Nursing profession in Iran: An overview of opportunities and challenges

Authors

  • Zahra FARSI,

    1. Faculty of Nursing, AJA University of Medical Sciences and
    2. Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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  • Nahid DEHGHAN-NAYERI,

    Corresponding author
    1. Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
      Nahid Dehghan-Nayeri, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Tehran, Iran. Email: Nahid.Nayeri@gmail.com
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  • Reza NEGARANDEH,

    1. Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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  • Soheila BROOMAND

    1. Faculty of Nursing, AJA University of Medical Sciences and
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Nahid Dehghan-Nayeri, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq., Tehran, Iran. Email: Nahid.Nayeri@gmail.com

Abstract

Aim:  Iran's health-care system has witnessed profound changes in the last decades. Despite its progress, the system has currently faced many challenges in one of the important subsystems, nursing. The present review article aimed to present an overview of the opportunities and challenges of the Iranian nursing system, based on recent literature.

Methods:  A broad search of the English and Persian-language literature was carried out, incorporating both electronic and manual components from 1999 to 2009. The results of the investigations among the searched literature are summarized.

Results:  The major challenges are nursing shortages, job dissatisfaction, poor social position of nurses, the gap between theory and practice, lack of community-based nursing care, lack of an appropriate student recruiting system, and shortages in the nursing educational curriculums.

Conclusion:  The authors believe that media, political and public support play a pivotal role in improving the image of nursing in society, increasing motivation among Iranian nurses, and promoting the sociocultural climate and the welfare of nurses, which will result in higher levels of quality of care as well as greater patient satisfaction.

INTRODUCTION

Caring, the ultimate goal of the health system, has been attributed to high-quality nursing care (Rafii, Hajinezhad, & Haghani, 2009). As nursing has close connections to patients' safety, nurse staffing has become one of the most important concerns of governments, health-care providers, and the public (MacPhee, Ellis, & Sanchez, 2006). In this regard, many studies have identified close relationships between the level of nurse staffing (Anonymous, 2008; Dehghan Nayeri, Nazari, Salsali, & Ahmadi, 2005; Hurst, 2009; Rafii et al., 2009; Tschannen & Kalisch, 2009) and job dissatisfaction (Akhtari Shojaei, Nazari, & Vahidi, 2005; Emami & Nikbakht Nasrabadi, 2007; Hurst, 2009; Monjamed et al., 2005; Nikbakht Nasrabadi, & Emami, 2006) with the quality of patient care and patient satisfaction. In addition, human resource management insufficiency (fewer nurses and more patients) is recognized to be related to nurses' practice errors and danger of patient trauma (Anoosheh, Ahmadi, Faghihzadeh, & Vaismoradi, 2008). Patient satisfaction is one of the ultimate indexes of effectiveness and quality of care in nursing (Rafii et al., 2009). Unfortunately, patients' satisfaction levels are not as high as they should be (Anonymous, 2008). Lack of attention to nurses' problems and difficulties may lead to an increase in patient dissatisfaction and a decrease in the quality of nursing care.

Comprehensive data on the nature and extent of Iranian nurses' difficulties are lacking. Based on their clinical and educational experience, the authors suggest that an emerging nursing shortage, job dissatisfaction, poor social position of nurses, and challenges in nursing practice and nursing education are among the main barriers to a developed and respected nursing profession in Iran. These issues surely play significant roles in both current and future advancement of Iran's nursing. Moreover, few studies have been published to introduce of Iran's nursing challenges and provide culture-based strategies. Therefore, the present review article aimed to present an overview of opportunities and challenges faced by Iranian nurses based on the recent literature.

BACKGROUND OF NURSING IN IRAN

As a synopsis of the current situation, Iran is a large country with a population of approximately 70 million (Madad, 2007). More than 98% of the population is Muslim (Statistical Centre of Iran, 2007), and more than two-thirds is less than 30 years old, with a literacy rate of 82% (Statistical Centre of Iran). The life expectancy at birth has risen to 69 years for men and 73 years for women in 2006 (World Health Organization, 2008a). The health indicators of Iran show consistent improvement and now are near those of developed countries. The pattern of the burden of disease shows a definite shift toward non-communicable diseases, which is evidence that Iran has completed the epidemiological transition (Regional Health Systems Observatory-WHO, 2006). However, with an increase in the prevalence of chronic illnesses, the importance of screening and identifying such diseases at early stages has grown. Provision of early treatment can prevent long-term complications and would help reduce costs to the health-care system. For instance, the prevalence of diabetes in Iran, which was approximately 2 103 000 in 2000, is estimated to reach 6 421 000 in 2030 (World Health Organization-Regional Office for the Eastern Mediterranean, 2009). High blood pressure and cardiovascular diseases are also on the rise (WHO, 2008a). The burden of road traffic injuries is also high in Iran (Regional Health Systems Observatory-WHO, 2006).

All these issues indicate the necessity for an advanced health-care system with competent nurses as front-line staff and an effective protocol addressing priority health-care issues and needs in Iran.

IRAN'S HEALTH-CARE SYSTEM

When the Alma Ata declaration highlighted the importance of primary care, Iran revised its health-care system to meet the global aim of “Health for All” by 2000. This declaration, in 1984, led to the development of a primary health-care (PHC) network in Iran (Asadi Lari, Sayyari, Akbari, & Gray, 2004). Despite financial constraints imposed by the Iran–Iraq war (1980–88), the PHC network expanded rapidly with somewhat different models in the rural and urban areas. As such, improvements in the provision of community health care became obvious (Asadi Lari et al., 2004). Now, Iran's Ministry of Health and Medical Education (MOH & ME) oversees an extensive health-care network that offers basic medical services in addition to public health programs, such as primary, secondary, and tertiary health care and education of medical groups (Cheraghi, Payne, & Salsali, 2005). More advanced services, such as complex therapeutic and diagnostic procedures, are provided in a variety of hospitals (public, private or semiprivate) (Joolaee, Nikbakht Nasrabadi, Parsa Yekta, Tschudin, & Mansouri, 2006).

IRAN'S NURSING EDUCATION SYSTEM

In 1916, an American missionary established Iran's first nursing school in Tabriz. It remained the only nursing program in Iran until 1935 when the government established four new nursing schools in Mashhad, Shiraz, Rasht, and Tehran (Khoshnevis & Noghani, 1999; Tabari Khomeiran & Deans, 2007). A majority of the first nursing students were girls. After the Islamic revolution in 1979 and during the Iran–Iraq war, more male students enrolled in the nursing program. This increase occurred because male nurses were required to care for male soldiers in the armed services; also, politicians and the public demanded male-dominant voluntary emergency services in the war areas. In 1986, approximately 50 percent of the baccalaureate students admitted to the nursing program was men; however, at the present time, it has decreased to approximately 20 percent (Nikbakht Nasrabadi, Lipson, & Emami, 2004).

At present, the baccalaureate program is the basic nursing program at the academic level and is the only way leading to registration as a professional nurse. High school graduates are admitted to these programs on the basis of their ranking in the competitive National Higher Education Entrance Examination (NHEEE) (Tabari Khomeiran & Deans, 2007). The Iranian nursing education program lasts for 4 years and leads to a bachelor's degree. Nursing students begin clinical training from the second semester and this is run concurrently with theoretical courses until the end of the third year. The fourth year is allocated exclusively to clinical placement training. Nursing students are trained in teaching hospitals. In the clinical field, they are assigned to care for patients based on nursing processes. Case method is the applied teaching strategy, especially in intensive care units. Students have the opportunity to experience working with patients in different units, including intensive care and special wards. Their progress through these units has a “simple to hard” trend. They learn in the clinical environment under the direct guidance and supervision of a nurse instructor for the first 3 years. In the final year, they work under the direct guidance of staff nurses and supervision of nurse instructors. The student : instructor ratio ranges from 1:6 to 1:12 (Peyrovi, Yadavar-Nikravesh, Oskouie, & Bertero, 2005). At present, the nursing curriculum throughout Iran is accredited by the MOH & ME (Peyrovi et al., 2005). This program includes professional foundation courses (28 credits with a biological content), and nursing courses (53 credits on theory with a biomedical nursing content and 33 credits on clinical preparation) (Cheraghi, Salasli, & Ahmadi, 2008).

Enrolment in a Master of Science degree in the nursing program requires the applicant to hold a bachelor's degree in nursing and to successfully pass the annual competitive examination. The Master of Science degree in nursing is a 2–3-year classroom and clinical program containing about 32 compulsory and optional credits in total.

In the 14th year since the first PhD program officially began, the number of schools that offer PhD programs in nursing has grown to 12. The duration of the program is 4.5 years and consists of 45 credits including 20 credits for dissertation. The students accepted into the doctoral programs are Master of Nursing graduates who have been successful in both the annual competitive nationwide examination and the interview with the Iranian Board of Nursing.

Iranian Board of Nursing controls and supervises the bachelors, masters, and doctoral degrees in nursing. It is also responsible for school accreditation and determining school curriculums. All schools are obliged to follow a basic curriculum established by the Ministry of Health, although some flexibility is allowed within the predetermined curriculum (Nikbakht Nasrabadi & Emami, 2006).

LITERATURE REVIEW

A broad search of the English and Persian-language literature was carried out incorporating both electronic and manual components from 1999 to 2009. The electronic search was carried out using CINAHL, Ovid, Web of Science, Scopus, Google scholar, Blackwell, and Proquest. The Persian databases, such as SID, Magiran, Iran Medex, and Iran doc, were also searched. Initially, a broad search using terms such as nursing/nurse, Iran/Iranian, nursing education, nursing practice, nursing image, job satisfaction, human resources and nursing shortage was conducted. The search yielded over 700 results although not all were relevant to the topic under study. Consequently, search terms were narrowed down repeatedly until articles reviewed reflected terms and literature specific to nursing challenges. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts. Finally, over 50 studies were found to be relevant to be included in our study. The results of our investigation among the searched literature are summarized as follows.

RESULTS AND DISCUSSION

The results of the reviewed literature have been classified under the following subheadings.

Opportunities and challenges

Iranian nurses confront many challenges. Some of the challenges and their corresponding opportunities are presented briefly below.

Nursing staff shortages

Nowadays, the health-care system is experiencing an unprecedented global nursing shortage. This phenomenon has led to undesirable outcomes. It is believed that security of patients and quality of care are affected by staffing levels of nurses (Huber, 2000). According to Dehghan Nayeri et al. (2005), a shortage of nursing staff may lead to certain significant care procedures being overlooked and increased errors. It even necessitates involving unsuitable staff or patients' friends or family members in care processes. Finally, this will result in a decline in productivity and quality of care and cause patient dissatisfaction (Dehghan Nayeri et al., 2005; Hurst, 2009; Rafii et al., 2009). Studies show that personnel shortage results in nurses' loss of knowledge and motivation, exhaustion, burnout, and severe stress (Dehghan Nayeri et al., 2005; Rafii et al., 2009). More recent studies have also revealed an inverse relationship between nurse staffing levels and patient length of stay (Tschannen & Kalisch, 2009).

Although today's shortage is in many ways similar to the old one, there are different dimensions to today's shortage, in which old solutions alone will not work (Oulton, 2006). The nursing staff shortage in Iran is a very important and challenging issue. However, the related factors of this problem are different from those of other countries.

One important factor that influences the nursing shortage in western countries is the aging of the population (Oulton, 2006; Trice, Brandvold, & Bruno, 2007). The mean age of currently employed registered nurses in western countries is 48–49 years and it continues to rise (Trice et al., 2007). In the USA, the mean age of a registered nurse in 2000 was 45 years (Heinrich, 2001). On the contrary, this is not the case in Iran. The mean age of Iranian nurses is 35–38 years (Zare, Negarandeh, Dehghan Nayeri, & Rezaei Adaryani, 2009).

In a general comparison, enrolments in registered nursing programs have declined over recent years in western countries. However, enrolment shows a converse direction in Iran and is high. According to a report, the average number of annual graduations from nursing schools is more than 6400 (total number of 57 967 graduates from 1999 to 2007) (Zare et al., 2009). Although many factors have been determined as underlying causes of the nursing shortage in Iran, job dissatisfaction, and organizational and sociocultural factors have been more influential in this regard.

In 2008, approximately 90 000 nurses were working in Iran's health-care system (Zare et al., 2009), but many nurses are unemployed because of the government's recruitment policies in the last decade (Joolaee et al., 2006). Most Iranian organizations, including the health-care system, are dependent on governmental investments and monetary assistance. Currently, because of financial limitations and the policy of downsizing governmental organizations, many restrictions have been imposed on recruiting new health-care staff. A similar condition is true in private institutions. For the first time in the recent history of Iran, a high unemployment rate of medical doctors, nurses and technicians has become a matter of national issue and debate (Regional Health Systems Observatory-WHO, 2006). The number of jobs in the health-care sector has not kept up with the population increase in recent years; it has been found that there are more than 20 000 jobless nurses who are seeking public employment in large urban areas. Despite the number of jobless nurses, the lack of adequate and appropriate provision of health care in rural and remote areas is of great national concern. Most health-care workers who work in rural and remote regions are nurse auxiliaries rather than baccalaureate-graduate nurses (Nikbakht Nasrabadi et al., 2004). At present, Iran has 25 000 behvarzes (front-line allied health workers) that are staffed in rural health houses (Regional Health Systems Observatory-WHO); the health-care facilities need approximately 220 000 nurses in order to present optimal nursing care (Zare et al., 2009).

Adequate staffing must be assured to achieve better quality of care and job outcomes (Sung-Hyun et al., 2009). In response to these concerns, the MOH & ME has established a special bureau for dealing with the problem. Solutions proposed range from a reduction in the admission of new students to finding employment opportunities abroad. Both of these options are open to question and may take a long time to have noticeable impacts (Regional Health Systems Observatory-WHO, 2006).

A partially effective factor in meeting the problem is a governmental law that obliges all nurses and other health-care providers to work in public hospital settings for the first 1–2 years after graduation. It is a partial requirement to become eligible to apply for employment. Another factor is the activities of the Iranian Nursing Organization (INO). The INO tries to provide a higher salary and autonomy for nursing by lobbying the Parliament and other related resources. After the establishment of the INO, nurses have achieved more power in their own profession's policy-making processes. As a result, more nurses will be employed (Zare et al., 2009). Corresponding strategies for the nursing shortage are identified in Table 1.

Table 1.  Recommended strategies to decrease the nursing shortage in Iran
Finding employment opportunities
Recruiting graduate nurses in rural area, schools, factories etc.
Increasing job satisfaction
Improving nurses' social image
Supporting activities of the Iranian Nursing Organization (INO)
Promoting decentralization in health care

Job dissatisfaction

The shortage of nursing staff is an important factor contributing to job dissatisfaction among Iranian nurses. Job dissatisfaction may persuade nurses to leave nursing in order to find better careers (Monjamed et al., 2005; Rafii et al., 2004). Iranian nurses suffer from job dissatisfaction (Akhtari Shojaei et al., 2005; Habib & Shirazi, 2003; Monjamed et al., 2005; Shahbazi & Salimi, 2002). Following is a brief look at some causes of job dissatisfaction.

Based on the various studies, nurses report unhappiness with a variety of issues, including staffing, low levels of respect, recognition, and wages, heavy workloads, high patients' expectations, low level of participation in decision-making, limited clinical autonomy and authority, conflict with physicians, managerial issues, lack of powerful supportive work conditions, and being overburdened to overcome staffing shortages in the health-care system (Akhtari Shojaei et al., 2005; Habib & Shirazi, 2003; Labbaf Quassemi, Marbaghi, Kabiri, & Hosseini, 2005; Mogharrab, Madar Shahian, Ali Abadi, Rezaei, & Mohamadi, 2005; Monjamed et al., 2005; Nikbakht Nasrabadi & Emami, 2006; Shahbazi & Salimi, 2002). Nursing shortages compel Iranian nurses to work more than what is regulated; more than 192 hours per month based on working time standards. In some parts of the country, it, potentially adds 150 hours of overtime (Joolaee et al., 2006). Although previous studies have revealed that salary and job security are the most important factors of job dissatisfaction among Iranian nurses (Manokian et al., 2007; Mogharrab et al., 2005; Monjamed et al., 2005), it has been identified that the relationship between coworkers is a source for improving nurses' job satisfaction (Mogharrab et al., 2005). In their study, Labbaf Quassemi et al. (2005) showed that approximately 45% of nurses suggested that they were dissuaded from studying nursing, whereas 43.9% of them felt a loss of motivation during working in hospitals.

Current nursing workforce issues include a shortage of nurse aides. Nurse aides support nurses and assist patients with activities of daily living, such as dressing, feeding, and bathing. Nurse aide recruitment and retention is a problem for many employers. The shortage among nurse aides may be linked to difficult work conditions as well as dissatisfaction with wages and benefits. Nurse aides' recruitment will reduce nursing workload; also, it can increase job satisfaction among nurses and promote professional identity (Akhtari Shojaei et al., 2005).

Behavioral consequences of job dissatisfaction in nursing, such as low morale, absenteeism, turnover and poor job performance can potentially threaten the quality of patient care, organizational effectiveness, and nurses' professional identity (Emami & Nikbakht Nasrabadi, 2007; Nikbakht Nasrabadi & Emami, 2006). Therefore, efforts undertaken to improve the workplace environment's atmosphere and to increase salary and job security are among ways for health-care managers to improve job satisfaction.

Also, creating supportive, desirable, and participative working environments is central to improving nursing care (Nikbakht Nasrabadi et al., 2004). Therefore, nurse managers are advised to involve their staff in goal setting and decision-making. They should create participative environments so that the staff experience greater job satisfaction and organizational commitment and, ultimately, provide better-quality services leading to greater patient satisfaction (Akhtari Shojaei et al., 2005; Mohsen Pour, Navi Pour, & Ahmadi, 2006). Table 2 shows some practical strategies in this regard.

Table 2.  Recommended strategies to improve job satisfaction of Iranian nurses
Providing adequate staffing
Increasing salary and job security
Recruiting nurse aides
Participating in decision-making and creating a participative environment
Empowering nurses by increasing their authority domain

Poor social position of nurses

The poor social position of nurses is one another challenge for Iranian nurses (Nikbakht Nasrabadi, Emami, & Parsa Yekta, 2003). Because Iranian people have a poor image of nursing, those who choose nursing as a profession do experience a low level of self-esteem (Adib Hajbaghery & Salsali, 2005). They also feel frustration, hopelessness, and some confusion about self-image and social identity (Nikbakht Nasrabadi et al., 2003). Even now, many people think of nurses as simply assistants to physicians. As well, nurses in the media are seen as helpers to physicians. When nurses are shown as “doctor helpers” rather than as patient advocates, they lose credibility (Gonzalez, 2005). However, by increasing the number of male students motivated to select nursing as a future career, increasing postgraduate nurses, as well as introducing the nursing profession to families, the social image of nursing has improved drastically in the last decade in Iran, although nursing is still seen as a women's job and inferior to medicine (Nikbakht Nasrabadi et al., 2003). According to a study conducted by Asadzandi, Ebadi, Karimi Zarchi, Gholami, and Farsi (2007) , as the result of inappropriate distribution of power in hospitals, allocating power to only a select few at the top of the hospital hierarchy, powerlessness has become endemic among most nurses in their work settings (Asadzandi et al., 2007). In Iran, hierarchical structure between physicians and nurses originates from differences in educational backgrounds and the historical role of nurses and physicians (Nikbakht Nasrabadi & Emami, 2006). Many physicians also regard nurses as their helpers only and do not consider them as specialists in the art of caring (Nikbakht Nasrabadi et al., 2003).

The most commonly cited rationale for these misperceptions relates to the public's unawareness of the capabilities and opportunities for nurses and individuals who select nursing as a career (Huffstutler, Stevenson, Mullins, Hackett, & Lambert, 2001). Additionally, the public image of an occupation relates strongly to the financial remuneration of those who practice it, as well as to the nature of the work itself (Nikbakht Nasrabadi et al., 2004). How can nurses change the present image? Table 3 shows some of the recommended strategies to solve this problem.

Table 3.  Recommended strategies to improve the social position of Iranian nurses
Introducing the nursing profession to the public
Increasing wages and fringe benefits
Presenting an accurate portrayal of the nursing profession in the media
Involving nurses in policy-making and political affairs
Increasing the number of postgraduate nurses
Improving nurses' work conditions
Creating a participative environment

According to Abaan (2000) the value of a discipline is determined both by its members and by society (Abaan, 2000). One excellent way to improve the social position of nurses is to portray their profession accurately in the media, such as TV, radio, websites etc. (Aber & Hawkins, 1992; Gonzalez, 2005; Yazdan Nik, 2009). Individuals can also assume responsibility for writing letters to journal editors and to advertisers in order to inform them about images that are stereotypic and/or do not reflect current nursing roles (Aber & Hawkins, 1992).

Fuchs and Zeckhauser (1987) have suggested that if a society values health as a “priceless commodity”, then the professionals in health care are valued (Abaan, 2000). In fact, the most powerful image builder is how nursing presents itself to clients, peers, and the public (Andrica, 1997). The public needs to know what nurses do and can do, not what they used to do decades ago (Foong, Rossiter, & Chan, 1999). As well, nurses should become more involved in policy-making and political affairs (Nikbakht Nasrabadi et al., 2004). Nurses need to present themselves as though they belong to an important profession and to demonstrate their caring role more completely (Abaan, 2000).

Additionally, empowerment is essential for enhancing nurses' roles, strengthening their professional image, and continuously improving the health-care system nationally and globally (Adib Hajbaghery & Salsali, 2005; Asadzandi et al., 2007; Nikbakht Nasrabadi & Emami, 2006). Adib Hajbaghery and Salsali (2005) stress that restructuring nursing services will eliminate barriers to poor-quality nursing care, inadequate educational preparation, role ambiguity, and low self-esteem among nurses. Also, it is believed that the restructuring will enhance nurses' professional identity and their self-confidence. It will certainly empower them for developing and demonstrating their professional capabilities. Extending nursing services at the community level, developing a participative management style, mobilizing staff involvement in a councilor structure, and involving nurses in the process of decision-making will empower nurses and replace their routine-oriented style of delivering nursing care with decisions based on their professional knowledge and skills (Adib Hajbaghery & Salsali, 2005).

Gap between theory and practice

There is often a gap between theoretical knowledge and its application in practice. While nurse educators are striving to respond to changes in education, the dichotomy between theoretical knowledge and what is practiced or experienced later remains a problem (Landers, 2000). Although there are some barriers to be overcome, many nursing scholars believe that evidence based nursing (EBN) will fill the gaps that are present between research, theory, and practice. Adib Hajbaghery (2007) has identified factors affecting the implementation of EBN in Iran. These factors include: inappropriate work environment, inefficient management, heavy workloads, traditional ways of working, lack of self-confidence, lack of good role models, and inappropriate curriculum content. Also, factors facilitating the implementation of EBN were explained as positive attitudes to EBN, a desire to be up to date, a perceived need to change, and for care to be based on scientific evidence. Mehrdad, Salsali, and Kazemnejad (2008) have shown the major barriers to research utilization as lack of time to read research findings, inadequacy of facilities for research findings implementation and, finally, having not enough authority to change patient care procedures. Additionally, in Iran, many of the graduates of MSc and PhD degrees in the nursing program lean toward nursing education rather than nursing practice (Joolaee et al., 2006). Lack of higher educated nurses who are actively involved in the health-care system and practice is obviously a drawback in the pursuits of EBN.

Likewise, it seems that nursing education, along with organizational structure, have decreased nurses' self-confidence in applying their professional knowledge and skills (Adib Hajbaghery, Salsali, & Ahmadi, 2004). What is clear is the responsibility of nurses to deliver care based on evidence, to be able to access, evaluate, integrate and use the best available evidence in order to improve practice and patient outcomes (Rycroft-Malone, Bucknall, & Melnyk, 2004).

Approaches to the preparation of nursing students for a successful transition into the workplace have been found to be ineffective. The majority of the faculties encourage dependent work behaviors in students and not development of problem-solving skills. Such educators decrease students' self-esteem and negatively affect their self-concept and self-confidence (Adib Hajbaghery et al., 2004). Nurse educators have the opportunity to promote improved patient outcomes in the future by facilitating an EBN approach within clinical nursing education (Penz & Bassendowski, 2006). However, clinical faculties do not have enough authority to apply this approach in the clinical setting.

Also, managers and educators need to be committed to the principles of evidence based practice (EBP), provide resources and create a supportive environment for its implementation. Moreover, researchers should work with practitioners to generate high-quality evidence to support nursing practice (Adib Hajbaghery, 2007). Table 4 illustrates some recommended strategies to reduce the gap between theory and practice.

Table 4.  Recommended strategies to reduce the gap between theory and practice
Conducting related researches
Improving access to research findings
Educating nurses to critically assess and analyse research
Establishing evidence based nursing (EBN) groups
Holding research utilization conferences
Providing partnership between researchers and decision-makers
Conducting multidisciplinary research
Teaching evidence based practice (EBN) at different educational levels
Teaching problem-solving strategies
Encouraging independent behavior among students
Increasing the authority of clinical faculties to apply EBN
Providing resources and creating a supportive environment

Based on the above-mentioned points on the challenges faced by Iranian nursing and their corresponding strategies, the authors suggest the changes listed below should take place in order to help Iranian nursing to reach its deserved status.

Need to establish community- based nursing care

Historically, nurses have worked predominantly in hospitals. A smaller number of nurses work in other settings, such as clinics, polyclinics, and private health agencies to provide nursing care at home (Tabari Khomeiran & Deans, 2007). It is necessary that nurses should be embedded in community-based health-care services to improve public health. However, most Iranian nurses work in hospital settings and their role in the Iranian health system is limited to acute care. Hence, more efforts are needed to change policy-makers' decisions on this issue.

Need to revise the student recruiting system

The current student recruiting system, in which authorities rely solely on NHEEE scores, has caused some problems. Students who enter the nursing schools under this system often have little or no information about nursing as a career, and some of them even enter the nursing program with reluctance. While some of these students are dissuaded from studying nursing, there is a risk that many others have insufficient motivation to strive to be a competent nurse (Tabari Khomeiran & Deans, 2007). Thus, an efficient way of improving the nursing student recruiting system should be designed, which focuses its attention on the screening of nursing applicants for key characteristics of ideal nurses, such as patience, interest in solving patients' problems, and informed selection of nursing as a future career.

Need to reform the nursing education curriculum

The PHC system in Iran was established in response to health-care needs identified in surveys, but such needs change over time. For example, new issues include urbanization, increased overcrowding, pollution, and chronic diseases in the elderly (Asadi Lari et al., 2004). As health needs have a dynamic nature and change over time, revising the current nursing curriculum in order to respond to these dynamic changes is necessary. For example, the aging population (65 years and over) that constituted 4.6% of Iran's population in 2005 (World Health Organization, 2008b), is expected to increase to 10.3% by 2021 (Cheraghi et al., 2005). Hence, future demand for competent nurses is expected to increase, with greater attention to geriatric nursing (Nikbakht Nasrabadi, Naji, Mirzabeigi, & Dadbakhs, 2007). Also, man-made or natural disasters appear to be occurring more frequently around the world (Nikbakht Nasrabadi et al., 2007). Iran is situated in one of the most disaster-prone regions of the world and is ranked as the fourth most disaster-prone country in the world (International Federation of Red Cross and Red Crescent Societies, 2008). Iran was confronted with more than 34 out of 41 types of known natural disasters (Ghanefar & Tabar, 2005). Iran is exposed to a range of natural hazards, including earthquakes, floods, and drought, as the most frequent disasters and is very prone to seismic risks (International Federation of Red Cross and Red Crescent Societies, 2008). Throughout history, this nation has frequently suffered large and devastating earthquakes that have caused heavy casualties as well as widespread economic losses (Nateghi-A, 2000). Therefore, nurses in all specialties should be prepared to care for people affected by disasters. It is suggested that disaster nursing be developed as a specialty in the nursing program (Nikbakht Nasrabadi et al., 2007). Glick, Jerome-D'Emilia, Nolan, and Burke (2004) have also emphasized the importance of collaboration between public health departments, local hospitals and nursing schools in the community to address disaster preparedness.

Moreover, Iran, as a religious country and with a humanistic approach to care rooted in Iranian cultural context, experiences conflict with the biomedical approach advertised in today's curriculum. Therefore, the nursing education curriculum should be reformed in order to make it compatible with the context as well as to coordinate it with the newly emerged philosophical and theoretical caring perspectives.

CONCLUSION

Accessibility to advanced technology and greater emphasis on cost-effectiveness factors have led to many changes in the structure, organization, and delivery of health-care services in Iran. The changes will have direct impacts on nursing, and will play a major role in restructuring future nursing.

Although the nursing profession in Iran has witnessed many improvements in recent years, it also faces a number of challenges, many of which may be universal. The main Iranian nursing challenges include nursing staff shortages, job dissatisfaction, poor social position of nurses, and the gap between theory and practice.

Because nursing care has a prominent role in patient satisfaction (Wagner & Bear, 2009), the authors suggested some strategies that could improve the working condition of nurses and lead to a higher level of quality of care and patient satisfaction.

This is a critical period in the history of nursing. Nurses must seize the opportunity to market nursing's role. Nursing should focus on its successes and contributions and better educate consumers concerning nurses' capabilities, which will lead to consumer requests for nurses to care for them. The public needs to view nurses as an integral part of the health-care system, capable of providing holistic nursing care. Perhaps it can now be said that the traditional public image of nursing should be eroded and slowly replaced with a more realistic and accurate one that truly reflects the unique and valuable work of nurses.

The authors hope that increasing the number of nurses with higher degrees and improving work conditions will facilitate the development of nursing, improve the status of Iranian nurses, and encourage young adults to consider nursing as a respectable career. However, there is still an enormous amount of work needed to be done to solidify the gains and resolve social, cultural, and economic issues.

Ancillary