Heydari H, Rahnavard Z, Ghaffari F Original Article Exploring the Position of Community-Based in : A Qualitative Study

Heshmatolah Heydari1, PhD; Zahra Rahnavard2, PhD; Fatemeh Ghaffari3, PhD

1Department of Community Health Nursing, School of Nursing and Midwifery, Lorestan University of medical sciences, Khorramabad, Iran; 2Department of Community Health Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran; 3Department of Nursing, Ramsar Nursing Care Research Center, Babol University of Medical Sciences, Babol, Mazandaran, Iran

Corresponding author: Fatemeh Ghaffari, PhD; Department of Nursing, Ramsar Nursing Care Research Center, Babol University of Medical Sciences, Babol, Postal code: 46917-14141, Mazandaran, Iran Tel: +98 11 55220590; Fax: +98 11 55222423; Email: [email protected]

Received: 13 March 2017 Revised: 24 April 2017 Accepted: 9 May 2017

Abstract Background: Community-based nursing focuses on providing health services to families and communities in the second and third levels of prevention and this can improve the individuals, families and communities’ quality of life, and reduce the healthcare costs. The aim of this study was to explore the status of community-based nursing in Iran. Methods: This qualitative study was conducted from March to November 2015, in Tehran, Iran, using the content analysis approach. The study setting consisted of Iran and Tehran Faculties of Nursing and Midwifery, Tehran, Iran. The purposive sampling method was used. Twenty faculty members and Master’s and PhD students were interviewed by using the face-to-face semi-structured interview method. Moreover, two focus groups were conducted for complementing and enriching the study data. The data were analyzed using the Graneheim and Lundman’s approach to content analysis. The trustworthiness of the study findings was maintained by employing the Lincoln and Guba’s criteria of credibility, dependability, and confirmability. Results: In total, 580 codes were generated and categorized into three main categories of conventional services, the necessity for creating infrastructures, and multidimensional outcomes of community- based nursing. Conclusion: Introducing community-based nursing into nursing education curricula and creating ample job opportunities for community-based nurses seem clearly essential.

Keywords: Community-based nursing, Qualitative Research, Iran

Please cite this article as: Heydari H, Rahnavard Z, Ghaffari F. Exploring the Position of Community-Based Nursing in Iran: A Qualitative Study. IJCBNM. 2017;5(4):386-396.

386 ijcbnm.sums.ac.ir Position of community-based nursing in Iran

Introduction epidemiology of diseases, occurrence of emerging and re-emerging diseases, and shifts Community-Based Nursing (CBN) focuses in the leading causes of death (from infectious on providing care to people and families in diseases to diseases of modern life such as their home or work environments. In CBN, hypertension, diabetes mellitus, obesity, specialized community-based nurses provide cancer, and accidents) have highlighted the comprehensive preventive care to clients for necessity for dramatic healthcare reforms.14 preventing them from entering the lengthy and Accordingly, providing healthcare-related arduous processes of diseases and treatments.1 education and consultation by specialized They encourage the idea of prevention-based nurses at community level has assumed health in communities. The basic aims of CBN greater importance. are to develop and modify self-care strategies One of the major reforms in the Iranian and skills at community level.2,3 Through CBN, healthcare system for achieving the goal nurses can plan and implement healthcare of ‘health for all’ was the establishment of programs for all clients in order to postpone the extensive nationwide Iranian Primary and even eradicate most contagious and non- Network (IPHCN) in the 1980s. contagious diseases and prevent clients from Accordingly, three types of health centers losing potential years of their lives due to were established all over the country—even diseases, disabilities, or premature death. The in small villages—for providing healthcare major benefits of CBN are, but not limited services at the three levels of prevention. to, decreased healthcare costs, deeper client The first type of such health centers includes satisfaction, and greater participation of people, health houses, rural and urban healthcare families, and communities in maintaining and centers, and health bases. As the first line promoting their own health.4 of healthcare delivery, these centers provide During the past two decades, economic primary health care to a wide range of clients. burdens and advances have caused significant The second-level centers are district health changes in healthcare delivery systems centers which provide supportive, planning, around the world. One of these changes was and supervision services to the first-level clients’ greater inclination for referring to centers. Moreover, diagnostic and medical health centers instead of medical facilities care services are provided in these centers. for receiving disease prevention and health At the third level, advanced diagnostic and promotion services. These significant changes rehabilitative services are provided to clients have increased the people’s need to and desire in provincial health centers.15 for CBN. Currently, CBN services have Formal nursing education initiated from been extended to homes, schools, industries, 1915, and behavior and social sciences were and health-centered clinics.5,6 In Canada, considered as an important section of nursing CBN emerged in 1987,7 and maintenance curriculum in 1958, and finally with the and health promotion of persons, families reform of medical sciences education in Iran and communities was its mission;8 also in 1986, the disciplines of community-oriented other countries such as Sweden,9 Japan,10 nursing and community-based nursing were and Norway,11 conducted such delivery of considered by educational politicians. Then, services in their community some decade community health nursing and epidemiology ago. Like other advanced countries, health were considered as mandatory courses authorities in Iran have found it necessary in the curriculum of bachelor degree in to shift from treatment-based approaches to nursing in Iran.16 Currently, nurses receive community-based healthcare services.12,13 education and training —during their formal In Iran, increases in urbanization and university educations at the Bachelor’s level— elderly population, changes in geographical for providing CBN services to the clients,

IJCBNM October 2017; Vol 5, No 4 387 Heydari H, Rahnavard Z, Ghaffari F families, and communities.17 However, official Data Collection statistics indicate that the majority of nurses Semi-structured face-to-face personal provide healthcare services at the third level interviews were performed for collecting the of prevention, mainly in medical facilities and data. Before each interview, we contacted hospitals.12,13 the intended participant to determine the Currently, knowledge about the status time and place of interview. All interviews of CBN is very little in Iran. For planning were conducted in a private room located and improved role of CBN in the society, in the Department of Health of Tehran we should know the status and type of the Faculty of Nursing and Midwifery. In total, delivered services by CBN in Iran. On the 20 interviews were conducted. Besides other hand, researchers have a rich experience interviews, we also conducted two focus about training of CBN and delivery of groups for complementing and enriching health care in the community as a nurse. the study data. Two researchers, one as the Investigating this concept through a qualitative team leader and the other as non-participant research, which includes multiplicity of observer and the recorder of verbal and data collection procedure and an event nonverbal reactions, contributed in the focus examination method, norms and values group. Four participants took part in each from the participants’ viewpoint, provides focus group- eight in total. These participants the possibility of an in-depth examination, were recruited from the aforementioned 20 clear and comprehensive understanding, and faculty members and students. Focus groups recognition of the phenomenon. Therefore, the were held by the first and second authors. aim of this study was to explore the position The first author managed the focus groups of community-based nursing in Iran. while the second one strived to cover all the intended topics. Focus group and interview Materials and Methods questions were: What kinds of gap exist in delivering healthcare services in Iran? How Design can community-based nurses help bridge This qualitative study was conducted by these gaps? What roles and tasks do you employing the qualitative content analysis envisage for community-based nurses? What approach, from March to November 2015. are the prerequisites for training competent community-based nurses? What are the Participants position and the functions of CBN in health Eleven faculty members and four students canters? Moreover, pointed questions (such graduated in community health nursing as well as Can you explain more? Would you provide as five PhD students in nursing were recruited an example?) were also asked during the from Iran and Tehran Faculties of Nursing and interviews and focus groups for enriching Midwifery, Tehran, Iran. Inclusion criteria the study data. The focus groups helped us were willingness to participate in the study, confirm and validate interview-related data at least five years’ experience for faculty and findings. Interviews lasted for 30–40 members engaged in clinical and theoretical minutes while the length of the focus groups teaching of community health nursing, PhD was 35–45 minutes. Sampling and data students with the base of community health collection were continued until reaching data nursing and engaged in community health saturation and obtaining no new data from nursing, and MSc students of community the interviews.18 health nursing field in the second year and more of their course. The only exclusion Data Analysis criterion in this study was lack of willingness For data analysis, we performed data to continue participation in the study. collection and data analysis concurrently. The

388 ijcbnm.sums.ac.ir Position of community-based nursing in Iran data were analyzed by using the Graneheim the participants for several times. Moreover, and Lundman’s content analysis approach.19 two faculty members having expertise in Primarily, interviews were transcribed qualitative research were invited to assess and verbatim. We listened to the interviews and confirm our generated codes and categories. read their transcripts for several times to reach In addition. For transferability of data, the a general understanding of their contents. A researcher tried to present all steps of the whole interview transcript was considered study with comprehensive detail. As to as the unit of analysis while meaning units ethical considerations, all the participants included words, sentences, and paragraphs. were informed about the aim and the methods Meaning units were sets of words or sentences of the study and they were assured of the which conveyed a similar meaning or were confidentiality of their information. The data related to the same concept in some ways. were managed anonymously. The participants Meaning units were condensed and coded had the right to voluntarily participate in or accordingly. Codes were compared with withdraw from the study. They were asked to each other and sorted into more abstract provide written informed consent. Member categories according to their similarities. check was used to assess the dependability Finally, categories were also compared with of data (to ensure stability and reliability of each other and grouped into higher-level main data). To this end, comments from colleagues categories.19 The MAXQDA 10 software was familiar with qualitative approach and review employed for managing the coding and the of participants’ transcriptions were used. categorizing the processes and linking the research notes to the codes. Ethical Considerations The participants were briefed on the Trustworthiness purpose and nature of the study, the voluntary To determine the data trustworthiness, nature of participation, the right to withdraw we used the Lincoln and Guba’s criteria of from the study at any time, and its guarantee credibility, confirmability and transformability of confidentiality and anonymity. Informed for maintaining the trustworthiness of the written consent was obtained for participating study findings.20 Accordingly, for credibility in the study and for voice recording. Interviews we attempted to have a close relationship were carried out in complete privacy, and with the study participants and a prolonged an attempt was made to keep the subject engagement with the study; in addition, of the interview hidden from other people, we made an attempt to recruit a maximum including companions and acquaintances of variation sample of participants who varied the participants. in age, gender, work experience, expertise, and working position. Also, we performed Results expert panels, for reaching the data. For conformability, we asked several participants Eighteen females and two males with a mean to determine whether our findings conform age and a mean work experience of 38±8.3 and to their experiences and viewpoints. The 17±7.4 years, respectively, participated in the researchers tried to be reflexive through study. In total, 580 codes were generated which rereading and revising the interviews and then were categorized into three main categories and coding and double checking the codes with the eight sub-categories (Table 1). Categories and participants. We also attempted to maintain sub-categories are explained in Table 1. reflexivity and avoid our own viewpoints from affecting the study data through reading Conventional Services interview transcripts, comparing codes with The first main category of the study was the raw data, and checking the findings with conventional services. Healthcare services in

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Table 1: Participants’ experiences and perceptions of CBN in Iran Categories Sub-Categories Conventional services Doing repetitive works in a predetermined framework

Perfunctory services The necessity for creating infrastructures Creating job opportunities for community-based nurses

Changing health policy-makers’ attitude towards CBN Preparing communities’ for receiving CBN services Multidimensional outcomes of CBN Direct access to first-hand healthcare services

More effective preventions Improved public’s health literacy

Iranian healthcare settings are mainly provided physician teams in Iran make home visits based on pre-established routines rather than superficially. Because of poor supervision, specialized job descriptions. This main category if any, the members of these teams value consisted of two sub-categories including doing treatment more than prevention and provide repetitive works in a predetermined framework healthcare services without considering and perfunctory services. individuals, families, and communities’ needs. Consequently, disease prevention Doing Repetitive Works In a Predetermined and health promotion have been taken for Framework granted; a faculty member with nine years Currently, healthcare services in Iranian of experience mentioned, “…Home visit has health centers are provided by technicians in been neglected. Family physicians either environmental health, occupational health, reside in urban health centers or simply refer family health, vaccination, and disease to rural health centers once a week together prevention. However, instead of assessing with their teams which include a midwife. In the communities’ health needs and problems, fact, visiting is the only function of these technicians do routine jobs such as these teams…” (P 4; a faculty member). completing checklists and forms. In other An interesting point is that there is no words, they provide healthcare services place for nurses in family physician teams. superficially; hence, they cannot develop and Most of health authorities in Iran believe implement effective strategies for fulfilling the that nurses either cannot provide significant communities’ health needs and resolving their services in family physician teams or their health problems. On the other hand, lack of an services are not appropriate for public health. effective management and supervision system A PhD student engaged in home health care had yielded to the provision of routine and services mentioned that he heard from a repetitive health services. As to this situation, family physician manager, “…What services a Master’s student said, “…Filling checklists can nurses provide which family physicians and forms is the predominant practice in are unable to? [The participant meant that different units of health centers. Healthcare besides their own services, family physicians services are limited to merely performing can also provide all services which nurses frequent visits without making any significant can]. Therefore, it is not necessary to include changes or providing follow-up care...” (P. 1; nurses in family physician teams…” (P. 12; a a Master’s student). PhD student).

Perfunctory Services The Necessity of Creating Infrastructures According to our participants, family The second main category of the study was

390 ijcbnm.sums.ac.ir Position of community-based nursing in Iran the necessity of creating infrastructures. This member mentioned, “…Training a Master’s category included the three sub-categories of CBN student incurs huge costs. However, creating job opportunities for community- they cannot offer any benefit due to having based nurses, changing health policy-makers’ no clear job description; therefore, we cannot attitude towards CBN, and preparing the employ them for promoting public health…” communities for receiving CBN services. (P. 14; a faculty member). These categories are explained below. Currently, despite community-based nurses’ great communication and counseling Creating Job Opportunities for Community- skills, treatment and preventive services in Based Nurses Iran have been defined to be provided solely Most of our participants highlighted the by family physicians. The reason is that necessity to create infrastructures for training there is no position for community-based and employing community-based nurses. nurses in family physician team. About this Currently, CBN has not been included in situation, a faculty member with twenty years the Iranian nursing education curriculum. of experience stated, “…Currently, there is According to our participants, it is necessary no official position for graduate community- to introduce into based nurses; hence, most of them are nursing education curriculum and develop practicing nursing in clinical settings…” (P. strategies for changing educational planners 9; a faculty member). and instructors’ attitude towards CBN. A faculty member with fifty years of experience Changing the Health Policy-Makers’ Attitude mentioned, “…Nurses should be educated in towards CBN such a way that they view the as a An essential prerequisite to CBN is unique person located in a family instead of to change health policy-makers’ attitude a single, detached individual. If they gain towards it in such a way that they understand such a perspective during their university the necessity for community-based nurses’ education, they will adopt it practically. In specialized services. According to our fact, instructors should instill such an attitude participants, the main reason behind in students…” (P. 20; a faculty member). community-based nurses’ unemployment in Community-based nurses have been rarely specialized positions is lack of an efficient employed in health centers in Iran. Despite management system. A faculty member the great need to their services, most of said “…Given the great need to community- community-based nurses cannot accomplish based nurses’ preventive care services, health the aims of CBN due to lack of a clear job policy-makers need to do strategic planning description. They are mostly employed in for using their abilities optimally …” (P. 2; a clinical settings as staff nurses or in educational faculty member). settings as instructors. Consequently, they simply provide stereotypical routine Preparing the Communities for Receiving CBN clinical care instead of public education and Services counseling. A Master’s student studying in Participants highlighted that communities the fourth term said “…Community-based should be or become ready for receiving CBN nursing is only a ‘title’ for enrolling students services; otherwise, major health challenges in Master’s degree and does not have any will arise and affect people’s health and other utility...”(P. 6; a Master’s student). quality of life. A faculty member with twenty Moreover, unclear job description has three years of experience about importance of prevented the community-based nurses from change in the policy-makers’ opinion stated, providing efficient CBN services. About “…Iranian health policy-makers also need the importance of job description, a faculty to change their attitudes. Otherwise, major

IJCBNM October 2017; Vol 5, No 4 391 Heydari H, Rahnavard Z, Ghaffari F negative outcomes will affect the individuals, healthcare services at the three levels of families, and communities. Treatment is like prevention. Currently, the elderly population administrating an [short-acting] analgesic. and, hence, the rate of chronic diseases Health policy-makers need to understand that are increasing progressively. Therefore, CBN is beneficial to communities…” (P. 2; a community-based nurses have a major role faculty member). in public education and disease prevention. Another prerequisite to CBN is the public On the other hand, health problems such as confidence in community-based nurses’ addiction, AIDS, and hepatitis are endangering abilities and services. In other words, people’s the adolescents and youths’ health and attitudes towards community-based nurses’ lives. Given the fact that Iran has a large abilities and services should also be changed. young population, training and employing About the importance of changing people’ community-based nurses for more effective attitude, a PhD student stated, “…People disease prevention and health promotion need to understand community-based nurses’ seem clearly crucial; in this regard, a faculty abilities and importance in order to trust member with seventeen years of experience in them and use their expertise…” (P. 3; a PhD clinical and theoretical teaching of community student). health nursing stated, “…A community-based nurse can play an important role at the three Multidimensional Outcomes of CBN levels of prevention through communicating The third main category of the study with families and identifying their problems. was multidimensional outcomes of CBN. Consequently, they can promote a healthy Three sub-categories fell into this main lifestyle, improve quality of life, and support category which included direct access to the families’ domestic economy…” (P. 16; a first-hand healthcare services, more effective faculty member). preventions, and improved public health literacy. Improved Public’s Health Literacy According to the study participants, Direct Access to First-Hand Healthcare another outcome of CBN is improved public Services health literacy. Improved health literacy can, Easy and direct access to first-hand in turn, help people shift from receiving care healthcare services is one of the main outcomes from healthcare professionals toward actively of employing community-based nurses. They engaging in self-care activities which finally can make home visits and collect valuable reduces the families and communities’ health- information which people might avoid sharing related costs and also decreases the disability- them while attending healthcare settings; a adjusted life years. With regard to this, a faculty member with long experiences in PhD student engaged in delivery of health community health nursing stated, “…One of services to public in the health centers stated, the instances which highlight the necessity of “…Nurses can improve the public’s health CBN is the issue of home visit. Community- literacy. For instance, they can minimize the based nurses can provide specialized clients’ repetitive attendance at specialized healthcare services during home visits for care settings and reduce healthcare costs promoting public health and minimizing the through educating palliative care remedies families’ health-related costs…” (P. 17; a to them…” (P. 7; a PhD student). faculty member). Discussion More Effective Preventions Study findings highlighted the critical This study aimed at exploring the status and role of community-based nurses in providing functions of CBN in the Iranian healthcare

392 ijcbnm.sums.ac.ir Position of community-based nursing in Iran system. The findings revealed that, currently, studies conducted in Iran also showed that most health services in Iranian health centers are Iranian healthcare authorities consider nursing provided conventionally and superficially by as a hospital-based profession and allocate non-professional care providers who have poor nurses mainly to clinical work settings. The professional communications with each other. reason behind such practice is probably the The findings of other studies also showed that fact that most Iranian healthcare decision- and role conflicts and role ambiguities as well as policy-makers are physicians who have disease- poor inter-professional communications have oriented approaches to care and view hospitals caused healthcare services to be non-holistic, as the main site of care delivery. In line with repetitive, and non-organized.21,22 The findings our findings, the results of a study indicated of the study also indicated that family physician physician-based management as a negative team in Iran has conventionally encouraged point in the health care system of Iran;27 such the idea of treatment-centeredness. The aims an attitude is apparently in conflict with and of this initiative were to promote public health negatively affects community-based healthcare based on the three levels of prevention and delivery. organize the patient referral system.23 However, The statistics released by the Iranian family physician teams which are directed by Ministry of Health and Medical Education physicians mainly focus on administrating also indicate that almost all Iranian nurses medical treatments instead of providing are providing healthcare services in hospitals preventive care, and don’t have proper referral and other clinical settings.12 Moreover, follow-up and communication to people;24 also, although Iran is among the signatories of the in these teams, nurses have been defined to be Alma-Ata declaration, Iranian nurses having assistants to physicians. Such an approach to Master’s degree in CBN are not employed nursing and nurses is not consistent with health in primary healthcare delivery centers. The education, counseling, and disease prevention Alma-Ata declaration of health for all was tasks of professional community-based issued in the 1978 International Conference nurses. An important point highlighted by the on Primary Health Care for promoting the participants was that CBN has not been included health of all people worldwide through in nursing curriculum at Bachelor’s degree. The providing primary health care services. These aim of Bachelor’s nursing education in Iran is findings highlighted the importance of and to train nurses who have a holistic approach to the necessity to develop measures for training care and value CBN. However, this aim is not and employing community-based nurses in fulfilled and nursing students do not acquire Iranian primary health care settings. the necessary skills for practicing nursing We also found that one of the positive at community level. Rather, they are simply outcomes of CBN would be direct access to familiarized with the roles and the functions first-hand healthcare services through home of community-based nurses; in line with result visits and home health care by community- this study, another study reported that graduate based nurses. In line with the results of this nurses in Iran are not have ready for delivery study, another study showed that home health of service in the community.25 Other studies care was a community-based service28 that also reported the same findings.26 Studies can be cost beneficial and decreases the rate highlighted that in contrast with the aims of the of readmission and hospital complications.29 Bachelor’s nursing education program in Iran, During home health care, the clients’ Iranian nursing graduates can work only as staff healthcare needs are assessed, planned for, nurses at hospitals.17,25 The results also indicated and fulfilled in their natural environment. that the current infrastructures of the Iranian However, currently more than 80% of such healthcare system have been developed and are services are provided by professional and non- suitable mainly for secondary prevention. Other professional healthcare providers who have a

IJCBNM October 2017; Vol 5, No 4 393 Heydari H, Rahnavard Z, Ghaffari F disease-centered approach to care.30 of Medical Sciences with the registration number There were limitations in the present of IR.TUMS.REC.1394. The authors would like study. Firstly, this study was conducted using to thank all individuals who supported and qualitative method and we cannot generate helped us to conduct this study. data in other areas. In addition, participants in this study were people in nursing field; if Conflict of Interest: None declared. other people in the health care team, such as policymakers, physicians and health care References workers, had participated in study, we could have gathered more data. 1 Stanhope M, Lancaster J. Public health The present study had several important nursing: Population-centered health care strengths. We performed expert panels to in the community. 9th ed. US: Mosby; enrich the data; moreover, we interviewed 2015. the pioneers of community health nursing in 2 Soriano JB, Zielinski J, Price D. Screening Iran. Through their assistance and use of their for and early detection of chronic opinion, we could highlight the significant obstructive pulmonary disease. Lancet. role of community health nursing in Iran. 2009;374:721-32. 3 Griffith R. Failed home visits must be Conclusion recorded and followed-up. British Journal of Community Nursing. 2017;22:97-9. Health services in Iranian health centers are 4 Hunt R. Introduction to co.mmunity- provided stereotypically and superficially. based nursing. 4th ed. US: Lippincott Accordingly, employing community-based Williams & Wilkins; 2008. nurses, establishing effective inter-professional 5 Saberian M. The curriculum of nursing communications, and supervising healthcare BSc course in the viewpoints of the providers’ care practice are necessary for graduates and last-year students of improving the quality of health services. The Semnan . Journal of necessary infrastructures for CBN are creating Medical Education. 2003;3:65-70. positions in the healthcare organizational chart 6 Kisa S. Turkish nurses’ concerns for community-based nurses, changing health about home health care in Turkey. policy-makers’ attitude towards CBN, and Australian Journal of Advanced Nursing. preparing communities for receiving CBN 2008;25:97-106. services. Employment of community-based 7 Community health nurses of Canada. nurses can produce positive outcomes such as Canadian Community Health Nursing direct access to first-hand healthcare services, Professional Practice Model & Standards more effective preventions, and improved public of Practice [Internet]. Canada: Community health literacy. Community-based nurses can health nurses of Canada; 2011. [Cited effectively manage home visits, assess clients, 21 September 2016]. Available from: families, and communities’ real needs, and plan http://www.chnig.org/wp-content/ and provide effective home care, but we could uploads/2016/02/chnc-standards.pdf. not explore the activities of CBN in this fields; 8 Community Health Nurses of Canada. hence, we suggest further investigations should Community Health be conducted for identification of CBN roles in strategic plan. [Internet]. Canada: various fields. Community health nurses of Canada; 2011. [Cited 27 August 2016]. Available from: Acknowledgement https://www.chnc.ca/en/strategic-plan. 9 Anell A, Glenngard AH, Merkur SM. This project was registered at Tehran University Sweden: Health system review. Health

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