health economics is a branch of economics that studies and evaluates the quantity , quality , and value of the limited resources available to healthcare systems , as well as determining how these factors best combine to produce certain services , with the aim of maximizing effectiveness and efficiency .
us health costs are currently 17% of the gross domestic product ( gdp ) and continue to rise .
many other countries also have the same trend toward increasing costs , although they spend less of their gdp on healthcare .
hospital costs constitute the largest single component of healthcare expenditure , and in developing countries , 50 - 80% of total annual health expenditure is allocated to healthcare facilities . in iran , 40% of the total health budget is consumed by hospital services .
therefore , hospitals must be considered as the primary target of efforts to inhibit rising healthcare costs .
nurses are the main users of resources in the hospital setting , by the virtue of their direct links with the patients , and because they constitute the largest group of healthcare professionals .
thus , nurses play an important role in the economic management of nursing services , and they must be capable of meeting the demands of healthcare organizations , which have been increasingly concerned with growing costs and wasted resources .
their awareness of , and participation in , logical justification of hospital costs , suitable use of resources , waste control , and providing high quality services is of vital importance .
although great emphasis has been placed on the importance of the control of hospital costs and productivity , as well as on positive attitudes toward nurses participation in management and cost control , many nurses unfortunately do not understand how their work affects healthcare costs , or how nurses contribute to healthcare revenues .
several studies have confirmed that nurse have the insufficient knowledge of budget control and cost management .
for example , caroselli found that only 30% of nurses had any basic knowledge of health economics , and a qualitative study showed that nurses do not use cost management in their practice , because they focus only on the care issues .
we were unable to find any evidence that a study of this type had previously been conducted in iran .
therefore , given the importance of nurses participation in cost efficiency activities and subsequent cost savings , it is necessary to determine their awareness and performance with regard to health economics , as a first step .
the present study was conducted to evaluate the awareness and performance of nursing staff with regard to health economics in teaching hospitals .
a descriptive cross - sectional study was performed at three teaching hospitals affiliated to the mashhad university of medical sciences , mashhad , iran , between may and august 2013 .
the study population consisted of all nurses who worked in the medical , surgical , and critical units of these teaching hospitals .
the sample size was estimated to be 170 participants , on the basis of a previous study . and using the following parameters - s = 2.2 , z = 1.96 , d = 0.15 s. in consideration of the sample size and the number of nurses in each hospital , 175 clinical nurses were selected , via a random sampling method .
all the nurse managers , including the head nurse , the supervisors , and the matron from the three hospitals were asked to complete the questionnaire .
inclusion criteria were nurses employed in the hospitals of the mashhad university of medical sciences , and with at least 2 years of clinical experience .
the study protocol was approved by the ethics committee of the mashhad university of medical sciences ( grant number was 900582 ) .
the purpose of the study was initially explained to respondents , who were assured that participation was voluntary .
return of the completed questionnaire was considered as a provision of informed consent to participate .
the first of these concerned demographic characteristics , including age , gender , educational level , hospital units of service , job position , years of experience , management , and budgeting experience .
part two consisted of 16 multiple choice questions to assess the nurses awareness of economic issues related to healthcare .
this was divided into three subscales :  nurses awareness of national and regional budgeting 
( this comprised three questions , with a score ranging from 0 to 3 ) , 
( this consisted of four questions , with a score ranging from 0 to 4 ) , and  nurses awareness of factors that affect hospitals costs 
( this was composed of nine questions , with a score ranging from 0 to 9 ) .
wrong  and  do nt know  answers were given a value of zero ( to a maximum value of 16 points ) .
the passing score was determined by using the angoff method , which is one of the most common methods used for setting cutoff scores .
each question is rated by a group of five subject matter experts , using criterion - referenced procedures .
the expert estimates the percentage of minimally competent persons that will answer each question correctly , after which the judges totals are summed and averaged ( 8.75 + 7.25 + 8.5 + 7.75 + 6.75 divided by 5 ) to obtain a cutoff score of 7.8 , or 8 .
therefore , in the present study , following collaboration with an expert panel , nurses that answered at least eight out of 16 questions correctly ( 50% ) were considered to have good awareness of the field of health economics .
part 3 of the questionnaire contained 11 questions , and a 5-point likert scale was used to measure economic performance .
this section investigated the nurses performance with regard to nursing documentation , as well as consumption and use of drugs , medical supplies , and equipment .
the  never  option was the equivalent of zero and meant that the related performance was never observed in the nurses clinical activities .
always  option was set at four points and meant that the related performance was constantly observed in the clinical activities carried out . for each question , mean
scores above 3 , 2 - 3 , and below 2 were considered as desirable , moderate , and unfavorable , respectively .
the psychometric properties of the questionnaire were examined , and content validity was determined by the means of expert review .
four individuals with a ph.d . in nursing , three nursing administrators , and three health economists critiqued the questionnaire . to assess questionnaire reliability , we examined the internal consistency coefficient and achieved a cronbach 's  of 0.74 ; values of 0.7 or higher are appropriate and acceptable .
data were collected using a combination of the questionnaire , interviews , and observation , as well as an assessment of the available evidence .
the first and second parts of the questionnaire were hand delivered to individual units by researchers , and then distributed to staff nurses by the unit manager during different working shifts .
two days after distribution , the researchers picked up the questionnaires from the three hospitals .
a total of 125 clinical nurses and 50 of 68 nurse managers completed the questionnaire .
the third part of the questionnaire was completed by two co - researchers after observing and interviewing the head nurse and nurses working in different shifts , as well as checking the available evidence .
a multiple regression analysis was used to determine the predictive power of economics awareness and other variables on the economic performance of the participants .
an analysis of variance and pearson 's correlation test were used to evaluate the relationship between variables , and the level of statistical significance was considered to be p < 0.05 .
data were analyzed using spss ( 11.5 version , spss inc . , chicago , il , usa ) .
a multiple regression analysis was used to determine the predictive power of economics awareness and other variables on the economic performance of the participants .
an analysis of variance and pearson 's correlation test were used to evaluate the relationship between variables , and the level of statistical significance was considered to be p < 0.05 .
of the 243 nurses who were invited to participate , 175 ( 72% ) completed the questionnaire .
most were female ( n = 134 ) , and aged between 25 and 56 years ( average , 37.5 years ) .
clinical work experience levels varied between 2 and 30 years ( mean 13 years ) .
n = 166 ) stated that they had not received any education on health economics and cost control activities during their entire career .
in addition , 97% ( n = 170 ) reported that they did not participate in economic decision - making related to hospital care .
nevertheless , 70% ( n = 123 ) of participants positively answered the question regarding the necessity of nurse participation in budgeting and economic issues at all levels .
frequency distribution of individual and job characteristics the mean economic awareness score was 5.94  2.11 ( range , 0 - 13 ) .
table 2 shows that only 22% ( n = 39 ) of nurses had a good awareness of health economics , while table 3 shows the mean scores of economic awareness and its subscales .
awareness of factors that affect hospitals costs was higher ; approximately 50% of participants were knowledgeable in this regard .
the level of awareness of national and regional healthcare budgeting was the lowest , and 92% of nurses did not have sufficient knowledge in this field .
comparison of economic awareness in clinical nurse and nurse manager the mean scores of economic awareness and its subscales there was a significant overall difference between the economic awareness of the clinical nurse and the nurse managers ( p = 0.001 , 95% ci : 1.87 to 0.51 ) , such that nurse managers had a high level of knowledge on each of the three subscales of the questionnaire .
however , among the three subscales , a significant difference ( p < 0.001 , 95% ci : 1.07 to 0.41 ) between the economic awareness of the clinical nurse and nurse managers was shown only in 
as shown in table 4 , the highest scores were related to the control of the expiration date of drugs and supplies ( 3.79  0.40 ) , recording the used drugs and supplies ( 3.38  0.51 ) , and the nurses supervision of the use of supplies ( 3.35  0.87 ) .
the lowest scores were  resterilization of surplus gauzes and dressings  ( 1.80  1.48 ) and  recording routine nursing care activities  ( 1.74  1.60 ) .
performance of nurses regarding health economics pearson 's correlation coefficient showed that there was a significant and positive relationship between the economic awareness of nurses and their performance ( r = 0.22 , p = 0.01 ) .
economic awareness , clinical work experience , job position , and age were simultaneously considered as independent variables , and the mean score of economic performance was considered as a dependent variable .
table 5 shows that economic awareness is only within 5% in predicting nurses economic performance ( r = 0.05 , see = 4.05 , f = 3.28 , p = 0.04 ) , whereas the model for clinical work experience , job position , and age was not significant ( p > 0.05 ) .
multiple regression analysis economics awareness , clinical work experience , job position , and age on mean of economic performance of nurses
one of the most important findings of this study was that iranian nurses had an insufficient awareness of health economics , such that only 22% of those studied and showed good economic awareness .
potential reasons for this knowledge deficit may be a lack of health economics education during nursing training courses , no nurse participation in decision - making regarding economic issues , an absence of continuing education courses and workshops , and little attention to nurses capacity to impact on health system costs .
de oliveira et al . argued that the nurses lack of commitment toward economic issues is related to either a lack of time or to a lack of interest regarding management issues , with the justification being that they have received no academic education in relation to economic management and had no understanding of these concepts
. a higher level of awareness with regard to  factors that affect hospitals costs ,  compared to the other two subscales was another notable finding . since the factors that were evaluated in this subscale were more tangible for nurses , and nurses were more involved with them in clinical practice , they had greater awareness in this area .
nurses in clinical practice understood the positive effects of various factors , such as standards of care , proper use and maintenance of supplies and equipment , and recording of medication and diagnostic tests . in another study , although 94% of nurses were not involved in the hospital budgeting process , their perception of cost containment and control of supplies and equipment was positive , and over 90% were focused on the importance of procedure standardization for nurses to keep costs down . in the present study
, nurse managers had a greater awareness of health economics , but most of them did not have any role in the hospital economic decision - making process .
it appears that several factors , such as the nature of the task , a greater number of administrative responsibilities , participating in related meetings and committees , and previous experience are the reasons behind this .
nurse managers are in an ideal position to not only affect unit - based economics but also to increase economic awareness and the behavior of staff nurses
. however , the centralized organizational structure of almost all of iran 's general governmental hospitals makes it difficult for members within the hospital to contribute to decision - making and organizational policy .
the findings showed that there was a significant relationship between the awareness and performance regarding health economics . however , this relationship was very weak , and awareness scores could explain only 5% of the variance in performance scores .
this means that although nurses do not have sufficient economic awareness , they pay attention to clinical care matters , such as documentation of consumed drugs and supplies , and careful operation and maintenance of equipment and devices in practice , which have an effect on adjustment of hospital costs .
these conditions are primarily the result of formal written clinical guidelines , a shortage of equipment and materials , and close control by the hospital management of the use of expensive drugs and equipment .
moreover , the results showed that the lowest score was associated with the recording of routine nursing care activities in patients medical records , which may be a result of its the lack of effect on patients final billing and hospital income . in the present study
, 97% of nurses stated that they do not participate in decision - making regarding hospital economy , while the majority ( 70% ) had a positive opinion with respect to the necessity of nurses contribution to economic programs in hospital and cost control activities .
it is necessary to make structural changes in the process of hospital budgeting to allow for a greater contribution from the nursing unit .
showed that only 6.6% of nurses played a role in hospital budgeting ; however , 69.9% of these indicated that nurse managers should be involved in the planning of a hospital budget .
a qualitative study showed that most managers believe that the contribution of nurses to the cost efficiency of interventions would further boost clinical activities and job development , and , subsequently , would have a positive effect on patient care activities .
it is clear that nurses should receive health economics training prior to entrance into the profession , with the aim of enhancing productivity , reducing costs , and improving the quality of care . in the present study
, 81% of nurses indicated that educational programs can help to reduce hospital costs . in another study
, 96% of nurses stated that in - service education sessions on cost containment should be held for all the categories of nurses .
since less attention is paid to managerial and economic issues in nursing courses , it is important that nursing students become familiar with the management and economic aspects of the profession , so that in future , they are capable of properly meeting new challenges in this field .
the main limitation was the broad nature of the health economics field , which prompted the researchers to implement a broader view in their approach , as well as the design of the questionnaire .
taking a more detailed approach , and thus evaluating all of the factors influencing nursing care , such as work environment conditions , communications , and educational and administrative plans that have an effect on costs and outcomes , would severely have affected the size of the questionnaire , which , in turn , would have contradicted the research tool designing principles , and would also have reduced the accuracy of the answers . therefore , in order to increase the validity of the questionnaire , in addition to a preliminary study , the views of several healthcare and economics experts were also considered to maximize the healthcare economics relevance and coverage of the final questionnaire . the small sample size and inclusion of only government teaching hospitals mean that the results may only be cautiously generalized to other settings . nevertheless , this study is a critical and preliminary step that allowed a detailed assessment of economic awareness and performance in nursing clinical practice .
an evaluation of the effects of the educational courses and participation of nurses in the cost management of both unit and hospital is suggested for future studies .
considering the importance of health economics and priority in healthcare systems in the near future , managers , and staff nurses should upgrade their basic knowledge of economics , cost saving , and optimal usage of equipment and resources .
 background : health costs have risen everywhere , worldwide , and nurses play a pivotal role in cost savings and in contributing to the financial stability of hospitals.aim:this study evaluated the awareness and performance of iranian nursing staff , with regard to health economics.materials and methods : a total of 175 nurses who worked in three teaching hospitals in mashhad ( iran ) were selected for this descriptive cross - sectional study , and data were gathered via a 27-item questionnaire . 
 statistical analysis was performed using one - way analysis of variance , multiple regression analysis , and pearson 's correlation coefficient.results:a total of 78% ( n = 39 ) of nurses did not have a good awareness of health economics . 
 the overall mean score for economic awareness was 5.9  2.1 ( possible range , 0 - 16 ) , and for economic performance was 26.6  4 ( possible range , 0 - 44 ) . 
 there was a significant relationship between the economic awareness and performance of nurses , and nurses in higher positions had a greater awareness of health economics.conclusions:considering the inadequacy of the health economics awareness and performance of nurses , it is essential that efforts are made to enhance their knowledge and behavior with regard to economic issues and cost saving in all the fields of nursing , through the use of continuing education courses and workshops . 
Introduction
Materials and Methods
Statistical analysis
Results
Discussion
Conclusions
Financial support and sponsorship
Conflicts of interest