Introduction
As sociological theories assess the concept of social class, occupational prestige reflects social status [1]. The social status of the job determines the status of the occupational prestige, and if damaged, it would lead to stress and uncertainty in the occupational prestige [2, 3]. The high occupational prestige may create high self- confidence associated with high job satisfaction [1, 4]. Respect gained from occupational prestige represents a key pathway to one’s success [5]. On the other hand, low occupational prestige has been associated with the risk of cardiovascular disease, metabolic syndrome, respiratory disease, cancer, and mortality [6, 7].
In a study, people while self-assessing their health, showed that the better their occupational prestige, the better their health scores [8]. Also, research results in California showed that working in an environment full with a sufficiently occupational prestige would reduce depression and job stress [9]. Other studies in Iran have also shown that neglecting the occupational prestige and social status of nurses causes about 70% of job dissatisfaction and, consequently, their unprofessionally performance [2, 3].
Although the role of nurses is important in changing the health care system, planning, and service delivery, unfortunately, the nursing position in Iran is not well understood [10, 11]. Many of the negative perceptions of the community about the nursing profession are due to working as a subaltern of the physician, low academic standards, few job opportunities, and low payments [12].
Lack of independence is one of the factors affecting the nursing occupational prestige [3]. Studies show that patients are more satisfied with the nurses who have more work autonomy, decision-making power, and cooperation with other service providers [13, 14]. Unfortunately, nurses do not have a clear involvement in the treatment process and the physician control all their functions, which leads to stress and may even make them think about getting rid of it [3, 15].
In the resent studies, nurses believe that the general image of nursing in Iran is a relatively negative one, reflecting a disregard for the status of the nursing occupational prestige. This may reduce the level of motivation for nurses’ professional performance [2, 3, 16]. On the other hand, the current shortage of the number of the working nurses is also a major challenge for the nursing profession around the world, and since it is also a serious challenge in Iran, studies of the nursing occupational prestige are of the research priorities of the Nursing Department [1, 16].
In a study, 66.5% of nurses reported their occupational prestige status as moderate [1]. Another study also showed that 54.83% of nurses in a hospital in Birjand City were not satisfied with their occupational prestige status [3]. Smaller cities such as Kashmar are thought to be more likely to have occupational prestige because of delivering service to more limited communities.
 Given the few studies on the nursing occupational prestige and, on the other hand, the importance and necessity of the occupational prestige to nurses, whose job is directly related to the spirit and body of human beings, this study aimed to evaluate the occupational prestige and its relationship with demographic characteristics of nursing in the viewpoints of nurses busy in Kashmar City hospitals. Regarding the results from the nurses’ view of their occupational prestige in small towns, it may be possible to anticipate and plan for the weaknesses that lead to the likewise problems in the big cities.
Materials and Methods
In this cross-sectional study, the statistical population consisted of all nurses in two hospitals of Kashmar City in 2018, which included 230 subjects. They applied a full-scale census method, first a list of all departments in which the nurses were active was provided, and then all nurses who met the inclusion criteria, including minimum a bachelor’s degree, one year of work experience, and willingness and informed consent were recruited to participate in the study. Exclusion criteria included non-completion of more than 10% of the questionnaires.
In order to achieve the goals of the study, the data collection tool consisted of two parts. The first part of the questionnaire included demographic information including age, sex, marital status, educational level, the university educated in, employment status, work experience, workplace section, organizational position, whether there is a nurse in the family and if yes what is her relationship, and adequate awareness as choosing the nursing as a course of study. The second part of the questionnaire (nursing occupational prestige) had 16 items designed in Persian by Tohidi et al. based on social and managerial theories [1]. The designer permitted using of the questionnaire. The dimensions of this questionnaire include the following items: nursing prestige and self-confidence, nursing prestige and the treatment team or staff, nursing prestige and the community, nursing prestige, and the managers.
 The scores for each section vary based on the number of questions in that section. Each item of the questionnaire is scored 1-4, based on the four-point scale principle: (1= not at all, 2= low, 3= moderate, 4= high). The scores range from 16 to 64, according to the designer›s recommendation. A score of 16-26 indicates very low prestige, 27-38 shows low a score of 39-50 moderate and a score of 51-64 shows a high occupational prestige.
Tohidi et al. in a study titled «Investigating the Relationship between Nursing Occupational Prestige and Social Health», concluded that the questionnaire had high face and content validity. The reliability of this questionnaire, confirmed by Cronbach›s alpha coefficient, was 85% [1].determine the internal consistency of the instrument in this study, the reliability of the questionnaire was determined 86% by Cronbach›s alpha coefficient.
 In order to comply with the ethical principles, after receiving a letter from the Vice-Chancellor for Research of Mashhad University of Medical Sciences and obtaining permission to enter the research environment, a questionnaire was provided to the nursing staff and information was given to the participants about the purpose of the study and its implementation. They were also assured that the study would be voluntary and that all information recorded in the questionnaire would be anonymous and confidential.
In this study, CCU, ICU, dialysis, and emergency were classified as special wards and other wards regarded as general. Data were analyzed by SPSS software v. 22 with descriptive and inferential statistical tests (Spearman correlation coefficient, Kruskal-Wallis and Mann-Whitney U). Statistical significance level was set at 0.05. Kolmogorov-Smirnov test was used to check the normality of data distribution.
Results
Of the 230 questionnaires analyzed, 220 responded to questions about the status of the nursing occupational prestige, which their response rate was 95.65%. The age range of nurses was 22-55 years with a mean of 31.56±6.82 years. Results showed that 64.5% of the participants were female and 35.5% were male. In terms of the level of education, 94.1% had a bachelor’s degree and 5.9% had a master’s degree. In this study, 80.5% of the participants were married, 1% with more than one-year work experience, 55.9% was graduated from Islamic Azad University, and 69.5% had less than 10 years of work experience. Also, the findings of this study showed that 52.3% of participants did not have sufficient information before choose nursing for academic career.

The results of Kruskal-Wallis test showed that occupational prestige among the supervisors was higher than other nurses participating in this study (P<0.05). Other demographic data are shown in Table 1. The mean and standard deviation of the total score of occupational prestige was 44.09±6.18. According to the descriptive-statistical findings, 21.3% (n=47) of participants had low occupational prestige, 65.5% (n=144) had a moderate occupational prestige, and 13.2% (n=29) had a high occupational prestige.
The results presented in Table 2 show that among the different dimensions of occupational prestige, the highest and the lowest mean percentage scores are related to occupational prestige and self-confidence, and occupational prestige and the managers, respectively. In the present study, the results of Spearman correlation test on the different dimensions of nursing occupational prestige showed a significant positive relationship between the dimensions of occupational prestige (P<0.05) (Table 3).

Discussion
The aim of this study was to determine the occupational prestige and demographic variables of nursing. According to the findings of this study, the majority of nurses had a moderate occupational prestige. Tohidi also reported a moderate status of nursing occupational prestige in his research [1]. However, Bahrami in his study “Investigating the Relationship between Social and Occupational Prestige with Job Components from the Nurses’ Viewpoint” showed that the level of occupational and social prestige among nurses was low [3].
 The difference in results may be due to the examination of occupational prestige in different environments, which can affect the perception of prestige. In addition, occupational factors and the psychological state of the individuals under study may also be affected. Occupational factors have been identified as the most important obstacle to the socialization of the nursing as an occupation. Lack of staffing, discrimination between nurses and physicians, lack of independence of nurses, low job motivation, and job burnout are all occupational factors that may affect perceptions of social status [15].
In this study, occupational prestige of different dimensions was evaluated, so that the highest mean of it was related to self-confidence and the lowest mean of occupational prestige belonged to managers. Also, in a qualitative study conducted by Barazpardanjani, the results showed that the lack of attention to the nursing profession by the top ranks of nursing management undermined the value and importance of nursing and subsequently its social status. It was also found that the most participants were not satisfied with the current status of the nursing profession both at work and in community [17].
Prestigious occupation holders are more likely to receive different types of social support, which may be an effective factor in low occupational prestige among nurses [1]. In this study, occupational prestige of nurses with master’s degree was less than nurses with bachelor’s degree. It may be explained by the fact that with the increase of education level, nurses will need more support from managers. In Canada, occupational prestige mostly is related to the level of education [18]. Whereas in the studies of Tohidi and Bahrami occupational prestige was not statistically significantly correlated with the educational level [1, 3]. Obviously, as the level of education increases, the level of occupational expectation of individuals increases, and if these expectations are not met and the appropriate feedback is not received, the grounds for a lower occupational prestige are set.
In this study, nurses who were graduated from Islamic Azad University showed higher occupational prestige than graduates of state universities did. No relationship was found contributing of occupational prestige and the university they were graduated from and it seems to be the first time that this issue has been addressed concurrently. Obviously, part of social status and professional identity is formed at the very beginning of your university education. Universities are supposed to be the proper place to build a mature understanding of one’s social status. It seems that the role of nursing universities in preparing the community for the presence of the graduated people and their social status and prestige can be examined in future studies. In addition, according to the findings of this study, the graduates of Islamic Azad University have higher self-confidence.
Supervisors also had a higher occupational prestige in the present study, which may be due to their important class and different level of the nature of the work, as well as their job status compared to other nurses who have less direct relationship with physicians. On the other hand, greater responsibility may increase the status of a profession or job [19].
In the present study, there was no significant relationship between occupational prestige and employment status of nurses, while Bahrami in his study reported a higher occupational prestige among the contractual and officially employed nurses’ status, citing higher job security for these nurses. In addition, the results of this study showed that there is no significant relationship between occupational prestige and having a nurse in the family, as well as having adequate awareness about nursing before choosing the nursing as a course of study, which is consistent with the results of the study of Bahrami [3].
In Abdullahi’s study, resources such as the employment of some of the relatives in nursing profession identified as among the least important factors affecting people in formation of the general image of nursing in their mind, while from the perspective of nurses, employing of a relative of them in nursing has been reported to be of moderate importance [2].
Given that most studies on the occupational prestige of nurses in advanced countries were conducted prior to 2000, it can be concluded that this problem has been largely resolved in those countries. In Iran, however, nurses and even many other medical-related professions in many aspects do not have a positive opinion toward the nursing as a profession [3]. Regarding the importance of the function of the nursing as a member of the health care team and their key role in patient care − according to nurses’ understanding − is not well understood. 
According to the results of the present study, there was no statistically significant difference between the score of occupational prestige and classifications such as age, marital status, gender, workplace division, and work experience. Tohidi’s study also showed that these demographic factors not only had no significant impact on nurses’ occupational prestige but also on their social health, citing the individual and personal differences of the subjects as answer the questionnaire, accordingly [1]. However, according to the findings of a study, nurses working in the special care units had higher dignity and self-confidence and felt socially in a higher position due to the importance and distinction of working in the special care units comparing working in other sections [3].
Occupational prestige is a vital factor in promoting the nurses’ social health and is considered as one of the most important factors in promoting professional identity [1, 17, 20]. It is necessary to maintain and improve the nursing occupational prestige; thus, it is suggested to take into account the importance of occupational prestige in nursing courses at different educational levels, as well as in nursing training courses in hospitals. It is also suggested that in the effective role playing, proper planning is provided by the managers of the profession in the clinic, in order to achieve the deserving position and status of nurses in their workplace.
One of the limitations of this study was the failure to examine the nursing occupational prestige for each ward separately due to so much number of the wards of the hospitals. It is suggested that more extensive qualitative studies be carried out in order to be able to plan more broadly to enhance the occupational prestige of nurses with awareness of the nurses’ experiences in different wards of the hospitals.
Ethical Considerations
Compliance with ethical guidelines
This article is extracted from a research project approved by the Research Ethics Committee of Mashhad University of Medical Sciences (Code: IR.MUMS.REC.1397.276) in 2019. 
Funding
This study financially supported by the Mashhad University of Medical Sciences.
Authors contributions
design, implementation, data analysis, and final report verification: Hossein Sadeghnezhad; community access and data collection: Majid Ghanei Allhosseini; All of them approved the third revised article.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to thank the research assistant of Mashhad University of Medical Sciences for their support as well as all the nurses who participated in this study.


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