial reassurance to retain nursing staff and reduce attrition. A female nursing management officer from the university explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We\u0026rsquo;re currently facing a high rate of migration. If our colleagues had greater job satisfaction, motivation, and financial support, the number of nurses leaving the system would likely decrease.\" (Participant 6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStriving for Maturity\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e Participants identified revising contextual factors and reviewing existing guidelines as essential strategies for improving the implementation of the nursing services tariff law, viewing these reforms as crucial for professional growth and enhancing service quality.\u003c/p\u003e\u003cp\u003e One key factor in revising contextual elements is selecting knowledgeable and specialized individuals to develop or amend the guidelines. A male supervisor expressed his view as follows:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I think a professional working group should be formed from all departments. For example, the ICU provides specific services, and someone with years of experience should document these services, define them, assign codes, and determine their tariffs.\" (Participant 7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA male manager in a general hospital stated that addressing issues in the tariff system would lead to positive outcomes:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I believe that by resolving its problems, nursing tariffs can become more equitable in the future.\" (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis category also highlighted satisfaction, improved nursing care quality, and professional development resulting from receiving fair compensation. A male supervisor remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"When a nurse knows that they will receive payment for the care provided, they perform their duties wholeheartedly and strive for professional growth. For instance, if a patient has phlebitis, the nurse won\u0026rsquo;t just cover it with a bandage, leading to necrosis; instead, they will change the IV site, receive compensation for this care, and even seek additional knowledge to solve the problem.\" (Participant 7)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study aimed to explore the challenges and solutions related to the implementation of the nursing services tariff law in Iran through a qualitative analysis of the perspectives of frontline and administrative nursing participants. The findings revealed that the execution of this law faced multiple barriers, including insufficient education and awareness, lack of clarity in guidelines, infrastructural deficiencies, payment inequities, and delays in tariff disbursement. These challenges were categorized into three main themes: \u0026ldquo;Preparation for Birth,\u0026rdquo; \u0026ldquo;Infant Care,\u0026rdquo; and \u0026ldquo;Growth and Development,\u0026rdquo; which collectively represent the conceptual progression of the law\u0026rsquo;s implementation from inception to maturity.\u003c/p\u003e\u003cp\u003eThe theme \"Preparation for Birth\" highlights the need for education and clarification regarding the nursing services tariff law. A major challenge in implementing the law was the lack of formal training and awareness among nurses. Findings revealed that nursing schools do not provide official education on tariff calculation, and many nurses have an unclear understanding of the process. Proposed solutions include integrating tariff-related content into nursing curricula and offering in-service training with simplified, practical instructions. Similar challenges have been reported internationally; for instance, Akinyemi et al. (2022) found that clear education on wages and benefits reduces nurse dissatisfaction[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Likewise, Bagheri Lankarani et al. (2021) emphasized that the lack of nurse education on tariff calculation is a key barrier to effective implementation in Iran[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe theme \"Infant Care\" addresses the operational challenges and systemic issues affecting the implementation of the nursing tariff law and its impacts. Findings revealed that nurses face payment inequities, data entry errors, a lack of standardized tariff definition, and payment delays. Such problems have been reported in other studies, with unequal payment systems contributing to job dissatisfaction, turnover, and reduced care quality [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For example, Gautam et al. (2020) found that dissatisfaction with unfair pay structures and unclear tariffs decreases job satisfaction and increases nurses\u0026rsquo; intention to leave. These findings align with domestic studies highlighting similar issues[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, Callaghan (2025) reported that over 38% of Irish nurses plan to leave their jobs within two years due to dissatisfaction with work schedules, payment inequities, poor workplace relationships, and limited career advancement opportunities[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, nurses\u0026rsquo; dissatisfaction with the lack of an integrated payment system for nursing tariffs emerged as a significant challenge in implementing the nursing tariff law. This dissatisfaction is heightened when nurses performing similar duties receive different payments across hospitals. The absence of uniformity in payments fosters feelings of injustice, unfair comparison, and ultimately decreases motivation among nurses. Similarly, Imam et al. (2023) reported that nurses working in lower-income hospitals receive fewer benefits, leading to job dissatisfaction and perceived inequality[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study also highlighted issues with tariff calculation and payment delays due to inefficiencies in hospital HIS systems. Rahayudi et al. (2021) confirmed that optimizing hospital information systems can reduce payment calculation errors[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Regarding equipment shortages and the impact of sanctions, Moyimane et al. (2017) found a direct effect of medical equipment scarcity on nurses\u0026rsquo; wages[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In Iran, multiple studies have confirmed that sanctions exacerbate equipment shortages, worsening nurses\u0026rsquo; financial challenges[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProposed solutions included ensuring essential medical equipment to maintain clinical services, establishing transparent monitoring systems for defining care levels and tariff payments, optimizing HIS to reduce calculation errors, and expediting payments through government funding and insurance support.\u003c/p\u003e\u003cp\u003eThe theme of \"growth and development\" highlights strategies to address the challenges in implementing the nursing tariff law. Central to this theme is the emphasis on fair compensation and its impact on nurses\u0026rsquo; professional identity. The partial or flawed implementation of the law has led to demotivation, reduced intra-professional collaboration, and even increased intentions to migrate among nurses. Proper implementation of the law is thus seen as a key driver of motivation and interprofessional cooperation.\u003c/p\u003e\u003cp\u003eThese findings align with previous research. Motie et al. (2024) identified low wages and lack of payment equity as major drivers of nurse migration in Iran[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, Konlan et al. (2023) found that countries with equitable payment systems report lower migration rates among nurses[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. According to the present study, payment injustice has weakened intra-professional collaboration, as nurses feel their efforts are undervalued. Muench et al. (2015) also reported that inequitable pay contributes to unhealthy competition and diminished cooperation among nursing staff[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBased on the findings of this study, the proper implementation of the nursing tariff law has the potential to enhance nurses\u0026rsquo; professional autonomy and improve the quality of care, an outcome also supported by previous research. Salahat et al. (2022) demonstrated that fair compensation strengthens professional identity and improves patient care quality[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Accordingly, the present study recommends the establishment of a transparent and equitable payment system, increased financial support to reduce nurse migration, enhanced motivation, and improved interprofessional collaboration among healthcare providers.\u003c/p\u003e\u003cp\u003eA comparative analysis with international experiences revealed that Iran\u0026rsquo;s challenges in implementing the nursing tariff law mirror those of other countries during the early phases of developing nursing payment systems. However, nations that have adopted payment reforms, enhanced transparency, upgraded information systems, and secured sustainable funding have reported improvements in nursing conditions and job satisfaction. Therefore, revising tariff guidelines, institutionalizing financial equity, developing practical training, addressing operational barriers, and ensuring adequate funding are essential for the successful implementation of the nursing tariff law in Iran.\u003c/p\u003e\u003cp\u003eOne limitation of this study was the reluctance of some participants to engage due to privacy concerns. To address this challenge, the researcher made efforts to build trust by providing clear explanations about data confidentiality, obtaining informed consent, and ensuring the anonymity of participants. This approach helped encourage participation and improved the credibility of the data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe implementation of the Nursing Tariff Law in Iran resembles a vulnerable Infant, requiring careful, continuous, and strategic attention. Despite its potential to elevate the professional status of nurses and improve the quality of healthcare services, the law\u0026rsquo;s execution faces numerous obstacles. These include ambiguous guidelines, lack of specialized training in nursing curricula, inadequate software infrastructure, delays in payment, and equipment shortages. These challenges not only undermine the quality of nursing care but also diminish nurses\u0026rsquo; job satisfaction and professional motivation.\u003c/p\u003e\u003cp\u003eTo achieve the intended goals of this legislation, a revision of its implementation policies is essential. Recommended measures include developing clear and practical guidelines, updating nursing curricula to include tariff-related education, strengthening software and financial infrastructure, and enhancing nurses\u0026rsquo; professional involvement in decision-making processes. Such reforms could significantly improve the operationalization of the law and contribute to the overall enhancement of nursing services within the healthcare system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDRG:\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eDiagnosis related group; FFS: Fee-For-Service; NIW: Nursing Intensity Weights; HIS: Hospital information system\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere appreciation to all individuals who contributed meaningfully to the completion of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Shima Safazadeh and Dr. Shahla Abolhasani were involved in the study design, framework development, and coding. Somayeh Azimpour conducted the interviews and transcribed the interview content. The first draft of the manuscript was written by Somayeh Azimpour, and the final version was reviewed and approved by all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is based on a research proposal entitled \u0026ldquo;Identifying the Challenges and Strategies for Implementing the Nursing Tariff Law in Isfahan\u0026rdquo;, funded by the Research Committee of the School of Nursing and Midwifery, Isfahan University of Medical Sciences\u0026nbsp;under grant number 140344.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available in handwritten notes or supplementary files. All data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Isfahan University of Medical Sciences with the ethics code IR.MUI.NUREMA.REC.1403.042. All research procedures were conducted under Helsinki ethical standards, and participant confidentiality was rigorously maintained.\u0026nbsp;Written informed consent was obtained from all participants after a comprehensive explanation of the study objectives and procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBenhelal A, Gerry S, Mahmoodi M: \u003cstrong\u003eThe knowledge and satisfaction of nurses about performance pay (Qasedak plan) and its relationship with the quality of nursing care\u003c/strong\u003e. \u003cem\u003eQuarterly Journal of Nursing Management \u003c/em\u003e2018, \u003cstrong\u003e7\u003c/strong\u003e(2):37-48.\u003c/li\u003e\n\u003cli\u003eToulideh Z, Sadeghifar J, Nasiripour A, Roshani M: \u003cstrong\u003eRelationship between mechanisms of servicescompensation and job performance among nurses\u003c/strong\u003e. 2016.\u003c/li\u003e\n\u003cli\u003eMazdaki A, Rezapour A, Azari S, Khaliabad TH, Behzadifar M, Moghadam MR, Raei B, Raadabadi M: \u003cstrong\u003eA comparison of the earnings of specialist physicians and nurses before and after implementing the Iran\u0026rsquo;s New Tariffs Book\u003c/strong\u003e. \u003cem\u003eMedical journal of the Islamic Republic of Iran \u003c/em\u003e2018, \u003cstrong\u003e32\u003c/strong\u003e:37.\u003c/li\u003e\n\u003cli\u003eRajaei Z, Banihashemi SA, Khalilzadeh M: \u003cstrong\u003eIdentifying and Prioritizing Service Compensation Factors Influencing Nurses\u0026rsquo; Motivation: Application of Hybrid Fuzzy DEMATEL-BWM Method\u003c/strong\u003e. \u003cem\u003eFudan Journal of the Humanities and Social Sciences \u003c/em\u003e2023, \u003cstrong\u003e16\u003c/strong\u003e(1):63-88.\u003c/li\u003e\n\u003cli\u003eMosadegh Rad AM: \u003cstrong\u003ePayment mechanisms to health care providers in health insurance systems\u003c/strong\u003e. \u003cem\u003eSocial Security Journal \u003c/em\u003e2004, \u003cstrong\u003e6\u003c/strong\u003e(1):9-32.\u003c/li\u003e\n\u003cli\u003eTavakkoli M, Karimi S, Jabbari A, Javadi M: \u003cstrong\u003eA survey of the strengths of the performance-based scheme in selected teaching hospitals of Isfahan, Iran, in 2014: a qualitative study\u003c/strong\u003e. \u003cem\u003eJournal of Qualitative Research in Health Sciences \u003c/em\u003e2016, \u003cstrong\u003e5\u003c/strong\u003e(1):46-55.\u003c/li\u003e\n\u003cli\u003eNakata Y, Buchan J: \u003cstrong\u003ePaying nurses: a cross\u003c/strong\u003e\u003cstrong\u003e‐country comparison\u003c/strong\u003e. 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Mohammadi Kalaveh S, Mortezanasab M, Fallahi-Khoshknab M: \u003cstrong\u003eExploring the global nurses migration phenomenon: A Narrative Review \u003c/strong\u003e\u003cem\u003eNursing And Midwifery Journal \u003c/em\u003e2024, \u003cstrong\u003e22\u003c/strong\u003e(1):1-15.\u003c/li\u003e\n\u003cli\u003eKonlan KD, Lee TW, Damiran D: \u003cstrong\u003eThe factors that are associated with nurse immigration in lower\u003c/strong\u003e\u003cstrong\u003e‐and middle\u003c/strong\u003e\u003cstrong\u003e‐income countries: An integrative review\u003c/strong\u003e. \u003cem\u003eNursing Open \u003c/em\u003e2023, \u003cstrong\u003e10\u003c/strong\u003e(12):7454-7466.\u003c/li\u003e\n\u003cli\u003eMuench U, Sindelar J, Busch SH, Buerhaus PI: \u003cstrong\u003eSalary differences between male and female registered nurses in the United States\u003c/strong\u003e. \u003cem\u003eJama \u003c/em\u003e2015, \u003cstrong\u003e313\u003c/strong\u003e(12):1265-1267.\u003c/li\u003e\n\u003cli\u003eSalahat MF, Al-Hamdan ZM: \u003cstrong\u003eQuality of nursing work life, job satisfaction, and intent to leave among Jordanian nurses: A descriptive study\u003c/strong\u003e. \u003cem\u003eHeliyon \u003c/em\u003e2022, \u003cstrong\u003e8\u003c/strong\u003e(7).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nursing, Tariffing, Qualitative Study, Nursing Services","lastPublishedDoi":"10.21203/rs.3.rs-7105927/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7105927/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Nurses are a cornerstone of the healthcare system and play a key role in improving public health. Ensuring their well-being and satisfaction, particularly through fair compensation mechanisms, is crucial for policymakers. One such mechanism is the Nursing Services Tariff Law, which, despite its emphasis on justice, efficiency, quality, and accountability, remains in the early stages of implementation in Iran. This study aimed to explore the challenges and suggest corrective strategies for its effective execution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This qualitative study was conducted in 2025 using inductive content analysis based on Graneheim and Lundman’s seven-step approach. Data were collected through 27 in-depth semi-structured interviews with nurses and nursing managers, selected purposively from various levels within the healthcare system affiliated with Isfahan University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Data analysis led to the emergence of three main themes: “Preparation for Birth,” “Infant Care,” and “Growth and Development,” encompassing six main categories and 32 subcategories. The theme “Preparation for Birth” included the categories of eager parents and a secure cradle. “Infant Care” comprised the categories of care experience and perception of pain. The theme “Growth and Development” referred to attention to vital signs and efforts toward maturity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The implementation of the nursing service tariff law in Iran is hindered by challenges such as a lack of transparency, inadequate training, calculation flaws, delayed payments, and unfair tariff distribution, affecting both nurse satisfaction and care quality. Addressing these issues requires revising guidelines, providing accurate implementation training, ensuring timely budgeting, and simplifying tariff calculations.\u003c/p\u003e","manuscriptTitle":"Exploring the challenges and executive strategies of nursing services tariff setting in Islamic Republic of Iran :A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 14:27:56","doi":"10.21203/rs.3.rs-7105927/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0dac241f-955f-46d4-87f8-b03867c914bb","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T10:39:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 14:27:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7105927","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7105927","identity":"rs-7105927","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}