Iranian nurses' perception of the public image of nursing and its association with their quality of working life

Abstract Aim To investigate the association between the nurses’ perception of the public image (PI) of nursing and the quality of nursing work life (QNWL). Design A descriptive correlational study. Methods 250 nurses of 12 hospitals affiliated with Tabriz University of Medical Sciences were sampled using a proportionate stratified sampling technique. Porter Nursing Image Scale and Brooks QNWL Scale were used for collecting data. Results There was a significant positive correlation between nurses’ perception of their public image and QNWL (r = .158, p = .012). Nurses’ perception of their PI along with other significant predictors including gender, age, position, work shifts, residency, financial status, level of family support, spouse's education and spouse's job significantly explained 15.2% of the predictability of QNWL (F (10,175) = 3.017, p = .001). Findings imply that enhancement of nurses' psychological status (nurses' perception of the public image of their profession) may improve their functional status (quality of nursing work life).


| INTRODUC TI ON
The public image (PI) of nursing, which incorporates beliefs, ideas and impressions that people have of nurses and nursing, has always been a socio-cultural issue for this profession (Emeghebo, 2012, Wallace, 2007. Recently, the environment in which nurses do practice has changed and this change foreshadows significant evolutions in the nursing profession (Maxwell, 2015). There is ample evidence that the PI of nursing has improved globally, especially in developed countries, which holds high value and reputation for the nursing profession. However, there still remains some negative view with regard to the PI of nurses (Meadus & Twomey, 2007;ten-Hoeve et al., 2014). For example, in a recent integrative review, Glerean et al., (2017) found that young people's perceptions of the nursing profession were outdated, partly unrealistic and did not reflect the tasks of a modern nurse. According to the results of this review, these perceptions were largely influenced by social factors such as family and relatives, friends, media and significant others (Glerean et al., 2017). In developing countries, the public has a stereotypical view of nursing, in which nurses may be regarded as less intelligent than doctors, dependent on doctors, powerless and underpaid Price et al., 2013). This view, however, is not an accurate portrayal and is fuelled by misconception, misinformation and in some instances, by the actual realities of the profession (Cowin & Hengstberger-Sims, 2006;Jinks & Bradley, 2004).
In Iran, nurses are striving to gain respect from the public; however, they are fighting to develop from a subordinate position inherited over the years (Farsi et al., 2010;Nasrabadi et al., 2004, Salsali, 2000. Many Iranian nurses suffered from a poor PI and a low social status which resulting in feelings of frustration, general dissatisfaction, hopelessness and confusion about self-image and social identity (Nasrabadi et al., 2003). According to Varaei et al. (2012), in Iranian health care, the public often holds a negative stereotypical image of nursing, nurses and the role they play. This negative stereotypical image contributes to nurses' perception that their work is not appreciated or respected (Varaei et al., 2012). Similarly, Vaismoradi et al. (2011) identified the lack of a clear and acceptable PI of nursing as one of the main barriers to the development of nurses' professional identity (Vaismoradi et al., 2011). In another qualitative study, Valizadeh et al. (2014) discovered that the public considers nursing as a feminine, physician-subordinate and unrecognized career in Iran. They also identified that the feminine image of a "nurse" is a potential barrier for men considering nursing as a career and the majority of male nurses experienced significant personal, family and community resistance to entering a nursing profession (Valizadeh et al., 2014).
Overall, literature suggests that the PI of nursing impacts nurses' psychological and functional states. A positive PI of nursing is one factor which reflects high-quality nursing care and is recognized by nurses and other groups for the difference it makes to patients' well-being and will contribute to the empowerment of the profession (Takase et al., 2002, Ulmer, 2000. On the other hand, a poor PI of nursing is one of the biggest barriers to professionalization (Habibzadeh et al., 2013), professional socialization (Valizadeh et al., 2016b), professional autonomy (Roshanzadeh et al., 2018) and professional identity (Valizadeh & Ghorbani, 2016) of nursing in Iran. A poor PI of nursing may negatively impact not only the recruitment and retention, but also the attitudes towards work, work behaviours and performance of those in the nursing profession (Takase et al., 2002, Wallace, 2007. Likewise, a number of studies have contended that the social world nurses live in has an impact on nurses' professional world. They have reported that the quality of nursing work life (QNWL) is seriously influenced by the PI of the nursing profession (Mohammadi et al., 2011;Takase et al., 2002;Zamanzadeh et al., 2013). However, this assumption has not yet been explored sufficiently and the extent of this association is still uncertain due to a lack of evidence.
According to the O'Brien-Pallas and Baumann framework used by Brooks, QNWL is the degree to which nurses are able to satisfy important personal needs through their experiences in their work organization while achieving the organization's goals. The framework is synthesized into four dimensions: (a) work life-home life, (b) work design, (c) work context and (d) work world (Brooks & Anderson, 2005). Based on the socio-technical systems theory, assessing QNWL focuses on identifying opportunities for nurses to improve their work and work environment and affords organizations an opportunity to understand how work environments, work design, societal influences, and work and home life balance issues impact nurses' working life and ultimately organizational productivity.
Hence, assessing QNWL reveals areas for improvement where the needs of both the employees and the organization converge (Brooks et al., 2007). Therefore, given the importance of these two issues and their direct or indirect effects on the quality of health care, it is imperative to investigate different dimensions of nurses' perception of their PI and the extent to which this perception is associated with QNWL in Iran. Since the status of the nursing profession, nurses' perceptions, PI of nursing profession and QNWL may differ among cultures and countries, it is anticipated that the findings of this study will improve our knowledge and understanding of similar contexts with evolving healthcare systems that differ from the United States and the European systems. This study aimed to examine the nurses' perception of the PI of nursing and its association with QNWL in the Iranian context.

| The healthcare system and nursing in Iran
Iran is a developing country located in the Middle East of Asia with a population of approximately 83 million in 2020 (Sadeghi et al., 2020). The Iranian healthcare system is based on three pillars: the publicgovernmental system, the private sector and non-governmental organizations. It is highly centralized and almost all of the decisions about general goals, policies and allocation of resources for an extensive healthcare network that offers basic healthcare services in addition to public health programmes, such as primary, secondary and tertiary health care, and medical education are made at the national level by the Ministry of Health and Medical Education (MOHME) in the Iranian government (Azizi, 2007). The ministry consists of nine deputies as follows: deputy for food and drugs; deputy for research and technology; deputy for health; deputy for education; deputy for culture and students' affairs; deputy for treatment; deputy for legal, parliamentary and provincial affairs; deputy for management development, resources and planning; and deputy for nursing (Mosadeghrad & Rahimi-Tab ar, 2019). Yet, the ministry delegates its responsibilities to over 60 affiliated universities of medical sciences and health services across the country. There is at least one university of medical sciences and health services in each province whose president is the highest health authority in that province and reports to the Minister of Health and Medical Education. Moreover, the ministry and the affiliated universities of medical sciences and health services have the legal authority to oversee, licence and regulate the activities of the private health sector (Mehrdad, 2009).
Meanwhile, nursing forms the largest body of employees in the Iranian healthcare system, working across all segments of care. Nursing in Iran has witnessed profound advancements in the past few decades despite numerous issues and challenges that still exist (Ahmadi-Chenari et al., 2020). Early nursing in Iran was influenced strongly by the British nursing tradition, characterized by an apprenticeship style of nurse education. However, this influence has been replaced largely by transferring all registered nursing education into the university-based higher education sector. This change has led to a remarkable increase in scientifically educated nurses, quality and quantity of nursing researches, and qualified nursing faculties. Thereby, it has enhanced the professional status of nurses in Iran (Nasrabadi et al., 2004).

| Design
This descriptive-correlational study was carried out as a nursing master thesis approved by the institutional review board and the research ethics committee of Tabriz University of Medical Sciences (TUOMS). Moreover, study objectives were explained to the hospital officials, and permissions were obtained from them before data collection.

| Setting and participants
The study was conducted on a sample of nurses working at 12 university hospitals in Tabriz, Iran, from April-September 2018. The participants were chosen using a proportionate stratified random sampling technique. This was a combination of stratified sampling technique and proportional sampling technique followed by random sampling technique. First, the sample size of each university hospital was calculated proportionate to the population size of each university hospital. That is, the size of the sample drawn from each stratum is proportional to the relative size of that stratum.
Following these calculations, the researchers performed simple random sampling in each of the 12 university hospitals to select participants using the lists of nurses drawn from each university hospital.
Study inclusion criteria were as follows: (a) having a minimum of a bachelor's degree in nursing, (b) having at least 6 months of clinical work experience and (c) currently working as a nurse in one of the study settings. Being unwilling to participate in the study and incomplete questionnaires were the exclusion criteria. None of the participants met the exclusion criteria, and no one was excluded from the study. Following sample size calculation from each university hospital, a pilot study was carried out using 30 randomly selected eligible nurses of 12 university hospitals in the city of Tabriz. This was to determine initial data for performing a proper sample size calculation and to test for the applicability and clarity of the data collection instrument before proceeding with the main study. The data from the pilot study were not included in this study because it represented an initial validation of our methods. In the G*Power 3.1.2 software, a two-tailed test of the correlation coefficient in the bivariate normal model was used with the following input parameters (an alpha [α] error probability of .05, power of .8, correlation probability H 1 of .174 and correlation probability H 0 of zero) which yielded a sample size of 256 participants. Then, the calculated sample size was modified to 233 participants by finite formula (given the total population size of 2,625 nurses working at university hospitals of Tabriz) and assuming a non-response rate of 10%. The final sample size was determined to be 250 participants.

| Statistical analysis
Descriptive analysis included frequency and percentage for discrete data, mean and standard deviation (SD) for normally distributed continuous data, and median and interquartile range (IQR) for nonnormally distributed continuous data. The standard scores were also calculated for nurses' perception of the PI of nursing and QNWL, so they can be compared. Pearson correlation test was also used for evaluating the relationship between nurses' perception of the PI of nursing and QNWL. On the other hand, a multiple regression analysis was developed based on a two-step hierarchical strategy.
In the first step, a backward strategy using statistical differences analysis (including independent samples t test and one-way analy-

| Ethical considerations
The study was approved by the Institutional Review Board and the regional Research Ethics Committee of TUOMS (ethics code: IR.TBZMED.REC.1397.109). Moreover, permissions were obtained from the officials of the university hospitals. Each participant signed a consent form before the questionnaires were handed out. The questionnaires were completed in an anonymous manner, and respondents were assured of the confidentiality of their responses.

| RE SULTS
All distributed questionnaires were completed and returned (response rate = 100% As shown in Table 2, the total mean score of the nurses' perception of the PI of nursing was 123.7 ± 41.4 while the total mean score of the QNWL was 145.5 ± 26.9. Among the subscales of Porter Nursing Image Scale, "intrapersonal ability" had the highest mean standard score (53.6 out of 100), followed by "interpersonal relations" and "interpersonal power." On the other hand, "work design (profession)" had the highest mean standard score (58.2 out of 100) among the subscales of Brooks QNWL Scale while "work world (community)" had the lowest mean standard score (41.6 out of 100).
All pairwise Pearson's correlation coefficients were calculated to evaluate the possible relationship between the subscales of both Porter Nursing Image Scale and Brooks QNWL Scale, as presented in

| D ISCUSS I ON
Our study showed a positive relationship between the nurses' perception of the PI of nursing and the QNWL which implies that nurses' negative perception of the PI of their profession is associ-

TA B L E 3
The relationship between nurses' perception of the PI of nursing and QNWL (Kalisch et al., 2007). Similarly, an Australian study carried out by Takase et al., (2006) investigated how nurses' interpretations of the PI of nursing affect work behaviour and showed that perceived PI of nursing was strongly related to nurses' job performance and turnover intentions (Takase et al., 2006). Kemmer and Silva (2007) also concluded that a negative image diminishes nurses' ability to change the directions of health care (Kemmer & Paes-da-Silva, 2007).
Furthermore, this study showed that Iranian nurses' own perception of the PI of their profession was at a moderate range. However, the previous studies revealed a negative image of nursing in Iran and believed that the nursing profession is not well perceived by the public (Nasrabadi et al., 2003;Vaismoradi et al., 2011;Varaei et al., 2012). Varaei et al. (2012) described the domains of "characteristics required for entry to work," "social role characteristics of nursing" and "prestige, economic, social status and self-image" as the determinants of this negative PI in Iranian nurses (Varaei et al., 2012). A recent study conducted by Ameri et al. (2018) also uncovered the key role of the Islamic Republic of Iran Broadcasting in distorting the PI of nursing, as it left the viewers with a false negative and inaccurate outlook and mindset of the nursing profession (Ameri et al., 2018). Likewise, in Iranian television and media, nurses are hardly seen as a professional consultant or expert, but mostly as a feminine and physician-subordinate career (Valizadeh et al., 2016a).
In Iran, there is a substantial gap between the image of the nursing profession as perceived by nurses and that of the public . The Iranian public has a fuzzy image of nurses which derives from their lack of recognition and knowledge about nursing roles, responsibilities and competencies. This public's lack of awareness of the nature of current nursing work may partly be a result of the nurses' expansion into other healthcare fields, which has blurred professional boundaries between nursing and other healthcare professionals (Doiron et al., 2008;Lewis & Urmston, 2000). Also, there is still some adherence to the old traditional image of nursing in Iranian society considering nurses as an angel, handmaiden and/or battleaxe. Besides, part of the poor image is due to the semantic ambiguity of the term "Parastar," the Persian form of the term "nurse" and the improper and unprofessional use of this term in Iran, since Iranians define "Parastar" as someone with limited or no education who provides any type of care, such as a ward orderly, hospital attendant, nursing assistant or someone caring for children or the elderly at home .
On the other hand, the nurses' own perception of the PI of nursing is mostly positive. It can be inferred that this positive perception has partly resulted from recent advancement in the field of nursing education, practice and policy in the Iranian healthcare system. In Unlike the previous studies in Iran, our study indicated a more positive PI in male nurses than female nurses which may be explained by better job opportunities and security for male nurses as compared to the other professionals at the current financial and economic crisis in Iran.  also stated that the Iranian patriarchal healthcare system helps male nurses move up the ladder through the support they receive from physicians, and offer them unique career insights with higher pay (Valizadeh et al., 2016a).
Moreover, an extensive review of the literature shows that the actual PI of nursing is globally diverse and incongruous, depending on the country and the culture, nurses live and work in. However, this image is mainly positive in developed countries with advanced health care and nursing systems and partly negative in low-and middle-income countries with less advanced healthcare and nursing systems (Kalisch et al., 2007, Kemmer & Paes-da-Silva, 2007, Dahlborg-Lyckhage & Pilhammar-Anderson, 2009, Ben-Natan & Becker, 2010, de-Araujo-Sartorio & Pavone-Zoboli, 2010, Katz, 2007, Donelan et al., 2008, Huffstutler et al., 1998, Karanikola et al., 2011, Ozakgul et al., 2017. The finding that QNWL is not at a favourable level in Iran is consistent with existing literature (Moradi et al., 2014;Nayeri et al., 2011;Mohamadi et al., 2014;Fallahee-Khoshknab et al., 2007;Habibzadeh et al., 2012;Dargahi et al., 2007). The results from another Iranian study reflected a positive significant relationship between the QNWL and the nurses' productivity (Saber et al., 2013).
Two recent studies also concluded that the QNWL can well predict the nurses' burnout (Farsi et al., 2010) and tendency towards turnover (Almalki et al., 2012), that is, the higher the QNWL, the lower the burnout, the lower the tendency towards turnover. In studies carried out in the United States and Canada, it was found that income, autonomy and professional independence were among the important factors improving the quality of nursing work life. However, ambiguous organizational goals and policies and job stress significantly contributed to the nurses' dissatisfaction with their quality of working life (Nowrouzi et al., 2016;Best & Thurston, 2006). It is noteworthy to mention that the understaffing; heavy workloads; unconventional work hours; lack of support from managers and supervisors; inequality and discrimination in practice and workplace; conflict with colleagues, managers, and doctors; lack of opportunities for advancement; lack of appreciation from superiors; and lack of appreciation from patients and their relatives are some of the major hurdles in Iranian nurses' context of practice which explain their unfavourable quality of working life (Valizadeh et al., 2016a).

| Limitations
Despite the strengths of this study, it has certain limitations. First, we only studied a sample of nurses working at university hospitals of a metropolitan city in the northeast of Iran and a broader range of nurses in other regions may produce different results. Therefore, a cautious interpretation and application of the findings are necessary and future studies with broader samples should be conducted in different regions of Iran and diverse populations in different cultures of the world. Another potential limitation is the self-report nature of our questionnaire meaning that, in some cases, the participants might not have disclosed their real viewpoints and described their perception of the PI of nursing and/or their quality of working life to be better or worse than it really was. To combat this, we explained the objectives of the study and debriefed the measures taken to the study participants if required. Finally, the scales used in the questionnaire were developed in 1991-2001, and therefore relate to a time when nursing globally and culturally was very different. It would be useful if the questionnaire was updated for cultural relevance and incorporate more contemporary elements. Variations in the motivational characteristics, lived experiences, mental condition and cultural features of the participants were also of the factors influencing how they define the PI of nursing and quality of working life and might impact the results of the present study that, of course, were beyond the control of the researcher. Despite these limitations, however, we believe that the findings can be reasonably interpreted in terms of cultural differences between the countries concerned and provide an adequate snapshot of the QNWL for the study participants. and functional (quality of nursing work life) states. Also, more effective steps should be taken to provide professional orientation for nurses and nursing students and motivate them to improve the PI of nursing through better performance.

ACK N OWLED G EM ENTS
The authors would like to thank all those who spent their valuable time participating in this research project, and we are also immensely grateful to the "anonymous" reviewers.