From the qualitative data analysis, 80 primary codes emerged, which were finally ordered into three main categories; Competent authorities, Advancing the profession of nursing and COVID19 as an opportunity window which the first category having four subcategories and the second and third having two, Table 2.
Table 2
Categories and subcategories related to the participant's experiences on the nursing legislation structure in Iran
Categories
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Subcategories
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Competent authorities
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The Iranian Parliament
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The Deputy of Nursing
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The Iranian Nursing Organization
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The Iran’s Board of Nursing.
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Advancing the profession of nursing
|
|
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The necessity of Nursing Practice Act
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The need to determine nursing position
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COVID19 as an opportunity window
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|
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Loss of opportunities by nursing regulators
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Perceived Positive image of nursing by society
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3.1. Competent authorities
This category refers to the competent authorities for nursing legislation in Iran and describes organizations that playing a role in nursing legislation. There are four subcategories - The Iranian Parliament, The Deputy of Nursing, The Iranian Nursing Organization and The Iran’s Board of Nursing.
3.1.1. The Iranian Parliament
The Islamic Consultative Assembly also called the Iranian Parliament, is the national legislative body of Iran. The Parliament currently has 290 representatives (11). From a historical view; after the Constitutional Movement and following a strike by the Ulama (Muslim cleric) and people, the Mozaffareddinshah of the Qajar dynasty issued an order in August 1896, mandating the formation of a Consultative Assembly. However, four days later, Mozaffareddinshah had to force the government to hold elections and form a parliament to officially recognize the right of sovereignty of people. The first Legislative Parliament of Iran started work in 1942 with an address by Mozaffareddinshah (12). Since 1979, Iran has become an Islamic republic and its territorial integrity is based on Islam (13). Along with this, there is the Guardian Council which not only has the right to safeguard the constitution, but also can choose to review any decision the Parliament takes and interpret it according to the principles of Islam (14). A position that was reflected in the following statement from one of the respondents.
"The law is a word or an enactment that must be approved by the Iranian Parliament. This enactment must be approved by the Guardian Council and then, depending on who is the executor…… for example, if it is the Ministry of Health, it must become Execute rules, regulations and executive instructions "
[Participant No. 4]
3.1.2. The Deputy of Nursing
Participants reported that one of the entities that has the main role in nursing legislation, is The Deputy of Nursing. This Deputy is one of the nine deputies of the Ministry of Health and Medical Education (MOHME (and works under direct supervision of the Minister of Health. This is an emerging position that was founded by the Council of Ministers meeting dated June 2, 2013, based on the suggestion of the Ministry of Health and according to the Note (3) of Article (57) of the Law on the Fourth Five-Year Economic, Social and Cultural Development Plan of the Islamic Republic of Iran(15).
"Stewardship In Health System is responsibility of the Ministry of Health and Medical Education. Therefore, if it is going to be some changes in nursing profession or takes legal aspects…. since nursing is as a part of health system, its rational way is that the Ministry of Health should enter this field ... asking for comments of all stakeholders, because fortunately nowadays the Ministry of Health has a deputy called the Deputy of Nursing that can do this in this position and giving nursing voice to the government and the government to the parliament”
[Participant No. 2]
3.1.3. The Iranian’s Board of Nursing
According to the participants, the Iranian’s Board of Nursing (IBN) is one of the nursing regulators bodies in Iran. This board has the main responsibility for making educational nursing policies (16). It is located in the MOHME and is responsible for the designation of nursing curriculum (17). The IBN controls and supervises the bachelors, masters, and doctoral degrees in nursing. It is also responsible for school accreditation and determining school curricula (18). Participants mentioned that this board does not have any direct power to set educational regulations for nursing profession and its role is limited to an advisor to the Deputy of Education. The Deputy of Education in the MOHME has main responsibility for setting educational regulations and the Iranian’s Board of Nursing is just one of the advisory entities to this deputy.
“We have a nursing board, which is actually an organization that belongs to the Ministry of Health. It does not legislate. All nursing educational issues and processes handle in nursing board. But you know that in nursing, there is no decision-making power in the board”.
[Participant No.6]
3.1.4. The Iranian Nursing Organization
The Iranian Nursing Organization, is an independent organization with legal identity which is established to substantiate the main goals of the nursing community in Iran (19). This organization was approved by the Iranian Parliament in December 2, 2001 (20). Now, the INO has the legal responsibility to represent all nurses in all sectors of nursing(21). According to the law on the establishment and operation of the INO article 2, chapter 1; the main goals of the INO as a Non-Governmental Organization (NGO) is to grow and achieve excellence of nursing profession, defend nursing rights and those of the public regarding nursing services, support moral, material, and professional rights of nurses, promote the knowledge and skill of nurses through staff in-service, introduce nursing to the community, implement Islamic norms and values in nursing, accurately implement medical regulations and ethics in nursing and cooperation with legal authorities in both country and international forums.
“In my opinion, one of the most important nursing institutions that we can mention is the Iranian Nursing Organization due to the legal position of it. The INO is approved by the parliament and some authorities are among the duties of this organization such as excellence of the nursing profession, setting standards ... Ultimately, the legislator has given to the INO the right to do these duties”
[Participant No.2]
3.2. Advancing the profession of nursing
This category refers to necessity of advancing the profession of nursing in Iran. There are two subcategories; the necessity of Nursing Practice Act and the need to determine the position of nursing.
3.2.1. The Necessity of Nursing Practice Act
The majority of participants believed that there is a need for an Iranian Nursing Practice Act in the country. According to their experience there are a few laws in nursing that have been enacted in the Parliament and most of them are regulations that have been via the actions of the MOHME. They explicitly expressed that there is no Nursing Act enacted in the Parliament and this is an urgent need for nursing profession in Iran. The National Council of State Boards of Nursing (NCSBN) emphasizes the importance of having a Nurse Practice Act (NPA) as an instrument for protection of public health, welfare and safety of the public (22). The NPA is a law for governing and regulating nursing care providers (23). It protects the public in several ways such as licenses, disciplines, education, monitors, and rehabilitates(24). According to Russell (2017), all NPAs include definitions, authority, power, and composition of a Board of Nursing, educational program standards, standards and scope of nursing practice, types of titles and licenses, protection of titles, requirements for licensure and grounds for disciplinary action (23) and this is what we have not in Iran’s nursing, according to our participants. Iran’s nursing needs to have a NPA which be enacted by the Parliament and this requires all nursing regulator bodies effort to achieve this important goal.
“Imagine that I am a hospital administrator and for example instead of hiring 300 nurses, I hire 250 non-nurses and about 50 nurses………No one can challenge me about this except in hospital accreditation and reduction the credibility of the hospital. If we have a Nursing Act, they will take me as a criminal who did not follow the law… Nursing Act is a necessity for us and this is a reality”
[Participant No 9]
3.2.2. The need to determine the nursing position
According to the experiences of participants there is a need to determine the position of nursing in the country and the advocate for the establishment through legislation a NPA. Such an act they contend would, define scope of practice for the various levels of nursing a view also expressed by Russell (2017). Specifically, Russell highlights that in all the NPAs, there should be an explicit definition of the title and scope of nursing practice. The language of NPA generally defines who is entitles to use the term nurse and the differences between levels of nursing. These are legally enacted and the entire nation is obliged to observe them. This is currently missing in Iran. Hence, respondents argued here is an essential need to define the position of nursing in a legal way through the enactment of an Iranian Nursing Practice Act.
“If we would have Nursing Act, stakeholders cannot tell us that for example a practical nurse can does nursing work or nursing education duration could be reduced to 3 years or nursing education transmits to hospital from schools… I am saying that we should be strong enough to determine our position, our role should be clear to others, when our role is clear, their acceptance would be easier”
[Participant No9]
3.3. COVID-19 as an opportunity window for nursing policymaking
This category refers to the COVID-19 outbreak as an opportunity window for nursing policymakers. In this category there are two subcategories; Loss of opportunities by nursing regulators and Perceived positive image of nursing by society.
3.3.1. Loss of opportunities by nursing regulators
The experiences of our participants highlight that nursing regulators in Iran have lost many opportunities; which could be a golden time for them regards to legislation. Along with this they mentioned that as nursing policymakers we should learn from past lessons and be able to use our opportunities such as COVID-19 opportunity window that has opened for us.
"Today, in the Corona debate, I think this window of opportunity has been opened. It means if we had prepared something before…. now seems to be the best opportunity to do so…. This can be an example of opportunities that we have lost and failed to take advantage of it”
[Participant No 14]
3.3.2. Perceived Positive image of nursing by society
Some of our participants believed that the current COVID-19 pandemic provides nursing policy advocates with an ideal opportunity for legislative change, a view echoed by Benton et al (25). According to respondents the COVID-19 crisis presents a policy opportunity window as per the policy framework described by Kingdom (26). This crisis has brought unprecedented attention to the nursing profession in Iran - from public to the president and even the supreme leader. During this time when COVID-19 has spread across the country the profile of the profession has been raised and importantly perceived as a holy profession that has been in the service of the nation.
“There is the fact that the Supreme Leader praises nurses three times in four months is not a small thing, the President praises us several times, the Head of the Judiciary has praised nurses, it means that you have been seen as a nurse…. It means that nursing has been seen in this pandemic”
[Participant No.9]