Three main categories emerged from the data and each has 1–3 subcategories. These categories and their subcategories are representative of the main factors influencing the empowerment of nurses/nursing in Iran.
Category 1: personal empowerment
According to the participants, personal empowerment is dependent on three variables, these are "having authority" and "professional self-confidence" for the "application of professional knowledge and skills." According to two nurses, "A powerful nurse is one who has good knowledge and can use it well" and "The power of a nurse depends on his knowledge and skills as well as his self-confidence in application of his knowledge in the provision of care for their clients." Furthermore, participants pointed out that the culture and structure of organization negatively impacts nurses' self-confidence and authority and it is one that emphasizes "physician centeredness". Two participants noted that "I must have the right to do nursing care based on my diagnosis, but I haven't this authority now," "a person can be powerful only when he/she can decide on his/her own." Others pointed out that "the public hasn't an appropriate view on the nursing profession," "nurses cannot provide their own services to the public directly and people go to the doctor first," "nurses are only expected to do the doctors orders," "their workloads are high," and "there isn't any system for nurses' continuing education." Collectively all these variables have a negative effect on nurses' self-confidence and minimized their ability to exercise authority or power in the practice setting.
Category 2: collective empowerment
According to the participants "collective power" of nurses or the power of the profession of nursing comes from the interaction between two variables "supportive management" and "unity."
They considered the unity of nurses and coming together in nursing organizations as an efficient way to increase their professional power. Two participants commented: "to me the most important factor in the power and influence of a profession is the unity of its members". "We could be powerful when we are together and the best way for this is connecting to the nursing association, by this we can develop standards and regulations for our profession and these are the important prerequisites for supporting the nurses as professionals. These are prerequisites for determining our domain of professional authority."
The participants were aware that collective power brings them the possibility for obtaining better working condition as well as professional self-regulation. Also, collectively their voices are stronger and more influential. The latter would make it possible for them to develop standards for their profession and clearly define the scope of authority and responsibility of each nurse in his/her specific setting. Thereafter, these nurses will be able to apply their professional power in their practice settings to provide high-quality patient care. Nurses frequently stressed that supportive management will empower them. The participants' views and experiences on supportive management were categorized under the three subheadings of "provision of job related supports," "provision of financial support," and "provision of emotional support." However, a feeling of being unsupported was dominant among nurses. Shortage in the nursing workforce and lack of supplies such as sheets, dressing equipment and so on, prevented nurses from applying their professional knowledge and skills. Consequently, they were unable to meet their clients' needs, which give them a feeling of inadequacy and dis-empowerment.
Category 3: the culture and structure of organization
The culture and structure of the health care system was another important factor that either facilitated or inhibited nurses' abilities to feel empowered. As participants indicated, these factors hindered the nurses' power in the patient care settings. This is true; when nurses are part of an organization that is "physician centered" they are almost extinct. One nurse manager noted "the nurses capabilities are not use appropriately because of some cultural and organizational factors". Data related to the cultural and organizational variables were categorized under two sub-headings "the public culture" and "organizational culture and structure."
The public culture
Most of the nurses participating in this study mentioned the poor imagine of nursing being held by the Iranian people. Participants felt that the general public did not recognize the professionalism of nurses. One nurse commented in this regard: "the word nurse generalized to anyone who care for childes, sick or elderly, but not to a person who is expert in professional nursing care." Another nurses stated: "Because of the low social status and a poor public image involved with nursing, I always try to avoid conditions where people ask about my work, so I hate to say anything about it," "We are seen as doctors' handmaidens, for people goes to the doctors first, but they referred them to the hospitals, where nurses are."
The public status of physicians has affected the culture of health care organization. Inter-professional relationships have been affected by this culture and uneven power relations have developed in which the doctors have the last word. One of the participating doctors said: "the culture of health system doesn't regard nurses as professionals. There is an old and unscientific climate that induced a unilateral relationship between doctors and nurses. I think that many physicians don't know the real meaning of nursing."
Organizational culture and structure
The belief that public and organizational culture have led to the development of a physician favored structure in the health care system was well articulated by the majority of participants. This is evident in the following quotes: "the health system is at hands of the physicians," "all of the top managers of health system and also in hospitals are the physicians," "nurses are only considered as tools for carrying out the doctors orders." The design of the nursing system was affected by this physician-centered structure. The participants mentioned three parts of this system which included nursing services, nursing education, and nursing research.
The structure of nursing services
Classifying nursing services as in-patient settings was considered a barrier and limitation to the true potential and capability of the nursing profession. One participant's comment was "there are many nurses with a major in community health but they are not promised for working in the community." According to the participants, the root of this problem lies in the ambiguity of scope and standard of practice for nurses in the national healthcare system. One of the senior nurse directors who hold a position in the ministry of health shared: "we lacked a logic in our health system and also in our nursing system. So, the territory of nursing is not clear," Another participant emphasized that: "we are lacking a defined philosophy for nursing in Iran. This created structural obstacles that limited their power to implement their professional knowledge." It is obvious that there is an emergent need to clearly define the scope and standard of nursing practice in Iran, for only then can Iranian nurses practice as empowered professionals across the different areas within nursing. One of the senior nurses stated: "I believe that defining the mission and territory of nursing is the first step in the restructuring the nursing system." He believed that "we only offer some primary care within the hospitals, while we should integrate our services into the national health system. This is the best way for us to introduce our capabilities to the public." Also, this need is articulated by other nurses as evidenced in their statements "We have not clear professional rules and regulations;" "We don't really have a clear job description... one person's interpretation of what I should be doing could be different to mine... I would have some difficulties with my management over decisions that I would have made and they would say 'you should be doing that', and I would say 'I just can't'."
When the researcher asked the participants "what should be the first step in the process of empowerment of nursing in our country?" they responded, "We should define the personal and professional domain of nurses and their roles and position in health system." They believed that these should be done by the nursing organization. One of the senior nursing directors voiced "a group of specialists in the field of nursing from nursing unions, nursing schools, and the nursing office in the ministry of health should define the domain and roles of nursing...this is after such an important step that we could revise our nursing system and make it empowered so that nurses could implement their professional knowledge and skills for their clients at the level of hospitals and the community." The structure of in-patient nursing services was physician centered and routine-oriented. One of the supervisors stated: "...nothing could be done based on the nursing process...it is expected that nurses only obey orders, give the drugs, monitor the blood pressures ...but that they do not intervene independently." Inadequate staffing and having to perform non-nursing duties were felt to be disempowering and inimical to the recognition of nursing as a profession. These were highlighted as barriers to provide quality nursing care. "We've taken on every role. If something needs to be done and nobody else is going to do it I am compelled to it. There will be trouble if I don't do it" one nurse said.
The structure of nursing education
There was great concern regarding the education system even though this plays an integral role in the process of empowerment. This concern originates from entry into nursing school as supported by the statement of one participant: "entrance examinations only measure the academic capabilities of volunteers but do not measure their compatibility to the nursing profession." Another concern is the curriculum content, it is highly theoretical and one nurse said: "...nurse educators think the best nurses are the nurses who have more medical information. They give them an extensive range of disease-related, pharmacological and physiological information, but don't spend even ten minutes on the nursing care in a class of two hours."
Role models also played a significant role in the weakness of nurses. It seems nurse educators doubt their own confidence, competency, and autonomy and were ineffective role models for students. An experienced nurse educator believed that "due to inexperience and freshness of most of the nurse educators, they lacked self confidence and could not educate a good new nursing generation." A philosophy of nursing education was considered absent and the question at large was "what are the guidelines for nursing education"? Therefore, "there is no relationship between nursing and clinical setting and the clinical setting is inappropriate for students' clinical placement" as one senior nurse director said. As a result of all these factors, nursing schools will continue to graduate dis-empowered nurses.
Providing continuing education was judged critical for nurses to maintain competency in the clinical setting and to become life-long learners so they can develop confidence in "giving voice" to continually improve nursing practice and build a community of empowered professionals. However, low staffing and lack of staff development resources by 'the Ministry of Health and Medical Education' only blocked the cycle of empowerment. As one participant pointed out: "I think continuing education is empowering. People who are educated are more empowered to carry out their work, but the ministry of health doesn't support in-service education for nurses".
The structure of nursing research
Research utilization or the implementation of evidence-based practice was difficult for nurses for a variety of reasons. These are, the traditional structure of hospitals, poor quality of education, lack of continuing education, heavy workloads, no time, no mentoring and/or training in designing and conducting research, lack of financial resources, poorly defined nursing roles, lack of team work, and no opportunities for interdisciplinary relationships. These barriers are evident in the following quote of a nurse educator: "the research findings don't use in our nursing practice at all. We are two groups in nursing. One group is teachers and mainly teaches in nursing schools, another group is clinical nurses who are very busy and are also not educated for doing research... some of nurse educators also conduct researches not to be used in practice but only with the purpose of their promotion."