Iranian study explores stakeholders’ views of community health nursing in healthcare

Iran’s community health nurses possess the training and expertise to help manage chronic disease, coordinate primary care and improve public health, yet much of that capacity remains unused, according to a qualitative study of healthcare stakeholders. Researchers say the country has formally endorsed community health nursing in principle, but has not embedded it firmly enough in the policies, organizational structures or referral systems that determine how care is delivered. The result is a persistent gap between what community health nurses know how to do and what they are actually permitted, expected or supported to do within the healthcare system.

The findings emerged from in-depth interviews with 18 people involved in community health nursing, healthcare policy, nursing management, education and service delivery. Participants included faculty members specializing in community health nursing, nursing directors, health deputies, a comprehensive health-centre director and healthcare workers from urban centres. Their average age was 49.5 years, and they had an average of more than 22 years of professional experience. The interviews, conducted between February 2024 and May 2025, lasted from 30 minutes to nearly two hours and were carried out either in person or online. Researchers transcribed the conversations, identified meaningful statements and organized them through conventional qualitative content analysis.

That process generated 385 initial codes, which were refined into 11 subcategories and three broader categories. Together, the categories described the structural conditions needed for community health nursing to become a functioning part of primary healthcare: establishing a recognized professional position, facilitating integrated care and activating community participation to promote well-being. The researchers’ central conclusion was not that nurses lacked competence, but that the health system failed to convert competence into authority and routine practice. Community health nurses were portrayed as professionals capable of assessment, health education, counselling, home care, chronic-disease follow-up and coordination, while their actual roles were often unclear, fragmented or assigned informally.

The first major problem was the absence of a stable, clearly defined job position. Participants said that community health nurses’ responsibilities frequently overlapped with those of other healthcare workers, while existing descriptions of their work did not reflect changing population needs. Iran is confronting many of the same pressures reshaping health systems worldwide: population ageing, a growing burden of non-communicable diseases, physician shortages and financial constraints. These pressures make prevention and long-term management increasingly important, but the study found that policy and workforce arrangements remain heavily oriented toward hospitals and physician-led care. Participants argued that nurses need formal recognition in health policy, standardized job descriptions and coherent service packages, such as structured programs for diabetes management, elderly care or home-based follow-up.

A service package is more than a list of tasks. In health-system design, it defines who provides an intervention, which patients are eligible, how care is financed, what outcomes are monitored and how patients move between services. Without those specifications, community nursing can become dependent on individual managers or particularly motivated nurses. A nurse may organize home visits, educate families or track a patient’s condition, but those activities may not be recorded as a formal responsibility, supported by a dedicated budget or connected to a national performance system. Participants told researchers that packaging services in a recognizable form could make the value of community health nursing visible to policymakers and help transform scattered activities into an accountable component of primary care.

The second category concerned integrated care, especially for people with chronic illnesses and other vulnerabilities. Community health nurses often operate close to patients and families, putting them in a strong position to identify changing needs, reinforce treatment plans and connect people with physicians, nutritionists, psychologists, social workers and hospitals. Yet participants described referral pathways and communication channels as inconsistent. A patient moving between a hospital and a health centre might have to repeat information, wait weeks for a specialist appointment or navigate the system without a designated professional responsible for continuity. Nurses sometimes filled that coordinating role, but usually without formal authority, shared information systems or reliable mechanisms requiring different organizations to collaborate.

This weakness has technical consequences for care quality. Chronic disease management is not a single clinical encounter; it is a longitudinal process involving risk assessment, treatment adjustment, patient education, monitoring and timely escalation when a condition worsens. If information is lost between levels of care, clinicians may duplicate tests, miss warning signs or provide conflicting instructions. A community health nurse can function as a care coordinator by maintaining a patient’s history, checking adherence, identifying barriers and communicating with the wider team. But coordination depends on system architecture as much as individual effort. Clear referral rules, defined accountability, interoperable records and protected time for interprofessional communication are needed if the nurse’s role is to move from informal problem-solving to an integrated care function.

The third category involved community engagement, including health-literacy education, self-care training, local support networks and culturally adapted interventions. Participants described nurses as potential bridges between communities and the formal health system. In villages and urban neighbourhoods, nurses could work with families, volunteers, teachers, local officials and social institutions to identify priorities and make health information understandable. They emphasized that interventions are more likely to be accepted when they reflect local beliefs, languages, foods and traditions. Examples included using familiar foods when teaching older adults with diabetes and incorporating traditional storytelling into health education in nomadic communities. Such approaches can improve communication and participation, but participants stressed that they remain difficult to sustain when they depend on personal initiative rather than institutional support.

The study interpreted these findings through the policy-triangle framework developed by health-policy researchers Gill Walt and Lucy Gilson. The framework examines four interacting dimensions of policy: content, process, context and actors. Content includes the goals, rules and service packages a policy establishes. Process covers agenda-setting, formulation, implementation and evaluation. Context includes social, economic, political, cultural and environmental conditions. Actors are the people and organizations who shape or experience policy, including government officials, nurse managers, educators, healthcare workers and communities. Applying this model allowed the researchers to show that the problem is not simply a missing job description. Role ambiguity is connected to who has influence over policy, how decisions are implemented, how resources are allocated and whether nurses and communities have meaningful authority in those decisions.

From this perspective, the gap between education and practice reflects a broader imbalance in the health system. Iran has an extensive primary healthcare network, including health houses and comprehensive health centres, and has achieved important gains in areas such as child mortality reduction and infectious-disease control. However, participants said the system’s centralized governance and hospital-centred priorities limit the development of community-based nursing. Nurses may be consulted during policy discussions, but their participation is often advisory rather than decision-making. Communities may be asked for opinions, yet their views do not necessarily determine priorities or resource allocation. The researchers argue that formal recognition without institutional power could produce symbolic reform: community health nurses might be named in policy documents but still lack the authority, budgets and organizational backing required to act.

The research also highlights a tension between national standardization and local adaptation. A nationwide service package could establish consistent expectations and make workforce planning possible, but centrally designed programs may fail if they ignore regional differences in culture, geography, language or disease patterns. Participants therefore supported a system in which national policies define core services while local teams retain enough flexibility to adapt delivery. For example, a self-care program for older adults might use the same clinical goals across Iran but rely on different teaching materials, foods, community partners or communication methods in different regions. Decentralization of implementation, combined with national accountability, could help translate policy into practice without abandoning equity.

The researchers caution that the study does not measure patient outcomes or demonstrate that expanding community health nursing would automatically improve health. It captures the perspectives of a purposively selected group of stakeholders, and the sample included many academically affiliated participants. The small number of nurses working directly in comprehensive health centres also limited the range of frontline experiences. Some interviews were conducted remotely because of distance and scheduling constraints. Nevertheless, the investigators strengthened the analysis through maximum-variation sampling, concurrent data collection and analysis, reflective field notes, peer discussion and an audit trail reviewed by qualitative-research experts. They also reported the study according to the COREQ guidelines for interview-based research.

The findings point toward reforms that extend beyond adding more nurses to the workforce. Policymakers would need to define community health nursing roles in law and organizational policy, establish service packages linked to population needs, include nurses in decisions affecting primary care and create referral systems that assign responsibility for continuity. Health centres, hospitals and social-support organizations would need practical mechanisms for sharing information and coordinating care. Training programs may also need stronger connections to the realities of community practice, while evaluation systems should track outcomes such as preventive-care access, chronic-disease follow-up, patient experience and community participation. Most importantly, the study suggests that community health nurses cannot be expected to repair fragmented systems through individual effort alone. Their effectiveness depends on whether the health system gives them a recognized place at the intersection of professional knowledge, policy implementation and community needs.