The Structure of Nursing Legislation in Iran from the Perspective of Nursing Policymakers: A Qualitative Study

Nasim Hate -Moadab Tehran University of Medical Sciences https://orcid.org/0000-0003-4905-8003 David C Benton National Council of State Boards of Nursing Nooredin Mohammadi IUMS: Iran University of Medical Sciences Heydarali Abedi : Islamic Azad University Khorasgan Branch Maryam Hazrati Shiraz University of Medical Sciences Alireza Nikbakht Nasrabadi (  nikbakht@tums.ac.ir ) School of Nursing and Midwifery,Tehran University of Medical Sciences https://orcid.org/0000-00023970-4158


Nursing Legislation
According to the U.S. National Library of Medicine de nition (1) nursing legislation is de ned as "Laws and regulations, pertaining to the eld of nursing, proposed for enactment by a legislative body" As it is clear from this de nition, nursing can and is directly affected by the legislative structure and its associated governance. So, as Aiken et al (2) highlighted in their study, nursing regulators must be aware of their own legislative framework and as Benton (3) identi ed there is a need to understand the evolving trends that are taking place if a regulatory model t for the future is to be designed and implemented.
There are different types of legislative framework all around the world (Benton et al, 2013(Benton et al, , 2015NCSBN, 2020). Studies of these frameworks are essential in providing information that can assist public safety, nursing progression and health policy makers to inform and in uence the future of care delivery (4).
Furthermore, the Institute of Medicine (IOM), in its landmark report, The Future of Nursing: Leading Change, Advancing Health (5) offered similar sentiments. Additionally, the IOM in this report went on to challenge the nursing profession to ensure that nurses actively participate as leaders in decision making about health, health care and health policy (6). This theme has been repeated in the recently published State of the World Nursing Report (7). In this report, WHO has highlighted the need for nurses to be more effective and engaged in health policy and policy making through understanding the structure of legislative systems of government. This study aims to explore the structure of the nursing legislation system in Iran and highlight issues that have emerged as a result of responding to the COVID-19 crisis.

Design
A qualitative design using a content analysis approach was used to conduct this study from 2019 to 2020.

Participants
Using purposive sampling, 15 nursing policymakers currently working in regulatory bodies or who have had experience in this eld were interviewed. The sampling criteria were as follows; 1. The participants had to have experience in the eld of nursing or health legislation at least for two years 2. participants were drawn from various governmental and non-governmental institutions related to health policy.

Data collection
In addition to semi-structured interviews, reviews of the governmental websites were used for data collection. The interviews were conducted by the rst author (N.HM) and each interview lasted for 45-60 min. The interviews began using an open-ended and general question about the nursing legislative structure in Iran such as "Please according to your experience explain the nursing legislative process in Iran". Also, based on their responses, more questions were asked to gather in-depth data, including "Can you provide examples of the laws that have been enacted in the Parliament?" and "Can you explain which organization or regulatory body contribute to or play a role in the nursing legislative process?" The interviews were audio recorded and transcribed verbatim. These interviews were augmented by conducting a systematic search of governmental websites to examine, validate and evaluate how the various nursing regulatory bodies have played a role in the nursing legislative process in Iran. This provided a means of triangulating the data gathered from the interviews. The Demographic characteristics of the participants is shown in Table 1.

Data analysis
Data were analyzed concurrently with data collection using Graneheim and Landman's (2004) approach of qualitative content analysis (8). The transcribed interviews, and identi ed text from the various websites were read several times to obtain a general understanding. First, the meaning of units and phrases signi cant to the topic were outlined. The initial codes were then extracted and grouped into categories and subcategories based on similarities and differences. Finally, similar categories were grouped and labeled as major categories and subcategories (9). The data was managed with MAXQDA software version 10.

Rigor
To enhance the trustworthiness, the criteria proposed by Lincoln and Guba were followed (10). Long-term engagement with the data, by all four authors, provided a means of reaching consensus through research-team member checking. After analyzing the responses, short versions were returned to some participants to ensure the researchers' understanding was congruent with their intended meaning. For con rmability, the codes and categories were double-checked by the authors. To maintain dependable and transferable of results, we outlined a transparent methodological process and provided an in-depth description of the phenomenon for easy comparability (10).

Results
From the qualitative data analysis, 80 primary codes emerged, which were nally ordered into three main categories; Competent authorities, Advancing the profession of nursing and COVID19 as an opportunity window which the rst category having four subcategories and the second and third having two, Table 2.

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 o cially recognize the right of sovereignty of people. The rst 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 re ected 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 " 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".

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.

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.

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 de nitions, 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 nonnurses 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, de ne scope of practice for the various levels of nursing a view also expressed by Russell (2017). Speci cally, Russell highlights that in all the NPAs, there should be an explicit de nition of the title and scope of nursing practice. The language of NPA generally de nes 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 de ne 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"

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.

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 pro le 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"

Discussion
The purpose of this study was to identify and describe the structure of nursing legislation in Iran and the effect of COVID-19 pandemic. The ndings show that there are four main organization/entities playing roles in the nursing legislative process: The Deputy of Nursing, the Iranian Board of Nursing, the Iranian Nursing Organization and the Parliament of Iran. The history and description of these organizations has been delineated. It has also been identi ed and explored that most of the Iranian nursing policymakers believe that there is an essential need to de ne the position of nursing through an Iranian Nursing Practice Act. If we consider this as a new policy for the future of nursing which will require to be enacted in the Parliament, policymakers must use the opportunities the current crisis presents and leveraging the positive support afforded to the profession at this time. This approach would be congruent with what John Kingdon (27) represent in his Multiple Stream Framework (MSF). Kingdon's framework includes three elements or independent streams; the problem, policy and political streams. The interaction between these three streams determines the process of agenda-setting and effective policy implementation when all of these streams converge, taking advantage of an open policy window.
Examination of the MSF framework would suggest good alignment with the existing model. That is a lack of a Nursing Practice Act in Iran is a serious problem which is the rst stream. This absence can have undesirable consequences both for the public and nursing community. For example, when there is no law that determines who is a nurse or what is their scope of nursing practice at the various levels, then this may result in inappropriate deployment of health workers and reduction of quality of nursing care (28). Furthermore, when there is no cohesive law about who will address nursing violations, and these violations are dealt with inconsistently by employers or by physicians, this calls into question professional independence and potentially compromises public safety .
Kingdon's MSF, second stream focuses on policy solutions and can be informed by the question; what solutions have been found and adopted by individuals or groups to address this identi ed gap?
To answer this question, this study shows that the nursing community in Iran is proposing and seeking the approval an Iranian Nursing Practice Act (INPA), through the Parliament. This important action can give Iran's nursing legal standing that will protect the public and advance the profession. This would place the profession in a better position to contribute to policy and other fora. In the United States, all states and territories have a NPA which establishes a board of nursing (BON) with the authority to develop administrative rules or regulations to clarify or make the law more speci c. These rules and regulations must be consistent with the NPA and cannot go beyond it. They undergo a process of public review before enactment. Once enacted, rules and regulations have the full force and effect of law (29).
The third stream in Kingdon's MSF, is the political stream and requires a focus on the political factors that can in uence the process of enactment an Iranian Nursing Practice Act. According to the ndings of this study, for achieving this important goal there must be synergy between different nursing regulatory entities in Iran. There are three main nursing regulatory entities and two of them (The Deputy of Nursing and Iranian Nursing Board) are in the Ministry of Health and Medical Education, under supervision of the Cabinet. The third, the Iranian Nursing Organization is a non-governmental organization under the supervision of the Parliament. For achieving the desire identi ed by respondents to enact an INPA, nursing policymakers must be able to use the art of diplomacy such as lobbing. They should be able to convince the members of parliament about the necessity of passing this law and along with this, be in harmony with each other. This is what Prestia (30) highlighted in her study. She points out that today's nursing systems requires strong nurse leaders to effectively and diplomatically manage their teams. In her mind, there should be consistency, collaboration, clarity and communication between groups for successful diplomatic leadership. Moreover, Benton (31) recommends the art of nursing diplomacy as an essential instrument for the profession to play its full role in nursing, health and wider policy elds.
In Kingdon's MSF, the implementation of a policy innovation happens once a window of opportunity for policy change, we contend that based on the ndings of this study and the impact brought about by the COVID-19 pandemic such an opportunity window for all nursing policymakers currently exists. This pandemic despite all the problems it has presented can be the opportunity that the profession is looking for to address this long-identi ed gap in assuring public safety and advancement of the professions. Now, all the society from the public to the Parliament have a positive view of the nursing community as a sacred profession there is an atmosphere in the parliament conducive to taking positive action towards the passage of an INPA.

Limitations
Due to the outbreak of COVID-19 some of the interviews had to be conducted through telephone interviews at a time when respondents were extremely busy. Using a telephone interview may have resulted in loss of data such as a missed opportunity to note dissonance between what was being said and associated body language. Picking up on these anomalies may have resulted in a deeper understanding of some of the issues. Nevertheless, many useful insights were obtained and this does provide a useful basis for further study.

Conclusions
As indicated by the Institute of Medicine Report (32) and the recently published WHO (7) State of the world nursing report nursing must be cognizant of the structure of nursing legislation in our society. This study describes the structure of nursing legislation in Iran and identi es and highlights those entities that have role in this process. We have identi ed a strong desire to develop and implement a Nursing practice act that would support public safety and help advance the profession. The study has identi ed two ways to initiate nursing legislation in Iran. The rst, is through government ministries and the other through the Parliament. The authors conclude that there is an essential need to enactment an Iranian Nursing Practice Act. To achieve this goal nursing policy makers must be able to convince members of the Parliament about this necessity and capitalizing on the current positive view enjoyed by the profession. The pro le brought, as a result of the profession's contribution to addressing the COVID-19 pandemic, and through taking coordinated action we conclude there is an opportunity to take full advantage of the current policy window and achieve the enactment of a nurse practice act in Iran.

Implications For Nursing Policymakers
There is a growing interest in nursing role in health policy. This study describes nursing legislation in Iran and provides information that can assist nursing leaders and policy makers wishing to inform and in uence the future of care delivery. Accordingly, we postulate: -Nursing Practice Act is an essential part of nursing profession for every country such as Iran.
-The art of diplomacy is an essential skill for nursing leaders.
-The COVID-19 as a gate-crasher, provides such a golden opportunity window for nursing policy-making.

Ethics approval
This paper is a part of a PhD thesis and was approved by the ethical committee of Tehran University of the Medical Sciences (decree code: IR.TUMS.VCR.REC.1398.452). In this study, Participation was voluntary and participants were asked to give consent for audio recording after explaining the purpose of the study.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare no potential competing interest. Funding