Iranian Medical Staff ’ s Perception of the All Saints TV Series

The present study was an attempt to explore the Iranian medical staff’s perception of the All Saints TV series. 199 participants including doctors, nurses, interns, and paramedics took part in this survey study which was done in 2011. A 17-item Likert scale questionnaire was developed by the team of researchers to gather further evidence on the issues raised by the participants in the focus group which was formed in order to delve into their thoughts, attitudes, and feelings about the mentioned program. The supportive and non-blaming nature of the working relationship among the treatment team, their respect for the patients, their strong team work, the accuracy and precision of the presented medical information, and the discipline and sense of responsibility on the part of the medical staff were among the most frequent issues being mentioned and noticed by the participants. In addition, the majority of the participants considered the demonstrated model for providing healthcare services to be an efficient one; however, they believed that it was not possible to apply that model in the Iranian hospitals mainly due to the cultural differences between the two contexts and the current regulations in Iran. The participants were also observed to be only moderately satisfied with the system they were working in. It seems that healthcare systems in the developed countries can be used as models to identify the problems with the existing healthcare system in Iran. Authorities need to take appropriate measures to resolve such problems. The possible solutions and actions have been suggested in the present article.


Introduction
For professions other than one's own job, each individual has an image of what it looks like.This image is formed as a result of his or her life time experience of living in the society, being in interaction with others including the ones in those professions, and what he or she hears from others.The media have a very strong effect on the image we build for everything including others' professions [1].Sometimes these images are formed based on reliable information and are accurate as a result; however, sometimes they are shaped as a result of false or incomplete information we receive and are illusions rather than accurate images [2].
For instance, one's image of what doctors, nurses, and other hospital staff do can be shaped by a number of sources of information.One's visit to hospitals as a patient or visitor, what others say or have said about these professions, the internet, the news, and the TV programs and movies featuring these people and their professions.Due to their short duration, all these sources help shape this image bit by bit during time, and it is their repetition that helps build this image.However, when a TV program and more specifically a TV series is made revolving around a profession, one's image can be heavily affected either positively or negatively depending on the accuracy of the information presented [3].
Popular images can even affect people's decisions for choosing a particular profession [3].Many high school students are observed to choose to be doctors or engineers in Iran as a result of the popular image of these professions in the public.Such images can also impact students' perception of what they must do as individuals in that profession.Fictional characters in the medical TV programs may affect the way real people in the same professions may behave.For instance, watching a doctor in ER may affect the way one perceives real doctors' roles, behaviors, and responsibilities [4].These images can help shape students' expectations of medical ethics, identity, and practice [3].In a study on medical students in Iran, participants reported that movies were the most influential tool in shaping their attitudes toward mentally-ill patients [5].
Therefore, studies exploring the medical staff or students' perception of their public image presented on the media have been the focus of attention over the past few years.A number of studies have examined the kind of image being presented by the medical dramas.For example, it was observed that in American medical dramas, men nurses were often shown in ways which involved with explicit and implicit stereotypes which were sometimes even reinforced by those TV programs [6].[7], examining 484 undergraduate nursing students' perceptions of the nursing image being shown on TV, observed that the students were concerned about the kind of image which was being presented, though they also recognized some educational value in TV programs.[2] observed that due to sometimes inaccurate information being presented about medical practice, students with more clinical experience tended to have a more negative attitude towards these programs.
Medical dramas also can play an efficient role in education.Many TV series can be used to teach medical students issues in different areas.For example, clips from ER and Scrubs are said to be good for teaching and learning while episodes of House and Grey's Anatomy are good for teaching ethics and team working [8].However, [9] believes that Scrubs is more successful in teaching ethics than bioethics classes.
These programs can also be used to teach the general audience to affect their health beliefs.The "Family House" medical TV series, for instance, was produced in Egypt to disseminate key health messages in an entertaining context to affect Egyptians' health behaviors, beliefs, and attitudes [1].

The Present Study
In addition to the importance of the image such programs present, examining how this image is presented from the medical staff's point of view and their perceptions and attitudes toward such programs are of great importance.This image affects the general audience's attitude towards these professions and the people involved.Therefore, when a TV series is produced in one country and is supported to be broadcasted in another country, there may be mismatches between the image intended for the country in which the program was produced and the image appropriate for the country in which it is being broadcasted.The image the general audience form based on an ideal or at least standard healthcare system will enhance their expectations, which is two-folded.It can be problematic since such expectations may not be met due to infrastructural shortcomings or any other reasons, which will end up with the patients' dissatisfaction with the services they receive.However, at the same time, these mismatches can be used to identify the shortcomings in the present healthcare system in order to improve the system itself and the quality of the services being provided.
Regarding the hospital staff, a number of TV series have been produced.All Saints, House M. D., ER, and Grey's Anatomy are only some of them.These TV programs, due to their length and details, can be said to have the strongest effects on the image the general audience may form in their mind about the importance, difficulties, sensitivity, and responsibilities in those professions.
Among these TV series, All Saints invested more in the working environment and the relationship among the medical staff than their personal life.In addition, it is the only one which was broadcasted on the Iranian national TV.As such, the extent to which it presented an accurate image of this profession from Iranian medical staff's point of view is important and needs to be investigated.
All Saints, an Australian medical drama first aired in February 1998 on the 7 th Network, revolved around the incidents in Ward 17 which received the overflow of other wards in the fictional Western General Hospital.In 2004, the story shifted to the incidents in the Emergency Department (ED) in order to attract more audience.Also in February 2009, a Medical Response Unit was added to the story line.The last episode, which was the 493 rd episode, was aired on October 27, 2009.
All Saints presents the audience an in-depth view of nurses' life at hospitals.It pictures their good and bad days with moments of happiness, sadness, and frustration.It demonstrates their working relationship with others and their interaction with the patients.It also portraits the kind of healthcare and managerial system they were working in.All Saints was broadcasted in many countries including United Kingdom, Ireland, and Belgium.After the exclusion of the scenes which did not conform to the Iranian Islamic context and rules, the All Saints was also aired on the Iranian National TV Channel 1 under the title of "Nurses", which received a lot of popularity.
In the present study, the All Saints TV series was examined in terms of the impression it had on the Iranian medical staff.Their attitudes and thoughts about this program were studied using a questionnaire which was developed based on a focus group formed to delve into the extent to which the participants could communicate with this TV series.

Participants
199 participants (84 male and 115 were female) working in the health care system in military hospitals in Tehran took part in this survey study.Their age ranged from 20 to 45 with a mean of 30.32 (SD = 6.5) and an average working experience of 11.51 years (SD = 6.6, range = 1 -26).All participants were selected using convenience sampling.

Data Collection Tool
In order to collect data, a researcher-made questionnaire was used.It included two sections, with the first part gathering participants' demographical information and the second section gathering information on their opinion and attitude about the All Saints TV program.The second section included 17 items (16 five-point Likert scale items and one multiple-choice question) examining three factors: Satisfaction (with 4 items asking respondents about the extent to which they were satisfied with the system in which they were working), Comparison (with 4 Likert scale and one multiple-choice items asking respondents for their opinion about the extent to which the shown Health System corresponded with the one they were working in), and Realism (with 4 items asking respondents for their opinion about the extent to which the TV series matched the realities of their job).In the later analyses it was observed that two items did not load under any of the three identified factors and two items showed very low communalities.As such, these items were excluded from data analysis.

Procedure
Before developing the questionnaire, a focus group was formed, inviting the medical staff working at two hospitals to participate and share their opinion about the mentioned TV program.The meeting was held in the library at the Army Psychiatry Hospital with the presence of 13 medical staff (6 male and 7 female).The group consisted of a psychiatrist, two psychologists (one PhD holder and one MA holder in Clinical Psychology), four medical interns, five nurses (1 MA holder and 4 BA holders in Nursing), and two clinical assistants.The participants' opinions were later used to develop a checklist by each researcher.
After a checklist on the related issues was prepared by each researcher, all the items were pooled together, and the team of researchers evaluated each item.The repetitive and inappropriate items were excluded then.In the next step, a team consisting of the faculty members at the psychology and psychiatry departments, consisting of 3 psychiatrists and a psychologist (PhD in Clinical Psychology) helped analyze the questionnaire.As a result, a number of items were added and some were excluded from the final version of the questionnaire.
The final version of the questionnaire consisted of 17 items.One of the items was of multiple choice type, probing the reason why they had answered a particular question in a particular way (see below).The rest of items were of five-point Likert scale intended to measure three different factors of interest to the researchers: participants' opinion about the accuracy and reality of the medical and non-medical issues presented on the TV program, the extent to which the healthcare system shown on this TV show matched with or could be incorporated into the Iranian hospitals, and finally, the extent to which the participants were satisfied with the healthcare system they were working in.
The 16 Likert scale items were subject to principal component analysis (PCA) using SPSS Version 17.The suitability of the data for factor analysis was checked prior to the analysis.The KMO value was 0.62 with the Bartlett's Test of Sphericity reaching statistical significance, supporting the factorability of the correlation matrix.
The PCA revealed the presence of six components with eigenvalues above 1; however, the screeplot showed a clear break after the third component.This was further supported by the results of Parallel Analysis, showing only three components with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (16 variables × 199 respondents).
The three-component solution explained a total of 42.66% of the variance with each component contributing 16.25%, 13.81%, 12.60% of the total variance, respectively.Since the correlation among the components was very low, the results of Varimax and Oblimin rotation were very similar.The three component model as intended by the researchers was confirmed by the results of the PCA, with 2 items (items 8 & 11) not loading under any of these three components and 2 other items (items 4 & 10) showing very low communalities, which resulted in their deletion from later analyses.Table 1 presents the related statistics for a three factor solution oblimin rotation PCA.The internal consistency of the three components identified in the researcher-made questionnaire was checked using Cronbach alpha.The obtained reliability coefficient for Satisfaction was 0.67.It was 0.50 for Comparison and 0.56 for the Realism component.The low observed reliability coefficients could be due to the low number of items in each component.In addition, since the three components showed a very low correlation with each other, with the highest correlation coefficient being only 0.11, no reliability coefficient was calculated for the whole questionnaire because the three components could not be regarded as constituting a unified whole.

Data Analysis
Since the number of items was low and due to the nature of each item which was probing an almost different issue indicated by the participants in the focus group, the main type of statistics used was descriptive statistics in order to analyze the patterns of responses for each item.However, as minor questions probing more into the factors affecting the participants' opinion, inferential statistics were used, too.In order to check the effect of sex and experience on the three components examined in this study, a number of two-way between subjects ANOVA were run.Moreover, to check the effect of age, one-way between subjects ANOVA was used.

The Focus Group
Very interesting issues were raised in the focus group meeting.Participants were asked about different aspects of the program, and the responses they provided helped shape the questionnaire in order to further delve into the same issues raised in that session.In fact, the questionnaire was used in order to confirm the points pointed out by the medical staff participating in the focus group.
The participants were asked about the points and issues in All Saints which were attractive to them.The intimacy present among the characters; the intimacy the audience could feel while watching that TV program; the specificity of working domains for each member of the medical team; the close and supportive working relationship among the treatment team and more specifically between doctors and nurses; the observed working discipline; the presentation of true and accurate information about medical issues; the possibility for each member of the treatment team to express their feelings in the highly stressful situations and being supported by other members; and the separation of staff's job and personal life were among the most important points mentioned by the participants.As the psychologist of the group stated, "All Saints did in fact reveal all our psychological and mental needs and desires." The interns stated that in that program the patients looked quite real.In addition, the educational nature of the TV program, the non-blaming nature of the relationships among the treatment team, the staff's feeling of consciousness, and the respect they had for the patients and the kind of work they were doing were other points emphasized by them.
In the case of the differences between the two working environments, a number of discrepancies were mentioned.The medical staff in that program did their best to complete their responsibilities despite all the problems they might have faced.In addition, when a problem arose, instead of looking for somebody to blame, the treatment team tried to find a solution.The nurses believed that in comparison with what was going on in their working environment, one could see a more significant role for the head nurses in that TV series.Being in charge did not mean staying away from being involved in actions; instead the head nurses worked more than others.In addition, patients were respected more.More team working could be observed.Each member in the treatment team was emotionally supported by other members.The number of patients each nurse had to take care of was lower.They did not have to work in multiple shifts.Regulations rather than relations were important, and finally, despite all the difficulties, the medical staff were still cheerful and satisfied with their job.
Regarding the extent to which they could communicate with the program, the participants stated that it seemed as if their problems in the Iranian context were being filmed in All Saints.In response to whether this program could teach something to the participants, they stated that All Saints was instructive in terms of having more and better interaction with patients especially on the part of doctors.A major point emphasized by the nurses was the respect for each member's opinion in the treatment team and the permanent and instructive presence of the doctors in the ward.They believed that this presence could reduce the risk of malpractice and help other staff feel more secure.One of the nurses said that in that program she could see all the ideals she had in mind about this profession.
The characters' personality growth and cognitive development during the time in that TV series was another strong point noticed by the participants.The interesting point was that this growth happened in the hospital and in interaction with their colleagues and patients during time rather than overnight.It was better seen in the case of Luke, the surgeon, and Scott, the young ambulance staff.The participants also liked the fact that in that TV program the medical staff were not shown as mere medical service providers to the patients.Patients were also shown to bring about something new to the ward with their presence there.Even four of the participants stated that unlike some other programs by which they felt offended, All Saints made them feel proud of their profession.
Regarding the extent to which this program could affect their practice, the majority of the participants used the term "a lot."The psychologist of the group stated that "we had already heard a lot about the type of interaction we should have with patients, but we had not seen such a good demonstration of that.It was very difficult to find a problem with the type of interactions presented in that TV program as a model."

The Questionnaire
According to Table 2, the participants believe that the two systems do not differ that much in terms of the responsibilities and job-related issues (M = 9.24).However, regarding the extent to which the demonstrated medical issues were scientifically accurate and matched the realities of their profession, the participants were quite positive (M = 14.80).Finally, the participants' level of satisfaction with the system they were working in was not found to be high (M = 11.17).They were only moderately satisfied with the healthcare system they were working in.
Due to the fact that each item was developed in response to an issue raised in the focus group meeting and in order to collect more evidence on that subject, the individual items were of more interest to the researchers than the main factors.Table 3 presents the descriptive statistics for each item on the questionnaire.Regarding the comparison between the two working environments and healthcare systems, the majority of the participants believed that the relationships among the members of the treatment team on the TV program were quite different from those in the Iranian context.They also believed that while the shown nursing practice expectations were a little higher than those in the Iranian context (M = 3.54, with the maximum possible score being 5 and the minimum possible score being 1 for all items), the responsibilities the medical team in Iran have are much heavier, and the level of stress they experience is higher, too.
The majority of the participants believed that it is very difficult to apply the presented model on the TV program in the Iranian hospitals.For the reason why they believed so, 43.8 percent of the participants considered cultural differences as the main obstacle.The problems with present regulation stood as the second reason with 28.4 percent.A number of participants (18.3 percent) considered doctors' resistance to the shown model as the main problem in this regard.Fewer people (7.1 percent) blamed nurses' lack of professional commitment.However, 4 participants (2.4 percent) believed that the shown model was harmful for the Iranian hospitals.
The participants considered the demonstrated medical issues to be scientific and correspond the realities of their job (M = 4.25).They also found the approach to hospital management on All Saints to be quite different from the ones running in Iran (M = 4.45).In addition, more than 80 percent of the participants believed that the TV program was not offensive, with less than 20 percent perceiving it to be somewhat insulting to them as the medical staff.
Regarding the extent to which they were satisfied with the system in which they were working in, it was observed that the participants were only moderately satisfied with their job (M = 3.29) and colleagues (M = 3.34).Their level of satisfaction was even lower regarding their working environment (M = 2.34) and their managers (M = 2.24).
As complimentary questions, the effect of participants' age, sex, and working experience was checked on their responses to the items in the questionnaire.The effect of age was also checked on the participants' attitudes toward the program.However, the results of the one-way between subjects ANOVA did not show any significant differences among different age groups in any of the three factors: F Satisfaction (2, 195) = 0.24, p = 0.78, F Comparison (2, 179) = 1.48, p = 0.23, and F Realism (2, 189) = 1.21, p = 0.30.
In order to check the effect of sex and working experience on participants' opinion regarding the All Saints TV series and the related issues, a two-way between subjects analysis of variance was run for each factor.The variable Experience was binned into three groups using SPSS visual binning procedure, with those with 7 or less than 7 years of experience being in group one, those with 8 to 15 years of experience in group two, and those participants with 16 or more years of experience in the third group.The only significant difference was found in the case of the Comparison factor.For the other two, no significant difference was observed between male and female participants and among different experience groups.
As it is presented in Table 4, women tended to perceive the shown health system on the mentioned TV program to be more compatible with the system they were working in (M female = 9.06, M male = 8.77).Among the three experience groups, as in the case of the other two factor, group one (those with 7 or less years of experience) had a more positive attitude towards the compatibility of the two systems (M = 10.00).However, based on each group's mean score, it seems that both male and female participants in all experience groups did not believe that much in the compatibility of the shown health system with the one in the Iranian hospitals.While the interaction between Sex and Experience was not statistically significant F (2, 127) = 0.76, p = 0.47, the main effect for experience was found statistically significant F (2, 127) = 3.91, p = 0.02 with a moderate effect size (Partial Eta Squared = 0.06).However, the main effect for Sex was not found to be significant F (1, 127) = 0.59, p = 0.44.The post hoc comparisons using Tukey HSD test revealed that the observed difference in the case of Experience was between Group one (M = 10.00,SD = 3.06) and Group Two (M = 8.18, SD = 3.28).
Regarding the compatibility of the two systems, those participants who believed in the inapplicability of the shown health system model in the Iranian hospitals were asked for the reason why they believed so through answering a multiple choice question.Table 5 summarizes participants' answers to this question.

Discussion
The present study was an attempt to evaluate the impression the All Saints TV series had on the Iranian audience who were involved in the Iranian healthcare system.The results of the focus group and the follow-up survey study revealed a number of major points in this regard.
The most important subject expressed very extensively and emphasized by the majority of the participants was the kind of working relationship observed among the treatment team on that TV program.The intimacy among the medical staff and the supportive and non-blaming nature of their relationships were of great importance to the participants.They liked the way each member of the treatment team expressed her feelings and was emotionally supported by others.The participants also pointed out the good team work they had on the show, which was due to the kind of relationship among the staff and their approach to hospital management especially by those who were in charge of each department or ward.The way head nurses were involved in action and worked even more than other staff, as mentioned by participants in the focus group, can be an instance of this approach.
In addition, the kind and amount of interaction between the medical staff and patients was largely noticed by the participants.Patients were seen to be respected more in that system and their questions and concerns were paid more attention.This could be due to the better development and practice of medical ethics in the developed countries.In Iran, medical ethics is also being practiced and is of great importance.However, since it is only a few years that this concept has been largely introduced and emphasized, its practice is still far from the ideals.
The self-discipline, sense of responsibility, and keeping the work and personal life apart on the part of the medical staff on All Saints were among other issues attractive to the participants.The level of details and accuracy of the information presented regarding the medical problems and practices in all the scenes was largely noticed and liked by the participants.This indicates that a strong medical team supported the production of this TV series, which could be the reason why this program was successful in communicating with the general audience and more specifically the audience working in the healthcare system.
The presentation of the difficulties the medical staff had to face in everyday work and the significance and sensitivity of their job caused the participants to feel proud of their profession when watching this TV program rather than feel offended due to the demonstration of their occasional mistakes in the treatment process.While the majority of the participants considered the demonstrated hospital management to be an acceptable and efficient model to be used, they believed that applying this model in the Iranian hospitals is a very difficult task mainly due to cultural differences.These differences are not only in the way the hospitals are run, but they are also in the way people think, behave, and live.As one of the interns in the focus group mentioned, even the patients are different.People are more patient-wise in the more developed countries.A second obstacle in this regard was the current regulations in Iran, changing which is a difficult and time-consuming task.
All these could be the reason why the participants were only moderately satisfied with the healthcare system they were working in.Working multiple shifts, experiencing more stress, receiving less support from colleagues, and observing that in that context, unlike their working environment, those in charge work even more than others and are directly involved in action can give a clue to why the participants were not that much satisfied with their job, managers, colleagues, and working environment.
The authorities should be aware that the medical staff are the backbone in any healthcare system and the success and efficiency of any system is determined by the efficiency of the medical staff working in that system.When these individuals are not satisfied with their job or the environment they are working in, for sure the type of service they provide cannot be the one intended and approved by the system.Therefore, identifying and resolving the major problems with this system is of utmost importance.The results of the present study and the type of model presented on All Saints TV program can help achieve this goal.
The participants' emphasis and paying attention to the way patients were respected and treated indicates the importance of practicing and teaching medical ethics.Unfortunately, the practice of ethics in the Iranian hospitals is still far from the standards.It is not a long time that teaching medical ethics has been incorporated in the educational curriculum.More emphasis on that and its inclusion in the curriculum of all fields related to medicine seems to be quite necessary.In addition to medical ethics, courses in psychology need to be included in the educational curriculum of all fields whose graduates are supposed to be in interaction with other people and more specifically patients.This is a gap extensively felt in such fields in Iran.
An important implication the result of the present study has is the necessity of working on people's culture.This extremely hard but important task must target all individuals and more specifically those at very young ages.Team working should be taught and internalized.The type of education people receive in Iran is mainly individualistic and is not strong in helping them learn and internalize team working.It is quite necessary that the authorities need to revisit this system of education.

Conclusion
Another aspect of culture which needs to be worked on is concerned with the kind of relationship among the members of a team.All members need to learn to value each other's opinion and regard each teammate to be an important asset of the group who has a lot to contribute to the success of the team.Unfortunately, a common objection especially by the nursing staff is that the majority of the doctors tend to regard the nursing staff to lack the necessary knowledge to have an active participation in the treatment process.They believe that nurses are only supposed to follow their orders.However, they need to learn that the nursing staff, as members of the treatment team, have the knowledge and experience which can be quite helpful in the treatment process.Individuals from very young ages need to learn that when working in a group, each member's opinion is valuable and needs to be respected.Two heads are better than one.
As a health care provider, I think the dialogues were very strong. 2 The medical information presented on this TV show were accurate. 3 The kind of relationship among the medical staff looked appropriate to me.

4
I think the type of relationships among the treatment team were similar to those in the Iranian context.

5
I think the medical staff's responsibilities were similar to those in the Iranian hospitals.

6
I think the shown job stress was comparable with that in the Iranian hospitals.

7
I think the nurses' responsibilities were very similar to those in the Iranian hospitals.
8 I believe that one of the drawbacks in the presented working relationship was the eradication of power hierarchy.9 I found the presented hospital management system very different from those in the Iranian hospitals.

10 I
didn't feel offended because of the shown weaknesses with the medical staff.11Incase this TV show was to be produced in Iran, I would agree with showing the possible weaknesses with the medical staff.12I am happy with my job.13Iam happy with my workplace.14 I am happy with my boss.15 I am happy with my colleagues.16 I think the model for such relationships as presented in that TV show is applicable to the Iranian hospitals.17 In case you do not find that model applicable to the Iranian hospitals, what do you think is the reason?a) Cultural differences b) Problems with present regulations c) Doctors' resistance to the that model d) Nurses' lack of professional commitment e) The harmfulness of their model for Iranian hospitals

Table 1 .
The pattern & structure matrix for PCA with oblimin rotation of three factor solution.

Table 2 .
Descriptive statistics for participants' responses for the 3 factors.

Table 3 .
Descriptive statistics for participants' responses to each item.

Table 4 .
Descriptive statistics for sex and experience variables on the comparison factor.

Table 5 .
Participants' answers for the reason for the inapplicability of the presented model.