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|
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.