research problem statement of community health nursing

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16.3 Applying the Nursing Process to Community Health

Community health nurses apply the nursing process to address needs of individuals, families, vulnerable populations, and entire communities. See Figure 16.7 [1] for an illustration of the nursing process in community health nursing.

The community health nurse typically begins a community health needs assessment by determining what data is already available. [2] As previously discussed in the “ Community Health Concepts ” section, national, state, county, and local health needs assessments are widely available. Secondary analysis refers to analyzing previously collected data to determine community needs.

Community health nurses may also engage in primary data collection to better understand the community needs and/or study who may be affected by actions taken as a result of the assessment. [3]   Primary data collection includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Public Forums

Public forums are gatherings where large groups of citizens discuss important issues at well-publicized locations and times. Forums give people of diverse backgrounds a chance to express their views and enhance understanding of the community’s specific needs and resources. Forums should be planned in a convenient location with accessibility to public transportation and child care. They should also be scheduled at convenient times for working families to gain participation from a wide range of populations.

Focus Groups

Focus groups are a systematic method of data collection through small-group discussions led by a facilitator. Participants in focus groups are selected to represent a larger group of people. Groups of 6-10 people with similar backgrounds or interests are interviewed in an informal or formal setting. Focus groups should be scheduled at several dates and times to ensure a broad participation from members of the community. Here are advantages of focus groups:

• Community member involvement in assessing and planning community initiatives is encouraged.
• Different perceptions, values, and beliefs by community members are explored.
• Input can be obtained from specific subpopulations of the community. Example of subpopulations include young mothers caring for infants, individuals receiving home hospice care, individuals struggling to find housing, residents of the prison system, individuals coping with mental health disorders, or residents in group homes.

Interviews are structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue. Key informant interviews are conducted with people in key positions in the community and have specific areas of knowledge and experience. These interviews can be useful for exploring specific community problems and/or assessing a community’s readiness to address those problems. [4]

Advantages of interviews include the following [5] :

• They can be conducted in a variety of settings (e.g., homes, schools, churches, stores, or community centers).
• They are low cost and generally have low dropout rates.
• Respondents define what is important from their perspective.
• It is possible to explore issues in depth, and there is an opportunity to clarify responses.
• They can provide leads to other data sources and key informants.
• They provide an opportunity to build partnerships with community members.
• Data can be compared among local government officials, citizens, and non-government leaders.

Interviews can have these disadvantages:

• Interviews can be time-consuming to schedule and perform.
• They require trained interviewers.
• There is a potential for interviewer bias to affect the data collected during the interview.
• Rapport must be established before sensitive information is shared.
• It is more time-consuming to summarize and analyze findings.

Windshield Surveys

A windshield survey is a type of direct observation of community needs while driving and literally looking through the windshield. It can be used to observe characteristics of a community that impact health needs such as housing, pollution, parks and recreation areas, transportation, health and social services agencies, industries, grocery stores, schools, and religious institutions.

View the following YouTube video of a windshield survey [6] : Windshield Survey Nursing .

Surveys use standardized questions that are relatively easy to analyze. They are beneficial for collecting information across a large geographic area, obtaining input from as many people as possible, and exploring sensitive topics. [7] Surveys can be conducted face to face, via the telephone, mailed, or shared on a website. Responses are typically anonymous but demographic information is often collected to focus on the needs of specific populations. Disadvantages of surveys can include the following [8] :

• Surveys can be time-consuming to design, implement, and analyze the results.
• The accuracy of survey results depends on who is surveyed and the size of the sample.
• Mailed surveys may have low response rates with higher costs due to postage.
• They offer little opportunity to explore issues in depth, and questions cannot be clarified.
• There is no opportunity to build rapport with respondents.

Participant Observation

Participant observation refers to nurses informally collecting data as a member of the community in which they live and work. This is considered a subjective observation because it is from the nurse’s perspective. Informal observations are made, or discussions are elicited among peers and neighbors within the community.

Sociocultural Considerations

When analyzing community health needs, it is essential to do so through a sociocultural lens. Just as an individual’s health can be influenced by a wide variety of causes, community health problems are affected by various factors in the community. For example, a high rate of cancer in one community could be related to environmental factors such as pollution from local industry, but in another community, it may be related to the overall aging of the population. Both communities have a high rate of cancer, but the public health response would be very different. Another example related to mental health is related to various situational factors affecting depression. A high rate of depression in one community may be related to socioeconomic factors such as low-paying jobs, lack of support systems, and poor access to basic needs like grocery stores, whereas in another community it may be related to lack of community resources during frequent weather disasters. The public health response would be different for these two communities.

Nurses must also recognize and value cultural differences such as health beliefs, practices, and linguistic needs of diverse populations. They must take steps to identify subpopulations who are vulnerable to health disparities and further investigate the causes and potential interventions for these disparities. For example, mental health disparities pose a significant threat to vulnerable populations in our society, such as high rates of suicide among LGBTQ+ youth, reduced access to prevention services among people living in rural areas, and elevated rates of substance misuse among Native Americans. These disparities threaten the health and wellness of these populations. [9]

Key points to consider when assessing a community using a sociocultural lens include the following:

• Have the trends of assessment data changed over time? What are the potential causes for these changes in this community?
• How does the community’s needs assessment data compare to similar communities at local, county, state, and national levels? What target goals and health initiatives have been successfully implemented in other communities?
• What vulnerable subpopulations are part of this community, and what health disparities are they experiencing? What are potential causes and solutions for these health disparities?
• Input from members of vulnerable subpopulations must be solicited regarding their perspectives on health disparities, as well as barriers they are experiencing in accessing health care.

Similar to how nurses individualize nursing diagnoses for clients based on priority nursing problems identified during a head-to-toe assessment, community health nurses use community health needs assessment data to develop community health diagnoses. These diagnoses are broad, apply to larger groups of individuals, and address the priority health needs of the community. Resources such as Healthy People 2030 can be used to determine current public health priorities.

A community diagnosis is a summary statement resulting from analysis of the data collected from a community health needs assessment. [10] A clear statement of the problem, as well as causes of the problem, should be included. A detailed community diagnosis helps guide community health initiatives that include nursing interventions.

A community diagnosis can address health deficits or services that support health in the community. A community diagnosis may also address a need for increased wellness in the community. Community diagnoses should include these four parts:

• The problem
• The population or vulnerable group
• The effects of the problem on the population/vulnerable group
• The indicators of the problem in this community

Here are some examples of community health diagnoses based on community health needs assessments:

• Community Scenario A
• Assessment data: The local high school has had a 50% increase in the number of teen pregnancies in the past year, causing high school graduation rates to decrease due to pregnant students dropping out of high school.
• Community diagnosis: Increased need for additional birth control and resources for prevention of pregnancy due to lack of current resources, as evidenced by 50% increase in teen pregnancies in the last year and a decrease in graduation rates.
• Community Scenario B
• Assessment data: Fifty percent of residents of an assisted living facility were found to have blood pressure readings higher than 130/80 mmHg during a health fair last week at the facility.
• Community diagnosis: Increased need for education about exercise and diet and referrals to primary care doctors for residents of an assisted living facility due to increased risk for mortality related to high blood pressure, as evidenced by a high number of residents with high blood pressure during a health fair.
• Community Scenario C
• Assessment data: The local high school has had two cases of suicide in the past year.
• Diagnosis: Increased need for community education regarding suicide prevention and crisis hotlines, as evidenced by an increase in adolescent suicide over the past twelve months.

Outcomes Identification

Outcomes refer to the changes in communities that nursing interventions and prevention strategies are intended to produce. Outcomes include broad overall goals for the community, as well as specific outcomes referred to as “SMART” outcomes that are specific, measurable, achievable, realistic, and with a timeline established.

Broad goals for communities can be tied to national objectives established by Healthy People 2030, as previously discussed in the “ Community Health Concepts ” section.

Healthy People objectives are classified by these five categories [11] :

• Health Conditions
• Health Behaviors
• Populations
• Settings and Systems
• Social Determinants of Health

SMART outcomes can be created based on the objectives listed under each category. For example, if an overall community goal is related to “Drug and Alcohol Use” under the “Health Behaviors” category, a SMART outcome could be based on the Healthy People objective, “Increase the proportion of people with a substance use disorder who got treatment in the past year.” [12] Based on this Healthy People objective, an example of a SMART outcome could be the following:

• The proportion of people treated for a substance disorder in Smith County will increase to 14% within the next year.

View the Healthy People 2030 Objectives and Community Objectives .

Planning Interventions

Nursing interventions for the community can be planned based on the related Healthy People category and objective. For example, based on the sample SMART outcome previously discussed, a planned nursing intervention could be the following:

•  The nurse will provide education and materials regarding evidence-based screening practices for substance use disorder in local clinics.

Community health nursing interventions typically focus on prevention of illness with health promotion interventions. After performing a community health needs assessment, identifying priority problems, and establishing health goals and SMART outcomes, the nurse integrates knowledge of health disorders (e.g., diabetes, cancer, obesity, or mental health disorders) and current health risks in a community to plan prevention interventions.

There are two common public health frameworks used to plan prevention interventions. A traditional preventive framework is based on primary, secondary, or tertiary prevention interventions. A second framework, often referred to as the Continuum of Care Prevention Model, was established by the Institute of Medicine (IOM) and includes universal, selected, and indicated prevention interventions. Both frameworks are further discussed in the following sections. [13]

Primordial, Primary, Secondary, Tertiary, and Quaternary Interventions

Preventive health interventions may include primordial, primary, secondary, tertiary, and quaternary prevention interventions. These strategies attempt to prevent the onset of disease, reduce complications of disease that develops, and promote quality of life. [14]

Primordial Prevention

Primordial prevention consists of risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations. In other words, primordial prevention interventions target underlying social determinants of health that can cause disease. These measures are typically promoted through laws and national policy. An example of a primordial prevention strategy is improving access to urban neighborhood playgrounds to promote physical activity in children and reduce their risk for developing obesity, diabetes, and cardiovascular disease. [15] See Figure 16.8 [16] for an image of a neighborhood playground.

Primary Prevention

Primary prevention consists of interventions aimed at susceptible populations or individuals to prevent disease from occurring. An example of primary prevention is immunizations. [17] Nursing primary prevention interventions also include public education and promotion of healthy behaviors. [18] See Figure 16.9 [19] for an image of an immunization clinic sponsored by a student nurses’ association.

Secondary Prevention

Secondary prevention emphasizes early detection of disease and targets healthy-appearing individuals with subclinical forms of disease. Subclinical disease refers to pathologic changes with no observable signs or symptoms. Secondary prevention includes screenings such as annual mammograms, routine colonoscopies, Papanicolaou (Pap) smears, as well as screening for depression and substance use disorders. [20] Nurses provide education to community members about the importance of these screenings. See Figure 16.10 [21] for an image of a mammogram.

Tertiary Prevention

Tertiary prevention is implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease after it is diagnosed in an individual. [22] For example, rehabilitation therapy after an individual experiences a cerebrovascular accident (i.e., stroke) is an example of tertiary prevention. See Figure 16.11 [23] for an image of a client receiving rehabilitation after experiencing a stroke.

The goals of tertiary prevention interventions are to reduce disability, promote curative therapy for a disease or injury, and prevent death. Nurses may be involved in providing ongoing home health services in clients’ homes as a component of interprofessional tertiary prevention efforts. Health education to prevent the worsening or recurrence of disease is also provided by nurses.

Quaternary Prevention

Quaternary prevention refers to actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable. Targeted populations are those at risk of overmedicalization. [24] An example of quaternary prevention is encouraging clients with terminal illness who are approaching end of life to seek focus on comfort and quality of life and consider hospice care rather than undergo invasive procedures that will likely have no impact on recovery from disease.

See additional examples of primordial, primary, secondary, tertiary, and quaternary prevention strategies in Table 16.3a.

Table 16.3a Examples of Prevention Interventions [25] , [26]

In the United States, several governing bodies make prevention recommendations. For example, the United States Preventive Services Task Force (USPSTF) makes recommendations for primary and secondary prevention strategies, and the Women’s Preventive Services Initiative (WPSI) makes recommendations specifically for females. The Advisory Committee on Immunizations Practices (ACIP) makes recommendations for vaccinations, and various specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the American Cancer Society (ACS) make preventative care recommendations. Preventive services have been proven to be an essential aspect of health care but are consistently underutilized in the United States. [27] Nurses can help advocate for the adoption of evidence-based prevention strategies in their communities and places of employment.

Continuum of Care Prevention Model

A second framework for prevention interventions, referred to as the “Continuum of Care Prevention Model,” was originally proposed by the Institute of Medicine (IOM) in 1994 and has been adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA). [28] See Figure 16.12 [29] for an illustration of the Continuum of Care Prevention Model.

The Continuum of Care Prevention Model can be used to illustrate a continuum of mental health services for community members that includes prevention, treatment, and maintenance care:

• Universal prevention : Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities. [30] , [31] For example, wellness sessions regarding substance misuse can be planned and implemented at a local high school.
• Selected prevention : Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population. [32] , [33] For example, a research study showed that wellness programs implemented for adolescents who were already using alcohol or drugs reduced the quantity and frequency of their alcohol use and reduced episodes of binge drinking. [34]
• Indicated prevention : Interventions that target individuals who have a high probability of developing disease. [35] For example, interventions may be planned for adolescents who show early signs of substance misuse but have not yet been diagnosed with a substance use disorder. Interventions may include referrals to community support services for adolescents who have violated school alcohol or drug policies. [36]
• Treatment refers to identification of a mental health disorder and standard treatment for the known disorder. Treatment also includes interventions to reduce the likelihood of future co-occurring disorders. [37]
• Maintenance refers to long-term treatment to reduce relapse and recurrence, as well as provision of after-care services such as rehabilitation. [38]

See additional examples of prevention strategies using the Continuum of Care Prevention Model in Table 16.3b.

Table 16.3b Examples of Continuum of Care Prevention Strategies

Read  A Guide to SAMHSA’s Strategic Prevention Framework PDF for more about planning prevention strategies for substance misuse and related mental health problems.

Culturally Competent Interventions

To overcome systemic barriers that can contribute to health disparities, nurses must recognize and value cultural differences of diverse populations and develop prevention programs and interventions in ways that ensure members of these populations benefit from their efforts. [39]

SAMHSA identified the following cultural competence principles for planning prevention interventions [40] :

• Include the targeted population in needs assessments and prevention planning
• Use a population-based definition of community (i.e., let the community define itself)
• Stress the importance of relevant, culturally appropriate prevention approaches
• Promote cultural competence among program staff

Review additional concepts related to culturally responsive care in the “ Diverse Patients ” chapter of Open RN Nursing Fundamentals .

Evidence-Based Practice

It is essential to incorporate evidence-based practice when planning community health interventions. SAMHSA provides an evidence-based practice resource center for preventive practices related to mental health and substance abuse. See these resources, as well as examples of evidence-based programs and practices in the following box.

Examples of Evidence Based Prevention Practices related to Mental Health and Substance Misuse [41]

• Blueprints for Healthy Youth Development : Youth violence, delinquency, and drug prevention and intervention programs that meet a strict scientific standard of program effectiveness
• Evidence-Based Behavioral Practice (EBBP) : A project that creates training resources to help bridge the gap between behavioral health research and practice
• SAMHSA’s Suicide Prevention Research Center (SPRC) : A best practices registry that identifies, reviews, and disseminates information about best practices that address specific objectives of the National Strategy for Suicide Prevention
• The Athena Forum: Prevention 101 : Substance misuse prevention programs and strategies with evidence of success from the Washington State Department of Social and Health Services
• National Institute on Drug Abuse: Preventing Drug Use Among Children and Adolescents : Research-based drug abuse prevention principles and an overview of program planning, including universal, selected, and indicated interventions

View the SAMHSA Evidence-Based Practice Resource Center .

Implementation

Community health nurses collaborate with individuals, community organizations, health facilities, and local governments for successful implementation of community health initiatives. Depending on the established community health needs, goals, outcomes, and target group, the implementation of nursing interventions can be categorized as clinical, behavioral, or environmental prevention:

• Clinical prevention : Interventions are delivered one-on-one to individuals in a direct care setting. Examples of clinical prevention interventions include vaccine clinics, blood pressure monitoring, and screening for disease.
• Behavioral prevention : Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies. Examples of behavioral prevention interventions include community exercise programs, smoking cessation campaigns, or promotion of responsible alcohol drinking by adults.
• Environmental prevention : Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health. Examples of environmental prevention strategies include improving clean water systems, establishing no-smoking ordinances, or developing community parks and green spaces.

When evaluating the effectiveness of community health initiatives, nurses refer to the established goals and SMART outcomes to determine if they were met by the timeline indicated. In general, the following questions are asked during the evaluation stage:

• Did the health of the community improve through the interventions put into place?
• Are additional adaptations or changes to the interventions needed to improve outcomes in the community?
• What additional changes are needed to improve the health of the community?
• Have additional priority problems been identified?
• “ Nursing Process in Community Health Nursing ” by Open RN project is licensed under CC BY 4.0 ↵
• Community Tool Box by Center for Community Health and Development at the University of Kansas is licensed under CC BY NC SA 3.0 ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain . ↵
• Medrea, R. (2014, July 20). Windshield survey nursing [Video]. YouTube. All rights reserved. https://youtu.be/aAzW1bW_Dbw ↵
• McDonald, L. (2006). Florence Nightingale and public health policy: Theory, activism and public administration. University of Guelph. https://cwfn.uoguelph.ca/nursing-health-care/fn-and-public-health-policy/ ↵
• Office of Disease Prevention and Health Promotion. Healthy People 2030: Building a healthier future for all. U.S. Department of Health and Human Services. https://health.gov/healthypeople ↵
• Savage, C. L. (2020). Public/community health and nursing practice: Caring for populations (2nd ed.). FA Davis. ↵
• This work is a derivative of StatPearls by Kisling and Das and is licensed under CC BY 4.0 ↵
• “ Playground_at_Hudson_Springs_Park.jpg ” by Kevin Payravi is licensed under CC BY-SA 3.0 ↵
• “ 10442934136_1f910af332_b ” by Lower Columbia College (LCC) is licensed under CC BY_NC-ND 2.0 ↵
• “ US_Navy_021025-N-6498N-001_Mammogram_technician,_aids_a_patient_in_completing_her_annual_mammogram_evaluation.jpg ” by U.S. Navy photo by Ensign Ann-Marie Al Noad is in the Public Domain . ↵
• “ tech_zerog.jpg ” by unknown author at Gaylord.org is included on the basis of Fair Use ↵
• National Research Council (US); Institute of Medicine (US) Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults; and Research Advances and Promising Interventions. Defining the scope of prevention. (2009). In M. E. O’Connell & Warner B. T. (Eds). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. In Research advances and promising interventions. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK32789/ ↵
• This image is a derivative of the “IOM protractor” by unknown author and is included on the basis of Fair Use. Access for free at http://www.ca-sdfsc.org/docs/resources/SDFSC_IOM_Policy.pdf ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain. ↵
• Werch, C., Moore, M. J., DiClemente, C. C., Bledsoe, R., & Jobli, E. (2005). A multihealth behavior intervention integrating physical activity and substance use prevention for adolescents. Prevention Science, 6 (213). https://doi.org/10.1007/s11121-005-0012-3 ↵
• Substance Abuse and Mental Health Services Administration. (2019, July 19). Finding evidence-based programs and practices. https://www.samhsa.gov/sites/default/files/20190719-samhsa-finding_evidence-based-programs-practices.pdf ↵

Analyzing previously collected data to determine community needs.

Data collection that occurs through public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Gatherings where large groups of citizens discuss important issues at well-publicized locations and times.

Systematic method of data collection through small-group discussions led by a facilitator.

Structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue.

Interviews conducted with people in key positions in the community and have specific areas of knowledge and experience.

Type of direct observation of community needs while driving and literally looking through the windshield.

Standardized questions that are relatively easy to analyze.

A summary statement resulting from analysis of the data collected from a community health needs assessment.

Risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations.

Interventions aimed at susceptible populations or individuals to prevent disease from occurring.

The early detection of disease and targets healthy-appearing individuals with subclinical forms of disease.

Implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications.

Actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable.

Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities.

Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population.

Interventions that target individuals who have a high probability of developing disease.

Interventions are delivered one-on-one to individuals in a direct care setting.

Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies.

Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health.

Nursing: Mental Health and Community Concepts Copyright © 2022 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Research Issues in Community Nursing

• Jean McIntosh (QNI Professor of Community Nursing Research) 0

Department of Nursing and Community Health, Glasgow Caledonian University, UK

You can also search for this editor in PubMed   Google Scholar

• Brings together some of the most influential researchers in the field of community nursing to share their knowledge and experience Makes real links between the research itself and the potential effects on practice and policy

Part of the book series: Community Health Care Series (CHCS)

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Table of contents (10 chapters)

Front matter, introduction.

Jean McIntosh

Using research in community nursing

• Rosamund Mary Bryar

Evidence-based health visiting — the utilisation of research for effective practice

• Sally Kendall

Research questions and themes in district nursing

• Lisbeth Hockey

Exploring district nursing skills through research

• Jean McIntosh, Jean Lugton, Deirdre Moriarty, Orla Carney

Community nursing research in mental health

• Sawsan Reda

Community mental health nursing: an interpretation of history as a context for contemporary research

• Edward White

Assessing vulnerability in families

• Jane V. Appleton

Investigating the needs of and provisions for families caring for children with life-limiting incurable disorders

• Alison While

Supporting family carers: a facilitative model for community nursing practice

• Mike Nolan, Gordon Grant, John Keady

Back Matter

• nursing research

Book Title : Research Issues in Community Nursing

Editors : Jean McIntosh

Series Title : Community Health Care Series

DOI : https://doi.org/10.1007/978-1-349-14850-9

Publisher : Red Globe Press London

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Macmillan Publishers Limited 1999

Softcover ISBN : 978-0-333-73504-6 Due: 30 April 1999

Edition Number : 1

Number of Pages : XIII, 224

Additional Information : Previously published under the imprint Palgrave

Topics : Nursing Research

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16.3: Applying the Nursing Process to Community Health

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• Chippewa Valley Technical College via OpenRN

Community health nurses apply the nursing process to address needs of individuals, families, vulnerable populations, and entire communities. See Figure 16.7 [1] for an illustration of the nursing process in community health nursing.

The community health nurse typically begins a community health needs assessment by determining what data is already available. [2] As previously discussed in the “ Community Health Concepts ” section, national, state, county, and local health needs assessments are widely available. Secondary analysis refers to analyzing previously collected data to determine community needs.

Community health nurses may also engage in primary data collection to better understand the community needs and/or study who may be affected by actions taken as a result of the assessment. [3] Primary data collection includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Public Forums

Public forums are gatherings where large groups of citizens discuss important issues at well-publicized locations and times. Forums give people of diverse backgrounds a chance to express their views and enhance understanding of the community’s specific needs and resources. Forums should be planned in a convenient location with accessibility to public transportation and child care. They should also be scheduled at convenient times for working families to gain participation from a wide range of populations.

Focus Groups

Focus groups are a systematic method of data collection through small-group discussions led by a facilitator. Participants in focus groups are selected to represent a larger group of people. Groups of 6-10 people with similar backgrounds or interests are interviewed in an informal or formal setting. Focus groups should be scheduled at several dates and times to ensure a broad participation from members of the community. Here are advantages of focus groups:

• Community member involvement in assessing and planning community initiatives is encouraged.
• Different perceptions, values, and beliefs by community members are explored.
• Input can be obtained from specific subpopulations of the community. Example of subpopulations include young mothers caring for infants, individuals receiving home hospice care, individuals struggling to find housing, residents of the prison system, individuals coping with mental health disorders, or residents in group homes.

Interviews are structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue. Key informant interviews are conducted with people in key positions in the community and have specific areas of knowledge and experience. These interviews can be useful for exploring specific community problems and/or assessing a community’s readiness to address those problems. [4]

Advantages of interviews include the following [5] :

• They can be conducted in a variety of settings (e.g., homes, schools, churches, stores, or community centers).
• They are low cost and generally have low dropout rates.
• Respondents define what is important from their perspective.
• It is possible to explore issues in depth, and there is an opportunity to clarify responses.
• They can provide leads to other data sources and key informants.
• They provide an opportunity to build partnerships with community members.
• Data can be compared among local government officials, citizens, and non-government leaders.

Interviews can have these disadvantages:

• Interviews can be time-consuming to schedule and perform.
• They require trained interviewers.
• There is a potential for interviewer bias to affect the data collected during the interview.
• Rapport must be established before sensitive information is shared.
• It is more time-consuming to summarize and analyze findings.

Windshield Surveys

A windshield survey is a type of direct observation of community needs while driving and literally looking through the windshield. It can be used to observe characteristics of a community that impact health needs such as housing, pollution, parks and recreation areas, transportation, health and social services agencies, industries, grocery stores, schools, and religious institutions.

View the following YouTube video of a windshield survey [6] : Windshield Survey Nursing .

Surveys use standardized questions that are relatively easy to analyze. They are beneficial for collecting information across a large geographic area, obtaining input from as many people as possible, and exploring sensitive topics. [7] Surveys can be conducted face to face, via the telephone, mailed, or shared on a website. Responses are typically anonymous but demographic information is often collected to focus on the needs of specific populations. Disadvantages of surveys can include the following [8] :

• Surveys can be time-consuming to design, implement, and analyze the results.
• The accuracy of survey results depends on who is surveyed and the size of the sample.
• Mailed surveys may have low response rates with higher costs due to postage.
• They offer little opportunity to explore issues in depth, and questions cannot be clarified.
• There is no opportunity to build rapport with respondents.

Participant Observation

Participant observation refers to nurses informally collecting data as a member of the community in which they live and work. This is considered a subjective observation because it is from the nurse’s perspective. Informal observations are made, or discussions are elicited among peers and neighbors within the community.

Sociocultural Considerations

When analyzing community health needs, it is essential to do so through a sociocultural lens. Just as an individual’s health can be influenced by a wide variety of causes, community health problems are affected by various factors in the community. For example, a high rate of cancer in one community could be related to environmental factors such as pollution from local industry, but in another community, it may be related to the overall aging of the population. Both communities have a high rate of cancer, but the public health response would be very different. Another example related to mental health is related to various situational factors affecting depression. A high rate of depression in one community may be related to socioeconomic factors such as low-paying jobs, lack of support systems, and poor access to basic needs like grocery stores, whereas in another community it may be related to lack of community resources during frequent weather disasters. The public health response would be different for these two communities.

Nurses must also recognize and value cultural differences such as health beliefs, practices, and linguistic needs of diverse populations. They must take steps to identify subpopulations who are vulnerable to health disparities and further investigate the causes and potential interventions for these disparities. For example, mental health disparities pose a significant threat to vulnerable populations in our society, such as high rates of suicide among LGBTQ+ youth, reduced access to prevention services among people living in rural areas, and elevated rates of substance misuse among Native Americans. These disparities threaten the health and wellness of these populations. [9]

Key points to consider when assessing a community using a sociocultural lens include the following:

• Have the trends of assessment data changed over time? What are the potential causes for these changes in this community?
• How does the community’s needs assessment data compare to similar communities at local, county, state, and national levels? What target goals and health initiatives have been successfully implemented in other communities?
• What vulnerable subpopulations are part of this community, and what health disparities are they experiencing? What are potential causes and solutions for these health disparities?
• Input from members of vulnerable subpopulations must be solicited regarding their perspectives on health disparities, as well as barriers they are experiencing in accessing health care.

Similar to how nurses individualize nursing diagnoses for clients based on priority nursing problems identified during a head-to-toe assessment, community health nurses use community health needs assessment data to develop community health diagnoses. These diagnoses are broad, apply to larger groups of individuals, and address the priority health needs of the community. Resources such as Healthy People 2030 can be used to determine current public health priorities.

A community diagnosis is a summary statement resulting from analysis of the data collected from a community health needs assessment. [10] A clear statement of the problem, as well as causes of the problem, should be included. A detailed community diagnosis helps guide community health initiatives that include nursing interventions.

A community diagnosis can address health deficits or services that support health in the community. A community diagnosis may also address a need for increased wellness in the community. Community diagnoses should include these four parts:

• The problem
• The population or vulnerable group
• The effects of the problem on the population/vulnerable group
• The indicators of the problem in this community

Here are some examples of community health diagnoses based on community health needs assessments:

• Community Scenario A
• Assessment data: The local high school has had a 50% increase in the number of teen pregnancies in the past year, causing high school graduation rates to decrease due to pregnant students dropping out of high school.
• Community diagnosis: Increased need for additional birth control and resources for prevention of pregnancy due to lack of current resources, as evidenced by 50% increase in teen pregnancies in the last year and a decrease in graduation rates.
• Community Scenario B
• Assessment data: Fifty percent of residents of an assisted living facility were found to have blood pressure readings higher than 130/80 mmHg during a health fair last week at the facility.
• Community diagnosis: Increased need for education about exercise and diet and referrals to primary care doctors for residents of an assisted living facility due to increased risk for mortality related to high blood pressure, as evidenced by a high number of residents with high blood pressure during a health fair.
• Community Scenario C
• Assessment data: The local high school has had two cases of suicide in the past year.
• Diagnosis: Increased need for community education regarding suicide prevention and crisis hotlines, as evidenced by an increase in adolescent suicide over the past twelve months.

Outcome Identification

Outcomes refer to the changes in communities that nursing interventions and prevention strategies are intended to produce. Outcomes include broad overall goals for the community, as well as specific outcomes referred to as “SMART” outcomes that are specific, measurable, achievable, realistic, and with a timeline established.

Broad goals for communities can be tied to national objectives established by Healthy People 2030, as previously discussed in the “ Community Health Concepts ” section.

Healthy People objectives are classified by these five categories [11] :

• Health Conditions
• Health Behaviors
• Populations
• Settings and Systems
• Social Determinants of Health

SMART outcomes can be created based on the objectives listed under each category. For example, if an overall community goal is related to “Drug and Alcohol Use” under the “Health Behaviors” category, a SMART outcome could be based on the Healthy People objective, “Increase the proportion of people with a substance use disorder who got treatment in the past year.” [12] Based on this Healthy People objective, an example of a SMART outcome could be the following:

• The proportion of people treated for a substance disorder in Smith County will increase to 14% within the next year.

View the Healthy People 2030 Objectives and Community Objectives .

Planning Interventions

Nursing interventions for the community can be planned based on the related Healthy People category and objective. For example, based on the sample SMART outcome previously discussed, a planned nursing intervention could be the following:

• The nurse will provide education and materials regarding evidence-based screening practices for substance use disorder in local clinics.

Community health nursing interventions typically focus on prevention of illness with health promotion interventions. After performing a community health needs assessment, identifying priority problems, and establishing health goals and SMART outcomes, the nurse integrates knowledge of health disorders (e.g., diabetes, cancer, obesity, or mental health disorders) and current health risks in a community to plan prevention interventions.

There are two common public health frameworks used to plan prevention interventions. A traditional preventive framework is based on primary, secondary, or tertiary prevention interventions. A second framework, often referred to as the Continuum of Care Prevention Model, was established by the Institute of Medicine (IOM) and includes universal, selected, and indicated prevention interventions. Both frameworks are further discussed in the following sections. [13]

Primordial, Primary, Secondary, Tertiary, and Quaternary Interventions

Preventive health interventions may include primordial, primary, secondary, tertiary, and quaternary prevention interventions. These strategies attempt to prevent the onset of disease, reduce complications of disease that develops, and promote quality of life. [14]

Primordial Prevention

Primordial prevention consists of risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations. In other words, primordial prevention interventions target underlying social determinants of health that can cause disease. These measures are typically promoted through laws and national policy. An example of a primordial prevention strategy is improving access to urban neighborhood playgrounds to promote physical activity in children and reduce their risk for developing obesity, diabetes, and cardiovascular disease. [15] See Figure 16.8 [16] for an image of a neighborhood playground.

Primary Prevention

Primary prevention consists of interventions aimed at susceptible populations or individuals to prevent disease from occurring. An example of primary prevention is immunizations. [17] Nursing primary prevention interventions also include public education and promotion of healthy behaviors. [18] See Figure 16.9 [19] for an image of an immunization clinic sponsored by a student nurses’ association.

Secondary Prevention

Secondary prevention emphasizes early detection of disease and targets healthy-appearing individuals with subclinical forms of disease. Subclinical disease refers to pathologic changes with no observable signs or symptoms. Secondary prevention includes screenings such as annual mammograms, routine colonoscopies, Papanicolaou (Pap) smears, as well as screening for depression and substance use disorders. [20] Nurses provide education to community members about the importance of these screenings. See Figure 16.10 [21] for an image of a mammogram.

Tertiary Prevention

Tertiary prevention is implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease after it is diagnosed in an individual. [22] For example, rehabilitation therapy after an individual experiences a cerebrovascular accident (i.e., stroke) is an example of tertiary prevention. See Figure 16.11 [23] for an image of a client receiving rehabilitation after experiencing a stroke.

The goals of tertiary prevention interventions are to reduce disability, promote curative therapy for a disease or injury, and prevent death. Nurses may be involved in providing ongoing home health services in clients’ homes as a component of interprofessional tertiary prevention efforts. Health education to prevent the worsening or recurrence of disease is also provided by nurses.

Quaternary Prevention

Quaternary prevention refers to actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable. Targeted populations are those at risk of overmedicalization. [24] An example of quaternary prevention is encouraging clients with terminal illness who are approaching end of life to seek focus on comfort and quality of life and consider hospice care rather than undergo invasive procedures that will likely have no impact on recovery from disease.

See additional examples of primordial, primary, secondary, tertiary, and quaternary prevention strategies in Table 16.3a.

Table 16.3a Examples of Prevention Interventions [25] , [26]

In the United States, several governing bodies make prevention recommendations. For example, the United States Preventive Services Task Force (USPSTF) makes recommendations for primary and secondary prevention strategies, and the Women’s Preventive Services Initiative (WPSI) makes recommendations specifically for females. The Advisory Committee on Immunizations Practices (ACIP) makes recommendations for vaccinations, and various specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the American Cancer Society (ACS) make preventative care recommendations. Preventive services have been proven to be an essential aspect of health care but are consistently underutilized in the United States. [27] Nurses can help advocate for the adoption of evidence-based prevention strategies in their communities and places of employment.

Continuum of Care Prevention Model

A second framework for prevention interventions, referred to as the “Continuum of Care Prevention Model,” was originally proposed by the Institute of Medicine (IOM) in 1994 and has been adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA). [28] See Figure 16.12 [29] for an illustration of the Continuum of Care Prevention Model.

The Continuum of Care Prevention Model can be used to illustrate a continuum of mental health services for community members that includes prevention, treatment, and maintenance care:

• Universal prevention: Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities. [30] , [31] For example, wellness sessions regarding substance misuse can be planned and implemented at a local high school.
• Selected prevention: Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population. [32] , [33] For example, a research study showed that wellness programs implemented for adolescents who were already using alcohol or drugs reduced the quantity and frequency of their alcohol use and reduced episodes of binge drinking. [34]
• Indicated prevention: Interventions that target individuals who have a high probability of developing disease. [35] For example, interventions may be planned for adolescents who show early signs of substance misuse but have not yet been diagnosed with a substance use disorder. Interventions may include referrals to community support services for adolescents who have violated school alcohol or drug policies. [36]
• Treatment refers to identification of a mental health disorder and standard treatment for the known disorder. Treatment also includes interventions to reduce the likelihood of future co-occurring disorders. [37]
• Maintenance refers to long-term treatment to reduce relapse and recurrence, as well as provision of after-care services such as rehabilitation. [38]

See additional examples of prevention strategies using the Continuum of Care Prevention Model in Table 16.3b.

Table 16.3b Examples of Continuum of Care Prevention Strategies

Read A Guide to SAMHSA’s Strategic Prevention Framework PDF for more about planning prevention strategies for substance misuse and related mental health problems.

Culturally Competent Interventions

To overcome systemic barriers that can contribute to health disparities, nurses must recognize and value cultural differences of diverse populations and develop prevention programs and interventions in ways that ensure members of these populations benefit from their efforts. [39]

SAMHSA identified the following cultural competence principles for planning prevention interventions [40] :

• Include the targeted population in needs assessments and prevention planning
• Use a population-based definition of community (i.e., let the community define itself)
• Stress the importance of relevant, culturally appropriate prevention approaches
• Promote cultural competence among program staff

Review additional concepts related to culturally responsive care in the “ Diverse Patients ” chapter of Open RN Nursing Fundamentals .

Evidence-Based Practice

It is essential to incorporate evidence-based practice when planning community health interventions. SAMHSA provides an evidence-based practice resource center for preventive practices related to mental health and substance abuse. See these resources, as well as examples of evidence-based programs and practices in the following box.

Examples of Evidence Based Prevention Practices related to Mental Health and Substance Misuse [41]

• Blueprints for Healthy Youth Development : Youth violence, delinquency, and drug prevention and intervention programs that meet a strict scientific standard of program effectiveness
• Evidence-Based Behavioral Practice (EBBP) : A project that creates training resources to help bridge the gap between behavioral health research and practice
• SAMHSA’s Suicide Prevention Research Center (SPRC) : A best practices registry that identifies, reviews, and disseminates information about best practices that address specific objectives of the National Strategy for Suicide Prevention
• The Athena Forum: Prevention 101 : Substance misuse prevention programs and strategies with evidence of success from the Washington State Department of Social and Health Services
• National Institute on Drug Abuse: Preventing Drug Use Among Children and Adolescents : Research-based drug abuse prevention principles and an overview of program planning, including universal, selected, and indicated interventions

View the SAMHSA Evidence-Based Practice Resource Center .

Implementation

Community health nurses collaborate with individuals, community organizations, health facilities, and local governments for successful implementation of community health initiatives. Depending on the established community health needs, goals, outcomes, and target group, the implementation of nursing interventions can be categorized as clinical, behavioral, or environmental prevention:

• Clinical prevention: Interventions are delivered one-on-one to individuals in a direct care setting. Examples of clinical prevention interventions include vaccine clinics, blood pressure monitoring, and screening for disease.
• Behavioral prevention: Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies. Examples of behavioral prevention interventions include community exercise programs, smoking cessation campaigns, or promotion of responsible alcohol drinking by adults.
• Environmental prevention: Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health. Examples of environmental prevention strategies include improving clean water systems, establishing no-smoking ordinances, or developing community parks and green spaces.

When evaluating the effectiveness of community health initiatives, nurses refer to the established goals and SMART outcomes to determine if they were met by the timeline indicated. In general, the following questions are asked during the evaluation stage:

• Did the health of the community improve through the interventions put into place?
• Are additional adaptations or changes to the interventions needed to improve outcomes in the community?
• What additional changes are needed to improve the health of the community?
• Have additional priority problems been identified?
• “ Nursing Process in Community Health Nursing ” by Open RN project is licensed under CC BY 4.0 ↵
• Community Tool Box by Center for Community Health and Development at the University of Kansas is licensed under CC BY NC SA 3.0 ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain . ↵
• Medrea, R. (2014, July 20). Windshield survey nursing [Video]. YouTube. All rights reserved. https://youtu.be/aAzW1bW_Dbw ↵
• McDonald, L. (2006). Florence Nightingale and public health policy: Theory, activism and public administration. University of Guelph. https://cwfn.uoguelph.ca/nursing-health-care/fn-and-public-health-policy/ ↵
• Office of Disease Prevention and Health Promotion. Healthy People 2030: Building a healthier future for all. U.S. Department of Health and Human Services. https://health.gov/healthypeople ↵
• Savage, C. L. (2020). Public/community health and nursing practice: Caring for populations (2nd ed.). FA Davis. ↵
• This work is a derivative of StatPearls by Kisling and Das and is licensed under CC BY 4.0 ↵
• “ Playground_at_Hudson_Springs_Park.jpg ” by Kevin Payravi is licensed under CC BY-SA 3.0 ↵
• “ 10442934136_1f910af332_b ” by Lower Columbia College (LCC) is licensed under CC BY_NC-ND 2.0 ↵
• “ US_Navy_021025-N-6498N-001_Mammogram_technician,_aids_a_patient_in_completing_her_annual_mammogram_evaluation.jpg ” by U.S. Navy photo by Ensign Ann-Marie Al Noad is in the Public Domain . ↵
• “ tech_zerog.jpg ” by unknown author at Gaylord.org is included on the basis of Fair Use ↵
• National Research Council (US); Institute of Medicine (US) Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults; and Research Advances and Promising Interventions. Defining the scope of prevention. (2009). In M. E. O’Connell & Warner B. T. (Eds). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. In Research advances and promising interventions. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK32789/ ↵
• This image is a derivative of the “IOM protractor” by unknown author and is included on the basis of Fair Use. Access for free at http://www.ca-sdfsc.org/docs/resources/SDFSC_IOM_Policy.pdf ↵
• A Guide to SAMHSA’s Strategic Prevention Framework by Substance Abuse and Mental Health Services Administration is available in the Public Domain. ↵
• Werch, C., Moore, M. J., DiClemente, C. C., Bledsoe, R., & Jobli, E. (2005). A multihealth behavior intervention integrating physical activity and substance use prevention for adolescents. Prevention Science, 6 (213). https://doi.org/10.1007/s11121-005-0012-3 ↵
• Substance Abuse and Mental Health Services Administration. (2019, July 19). Finding evidence-based programs and practices. https://www.samhsa.gov/sites/default/files/20190719-samhsa-finding_evidence-based-programs-practices.pdf ↵

SYSTEMATIC REVIEW article

Community health nursing in iran: a review of challenges and solutions (an integrative review).

• 1 Student Research Committee, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
• 2 Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
• 3 Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Background and Objective: In recent decades, nursing has witnessed many changes in Iran. Despite the numerous advances in nursing, the health system faces many challenges in community health nursing. This study aims to review the challenges in community health nursing in Iran and provide an evidence-based solution as well.

Materials and Methods: This article is an integrated review of the literature regarding the challenges in community health nursing published between 2000 and 2021 in the databases Scopus, Medline, Cochrane Database of Systematic Reviews, Science Direct, Google Scholar, Scientific Information Database (SID). After performing searches, 20 articles were selected and studied. Data analysis was done using Russell approach (2005).

Findings: The results of this study were summarized in 6 themes consisting of challenges in community health nursing education, practical challenges in community health nursing, policy-making challenges in community health nursing, management challenges in community health nursing, and infrastructural and cultural challenges. Solutions were also proposed to address each of the above issue.

Conclusions: The results of the study showed that diverse challenges exist in community health nursing in Iran, considering that community health nurses play an important role in providing primary health care and community-based care. In order to solve these challenges, the authors have some recommendations: modifying the structure of the health system with the aim of moving toward a community-oriented approach from a treatment-oriented one, developing laws to support community health nurses, creating an organizational chart for nurses at the community level, modifying nursing students' training through a community-based approach, and covering community-based services and care under insurance.

Introduction

An examination of nurses' status and position in the service provision system around the world shows that nurses constitute the largest group of health care workers ( 1 , 2 ). Community health nurses are a major link between the community and health institutions. They are able to understand and interpret the needs of the society and the objectives of health policymakers ( 3 , 4 ). In addition, community health nurses have an excellent position and status for addressing many challenges in the health system including immigration, bioterrorism, homelessness, unemployment, violence, obesity epidemic, etc. ( 1 , 2 , 5 ). From the perspective of the World Health Organization (WHO) and the American Nursing Association, community health nursing is a special area of nursing that combines nursing skills, public health, and a part of social activities with the aim of promoting health, improving physical and social condition, and rehabilitation and recovery from diseases and disabilities ( 6 , 7 ). Considering the importance of nursing services in the health service provision system and their role in universal health coverage, in the 66th Session of the health ministers of WHO Regional Office for the Eastern Mediterranean, much attention was devoted to developing plans for improving and strengthening community health nursing ( 8 ).

In all developed countries, community health nursing has had a significant growth in the health care system ( 9 ). In Canada, the community-based community health nursing has been established in 1978, aiming to maintain and promote the health of individuals, families, and communities. It also participates in the family physician and primary health care delivery ( 10 ). In some European countries, including Norway, Finland, the United Kingdom, Ireland, Sweden, and France, community health nurses have replaced physician-centered and hospital-centered approaches, providing health services for the members of the community ( 4 , 9 , 11 – 13 ). A study conducted by WHO on community health nursing's status in some less developed and developing countries (Bangladesh, Indonesia, Nepal, Cameroon, Senegal, Uganda, Guyana, Trinidad and Tobago) shows a lack of commitment and the low capacity of the policymakers to implement global and regional political tools regarding community health nursing, although most of the countries under study had a basic and operational framework for the optimal activity of community health nurses. On the other hand, only 6% of the community health nurses in these countries worked in the field of health promotion, disease prevention, and rehabilitation care, while this sector is supposed to be their main field of activity. The existing barriers preventing community health nurses from playing their role in developing countries include the lack of consensus in the realm of community health nursing practice, the lack of necessary coordination for inter-professional activities, few job opportunities for community health nurses, insufficient recognition of community health nursing, and great emphasis on clinical care in health centers ( 6 ). In Asian countries, including Japan, China, and Malaysia, community health nurses play a key role, too, focusing on the assessment of community health needs, health care delivery, and health promotion ( 9 , 14 , 15 ).

Iran is a populated country in the Eastern Mediterranean region, where health services are provided at public, private, and charity sectors ( 16 , 17 ). In Iran, since 1958, behavioral and social sciences have been included in the nursing program as a major part of its curriculum. Then, in 1986, the disciplines of community-based and community-oriented nursing were considered by educational policymakers, followed by the inclusion of community health nursing and epidemiology courses in the undergraduate curriculum. Community health nursing program is developed in line with health-oriented policies and focuses on community health. Graduates of this field work in different settings of community by combining the nursing science with other health-related sciences and evidence-based practice ( 18 , 19 ). Due to its focus on health promotion, the position of this discipline in the country's health system is very crucial, and is a major contributor to directing the community toward the 20-Year National Vision and in an ideal position to address the countless challenges against the health system ( 2 ). However, the role of nurses in Iran has not made significant progress and is limited to providing services in medical centers ( 20 ), because the viewpoint and the attitude of most Iranian health authorities is based on the employment of nurses in the secondary level of prevention, i.e., clinical care in hospitals ( 2 ). Therefore, hospitals are the most common setting for community health nurses' activities ( 21 ). Comprehensive health centers are also managed to provide health services by the workers with bachelor's and associate's degrees in family health, environmental health, occupational health, and disease control, as well as midwives. These services are provided sporadically in health service centers ( 18 ) and no effective strategies tailored to the needs of the community are adopted in order to provide care ( 22 ).

It is noteworthy and interesting that also in the family physician team, no position has been defined for community health nurses and most of the Iranian health authorities believe that nurses cannot provide significant health services ( 18 ). However, the community health nurse can be a complementary project in the family physician program and even make up for its shortcomings. This can help the government understand the health for all as a goal, the proof of which is the presence of nurses in blood pressure screening program in 2012 ( 23 ). On the other hand, numerous studies indicate community health nurses' abilities and their key role in identifying health needs and promoting community health ( 24 – 28 ). Although the education and training of community health nurses is costly for the government, their expertise is not utilized. At present, the services of community health nurses in Iran are mainly provided at the third level and at hospitals, because no position is defined for them in comprehensive health centers ( 18 , 29 ). In other words, they have no defined job position to work in this field, although in the curriculums, the future job status of this discipline is designed ( 30 ). Therefore, one of the most important infrastructural issues is to create a position and a job description in the organizational chart for community health nurses in comprehensive health centers ( 31 ).

A brief review shows that studies in Iran have mostly focused on the challenges of community health nursing education and barriers against home care ( 1 , 16 , 18 , 19 , 32 – 34 ) and other aspects of community health nursing have rarely been studied. In addition, no study has been conducted to offer solutions for addressing the challenges of community health nursing. Although other studies have been conducted in different cultures and contexts, an integrated review of them can help identify and eliminate present barriers with the aim of facilitating future planning and policymaking to enhance the status of community health nursing. Therefore, by conducting an integrated review, the present study aimed to identify the challenges of and barriers against community health nursing and the strategies to address them.

Methodology

This is an integrative review study on the challenges of community health nursing and the related solutions. The integrated review of literature is the summarization of previous studies by extracting the study results. This method is used to evaluate the strength of scientific evidence, identify gaps in current research, detect the needs for future research, create a research question, identify a theoretical or conceptual framework, and explore the research methods that have been successfully used. The integrative review study is based on Russell model which consists of 5 steps as follows: (1) formulating the research problem, objective, and question, (2) collecting data or searching through articles, (3) evaluating data, (4) data analysis, (5) interpreting and presenting the results ( 35 ).

Formulating the Research Problem, Objective, and Question

Considering the items discussed in the introduction, this study is conducted to determine the challenges of community health nursing in Iran and the related solutions. Two key questions guiding the review process include “What are the challenges of the community health nursing discipline in Iran?” and “What are the solutions to address these challenges?” Answering these two key questions will help detect the challenges of community health nursing, propose solutions to address them, and promote the community health nursing discipline.

Collecting Data or Searching Through Texts

In this study, the target population consisted of all the studies (articles and dissertations) that had been conducted in the field of community health nursing regarding its challenges, barriers, and solutions, the full texts of which were accessible. Available resources, including all the studies on the challenges of community health nursing, were reviewed in this study. A comprehensive search was done through the databases Medline, Scopus, Cochrane Database of Systematic Reviews, Science Direct, Google Scholar, and Scientific Information Database (SID) for the papers published between 2000 and 2021 in eligible English or Farsi journals.

The keywords that were searched consisted of community health nurse, community-based nursing, public health nurse, nursing challenges, nursing position, and primary health care. The keywords were investigated both separately and in combination with each other ( Table 1 ). Finally, after preforming the search, 142 published articles were identified.

Table 1 . Search strategy.

Data Evaluation

The relevant articles were evaluated based on the title, abstract, text, as well as the inclusion and the exclusion criteria. The inclusion criteria for the studies consisted of the following: (1) examining the challenges of and barriers against community health nurses and its position, (2) containing the keywords or their equivalent in the title or abstract of the article (3) Being written in either Farsi or English. The exclusion criteria included the following: (1) not accessing the original paper and the information on its methodology, (2) being written in other languages, (3) being irrelevant to the research question. It is noteworthy that in this study, there were no limitations in terms of research method, so that the results of various studies could be used.

Selecting Studies

After doing the systematic search, the studies related to the search keywords were found. After removing the duplicate titles (79 articles), the title, the abstract, and the full text of the studies were reviewed by the research team, and the inclusion and the exclusion criteria were applied. Twenty-four articles were excluded due to being irrelevant and 55 articles entered the screening stage, 20 of which were excluded. Then 35 articles were examined regarding eligibility and, finally, 20 articles were included in the study. The studies were selected by a research team consisting of two nursing professors (faculty members of Ahvaz Jundishapur University of Medical Sciences and Tehran's Shahid Beheshti University of Medical Sciences) and one nursing PhD student (Ahvaz Jundishapur University of Medical Sciences). Furthermore, the research team came to a consensus through more discussion regarding the points of disagreement.

Data Analysis

At this stage, the articles were reviewed separately. Finally, 20 articles related to the purpose of the study were reviewed and analyzed. Each article was read completely and the results of the studies were extracted from them. After extracting the results of the articles, their results and statistical analysis were compared. The results with the highest frequency in these articles were further interpreted in the next phase.

Interpreting the Data and Publishing Information

At this stage, according to the analysis of the related studies, their comparison, and the data frequency, the following items were extracted.

Search Results

After eliminating the duplicate articles ( n = 79), 55 studies entered the screening phase and their titles and abstracts were evaluated. In total, 35 studies were included in the selection phase, and 20 remained in the study ( Figure 1 ). Twenty articles met the inclusion criteria and were included in the final analysis. The details are displayed in Table 2 .

Figure 1 . PRISMA flowchart for search strategy and results.

Table 2 . A summary of the critical review of previous Iranian and foreign studies.

The 20 remaining studies were published between 2010 and 2021. Five of them were review studies (systematic, meta-synthesis and integrated reviews). Seven reviews were of qualitative type (grounded and content analysis), seven reviews were cross-sectional descriptive, and one was a comparative study. Eighteen reviews were published in English and two were published in Farsi. The majority of the reviews investigated the position and the role of community health nursing in the health service delivery system and its challenges. About 40% of the reviews are related to the studies on the situation of community health nursing and the barriers against its provision in Iran. Two reviews have studied community health nursing education in Iran, and seven reviews proposed strategies to solve the challenges of community health nursing.

By analyzing the reviews, six themes emerged in the field of community health nursing challenges, and six other themes concerned the strategies to overcome the challenges. The details are displayed in Table 3 .

Table 3 . The challenges of community health nursing and the identified solutions.

The Challenges of Community Health Nursing in Iran

There are several challenges regarding community health nursing in Iran, which have been addressed in previous studies ( Figure 2 )

Figure 2 . Community health nursing challenges in Iran.

Challenges of Community Health Nursing Education

Several challenges were mentioned in the literature in regard with the education, which were divided into the three areas input, process , and output .

Input. Students' poor understanding of community health nursing lessons, considering the community health nursing apprenticeship as futile, and, in some cases, even as a chance to rest, as well as their poor motivation for active participation were mentioned as important challenges ( 32 ). Moreover, nursing students' treatment-based and disease-based perspective and their poor community-based and holistic perspective is another challenge in this area ( 1 , 2 ).

Another challenge in this area is the insufficient skills and experience of nursing educators in the field of community-based educational planning, their inadequacy in conducting community health apprenticeship programs and the related evaluations, and ineffectiveness of community health apprenticeship ( 19 , 42 ). In another study, the low quality of community health nursing education, the use of traditional methods, reviewing theoretical topics during apprenticeship, and not implementing appropriate educational models were mentioned as challenges ( 1 , 19 ). Other studies have shown that the educational system of medical universities is not adjusted to PHC and the educational content is not tailored to the needs. Therefore, the university graduates do not have the required skills to deal with problems and academic education courses should be promoted and based on PHC ( 22 , 47 ).

The Process. The poor presence of community-based care in the nursing education and focusing on hospital care have been referred to as one of the most important challenges according to several studies. Nursing education in Iran is more focused on clinical education. Most nursing schools train their students to play the traditional nursing role, while community needs the training of nurses according to holistic perspectives ( 1 , 16 , 19 , 40 ). Limited community health credits and the hours of apprenticeship in health centers will lead to poor productivity of apprenticeship programs ( 2 , 31 ). The theory-practice gap, i.e., the inapplicability of some health theory content in the apprenticeship settings, and the lack of community-based education standards in nursing were mentioned as other challenges in this field ( 1 , 19 ).

Output. Recruiting nurses only in clinical settings such as hospitals and the absence of a particular and appropriate professional position for nursing and community health nursing graduates in health centers has prevented nursing graduates from acquiring the necessary skills to provide health care ( 31 , 42 ).

Practical Challenges of Community Health Nursing

One of the most important challenges in this field is not defining positions for the provision of nursing services in the community and various settings of the health system. Therefore, in hospitals, which are considered as the main position of nurses, appropriate roles are not defined for them with the aim of health promotion ( 21 ). Another challenge is hiring nurses and community health nurses in medical settings and hospitals. Nursing care in Iran focuses on the provision of care at the secondary level of prevention; therefore, the preventive role of nurses is overshadowed and nurses are not involved in health care homes and comprehensive health centers, which is the first level of people's contact with the health care system ( 16 , 31 , 40 ). The lack of adequate and proper health care in remote and rural areas is one of the biggest national concerns, and most of the health care workers in rural and remote areas are Behvarzes (rural health workers) and practical nurses, while no job opportunities exist for community-based nursing postgraduates in comprehensive health centers, prevention units, and health care homes ( 2 ). The lack of clear job descriptions for community health nurses and community-based nursing in the country is another challenge, as community health nursing is only a field for study, not suited for practice ( 18 ). Another important challenge will be the inadequate professional development of nursing compatible with the needs of community, the lack of competent staff in the field of community-based nursing, and the lack of nursing promotion in accordance with the pattern of diseases in the country ( 29 ).

One of the important areas of community health nursing is performing home visits and the provision of care and counseling in the home environment. A challenge that community health nurses face in this regard is the problems with ensuring their safety ( 16 ).

Policymaking Challenges in Community Health Nursing

The lack of mutual interaction between nursing and other institutions of the health system and nurses' lack of involvement in policymaking regarding their own field of study has resulted in neglecting the role and the position of nurses in the health system. On the other hand, health policy makers have not taken the nursing profession seriously because physicians are dominant in the health system. In other words, the nurse's role and position in the field of prevention and community-based services has been ignored. The chaos and the disorder in the health system, as another challenge, has prevented the fulfillment of one's actual

role ( 21 ). On the other hand, the absence of interaction between nursing managers and the policymakers of the Ministry of Health to identify community health nurses' potentials is another challenge ( 31 ).

Managerial Challenges in the Field of Community Health Nursing

In the field of management, several challenges have been mentioned in the articles, which were divided into two areas: managerial actions , and the lack of knowledge of the community health nursing profession .

Managerial Actions. The lack of an effective management system for the use of community health nursing services has been mentioned as one of the most important challenges, as health managers have to make appropriate strategic plans ( 18 ). Another important challenge mentioned in the studies is the existence of specialty and subspecialty service providers in the health system, which has hindered the establishment and the development of health promotion centers; in other words, community-based care has no place in the Iranian health system ( 16 ). The managers' not using motivational mechanisms to encourage community health nurses to work in health centers is referred to as another challenge. One of the major motivating factors is the allocation of salaries and financial benefits, but since the health personnel's salaries are lower than those of the staff in treatment sectors, community health nurses are less motivated to work in the field of health ( 2 , 31 ).

The Lack of Knowledge of Community Health Nursing Profession . One of the important challenges is nursing institutions' lack of knowledge of nursing and its specialty disciplines ( 40 ). The health managers' lack of knowledge of the capabilities of nursing and community health nursing has resulted in their limited presence in community health service centers and the concept of community health nurse's role ( 2 , 31 , 40 ). In addition, Iranian health managers have not considered a position for community health nurses in the family physician team, because these authorities do not have any knowledge of the community health nursing profession ( 18 ).

Infrastructural Challenges

In regard with of infrastructure, several challenges were pointed to in the articles, which were divided into three areas: insurance coverage and funding, executive protocols , and interdisciplinary cooperation .

Insurance Coverage and Funding . Another challenge is the high cost of health service provision in the community in the form of home visits and the fact that they are not paid by insurance. Allocating less funds for providing community-based care than for treatment care and hospitalization is another challenge in the Iranian health system ( 16 , 17 , 31 , 33 ).

Executive Protocols . The absence of clear guidelines for making assessments, classifying patients and care seekers, wages and salaries, allocating funds and determining personnel adequacy and competency in the community-based care and home care system is another important challenge in this regard ( 16 ).

Interdisciplinary Cooperation . There is no interdisciplinary cooperation and coordination among different sectors of community such as health centers, municipalities, and the police to provide community-based care by community health nurses ( 16 ). While the desirable future of the community health nursing profession requires cooperation and communication with other institutions such as the Welfare Organization, the municipality, and the Broadcasting Corporation ( 29 ). On the other hand, Iranian health system is governed through unionism and tribalism. Therefore, as long as there is unionism, no interdisciplinary cooperation and partnership should be expected ( 31 ).

Cultural Challenges

Public distrust of and negative attitude toward the capabilities of non-physician experts in providing prevention and health services is another challenge in Iran ( 2 , 16 ).

In previous studies, several strategies were mentioned for each group of community health nursing challenges.

Appropriate Solutions to the Challenges of Community Health Nursing Education

Input . In order to solve the challenges in this area, the following strategies can be used:

1. A solution to instructors' challenges: one strategy is to hold training courses for community health instructors so that they can provide and train quality nursing services outside the hospital. It is also possible to provide information on new educational strategies, novel learning opportunities in the field of community health, new tools, and new methods of student assessment to the community health nursing instructors in workshops. In addition, qualified instructors should be hired to teach community health, and short-term training programs should be developed and prepared in the field of geriatric nursing, school nursing, occupational nursing, community-based rehabilitation, and behavioral disease counseling for senior community health nursing professionals in order to promote nurses' position and role in the educational, treatment, and health care teams ( 1 , 2 , 19 , 43 , 44 ).

2. A solution to students' challenges: the strategy is to hold pre-teaching workshops in various fields of community health with the aim of preparing students to share their apprenticeship goals and motivate them. Furthermore, to train nursing students for community health nursing discipline, participatory processes with key stakeholders such as health centers and deputies, regional hospitals, clinics and schools as well as specialty nursing programs should be used to empower nurses, instead of providing conventional and routine clinical trainings ( 1 , 6 , 16 ).

Process . Modifying nursing curriculums with the aim of focusing on community-based education, developing evidence-based curriculums based on the health needs of different regions of the country, and considering community health nursing practice is an effective strategy ( 1 , 2 , 29 ). Measures can be taken to overcome challenges in this area through changing teaching methods in apprenticeships (considering working with the community and family instead of the individual) and using nursing theories, including Betty Neuman's theory in community health education, the main purpose of which is comprehensive and continuous patient care and, accordingly, the actual position of nurses in care is all the three levels of prevention. We can take steps to address the challenges in this area ( 1 , 42 ). Using multiple approaches, and a combination of different methods in community health nursing apprenticeships has been effective in increasing nursing students' competence. Training courses in the field of community-based visits (home, schools, factories, and stores) had a positive effect on changing students' attitudes toward community services ( 34 ).

Appropriate Solutions to the Practical Challenges of Community Health Nursing

This group of challenges can be addressed by reviewing and reforming the process of hiring community health nurses and creating an organizational title for hiring community health nurses in schools, factories, prisons, and comprehensive health centers ( 1 ). In other words, this challenge can be overcome by shifting the health care delivery setting to the community, integrating nursing services into primary health care and focusing on health promotion and disease management ( 29 , 38 ). In addition, reviewing the educational needs of community health nursing graduates to provide ongoing responses to public health needs, especially plans to improve the skills and the abilities of nurses, is one of the effective solutions to this group of challenges ( 46 ). At large scale, nursing managers should formulate the job descriptions, roles, and responsibilities of community health nurses ( 6 , 9 , 16 ).

Solutions to Policymaking Challenges in Community Health Nursing

This challenge is possible to be solved by involving community health nurses, as professionals in this field, in health-related issues at large scale. Policymakers should also publicize laws and policies in support of community health nurses and develop guidelines that align community health nurses' roles with their skills and areas of practice ( 1 , 2 , 6 , 26 ). It is suggested that legislators prioritize accountability principles based on community, justice, and accessibility. In addition, policymakers need to develop a strategy to reform policies in order to lay the ground for the development of nursing at the community level ( 33 ).

Solutions to Managerial Challenges in Community Health Nursing

Health and treatment managers should support community health nurses in establishing community health clinics ( 1 , 6 , 21 , 30 ). Nursing managers should also take action to set up home visit centers using a health promotion approach with the help of community health nurses ( 33 , 46 ). Nursing managers should take the necessary measures to explain and promote the concept of community health nurse and its capabilities ( 46 ). Furthermore, health system managers should use motivational strategies to attract and retain competent community health nurses ( 6 , 9 , 45 ).

Solutions to Infrastructural Challenges in Community Health Nursing

Nursing managers should provide appropriate guidelines and instructions for community-based care and its management and the insurance coverage of home and community based care and services, as is done in developed countries, which results in more people seeking this type of service from community health nurses ( 6 , 9 , 16 , 45 ). Necessary measures should be taken to increase inter-sectoral cooperation between the nursing profession and different fields of community in order to progress, address global health objectives, and strengthen interdisciplinary cooperation ( 46 ).

Solutions to the Cultural Challenges of Community Health Nursing

Strategies that are effective to address this challenge include informing the community and raising public awareness of the significance and the role of nurses in providing and offering community-based services through social media, as well as developing comprehensive supportive programs in collaboration with the Nursing Deputy of the Ministry of Health, Iranian Nursing Organization, and the National Broadcasting Corporation in order to raise public awareness and understanding of community health nursing ( 16 , 18 ). Moreover, some studies have proposed a research approach to address the challenges in various fields of community health nursing. Some examples are conducting research to evaluate the effectiveness of community health nursing approach and determine the position of nursing in the health care system, or doing more research on the services provided by community health nurses to make the other members of the health team acquainted with their activities ( 2 , 9 , 13 ).

The aim of this study was to investigate the challenges of community health nursing in Iran and the related solutions in an integrated manner. According to this study, the main challenges included the challenges of community health nursing education, practical challenges in community health nursing, policy-making challenges in community health nursing, managerial challenges in community health nursing, and infrastructural and cultural challenges.

It was discovered that the factors related to community health nursing education are among the challenges. Since health care delivery to people has shifted from hospitals to community centers, nursing students should be educated through community-based approaches. The results of a study on the experiences of nursing instructors showed that the practical training of students in the field of community health is not compatible with the needs of community and education is not community-oriented ( 48 ). According to other studies, although one of the goals of community health nursing education is community-based education, it is currently forgotten and ignored ( 1 , 49 ). The results of the study by Oros focused on education through community-based care models instead of using traditional health models ( 45 ). The results of a systematic review study also showed the impact of the effective training and the preparation of nurses in the practical fields of community health to overcome the challenges of community health nursing ( 24 ). In their study, Jarrín et al. ( 50 ) stated that launching a community health nursing education program in the form of lectures in the first months of university, introducing textbooks, and performing simulations regarding community and home care will significantly affect their attitudes toward and beliefs about community-based nursing because traditional curriculums has resulted in the students' considering community activities and home care unimportant.

The approach through which nurses have been educated during the 20th century is not tailored to the health care needs of the health system in the 21st century. Therefore, nursing educators and planners should constantly review the content of community health nursing education based on the needs assessment of community health students and graduates and according to the needs of the community ( 37 , 44 ). The study by the World Health Organization also considered the lack of educational standards for community health nursing as a challenge and referred to the need to develop programs in accordance with the educational needs of community health nurses ( 6 ). Kemppainen et al. ( 13 ) showed that continuing education in accordance with the needs of nurses is effective in their performance in the field of health promotion. Another challenge in this area is the community health nursing instructors' inadequate skills and experiences in providing effective education. In another study, Khorasani reported that the training and nursing courses for nursing students in the field of community health nursing are more focused on filling out care seekers' medical records and collecting health statistics and reports, which are usually done by midwifery or primary health technicians. However, it is less focused on issues such as establishing close relationships with the community and especially families in community health apprenticeship and pays more attention to reviewing theoretical content and superficial visits ( 51 ). In other studies, students considered community health apprenticeship futile and useless and believed that there is a relative relationship between theoretical education and the practical field of community health nursing ( 52 , 53 ).

Challenges related to the field of community health nursing practice are also very important. One of the challenges in this dimension is the lack of competent workforce in the field of community-based care. This finding is in line with the study of Kemppainen et al. ( 13 ). One of the reasons behind this is the lack of job opportunities for them to acquire the necessary skills and the lack of retraining courses, while in developed countries like Denmark, nursing graduates are able to make assessments and planning, perform prevention, treat all patients and provide community-based care ( 54 ). Another challenge in the practical field of community health nursing in Iran is the lack of a clear job description for community health nurses. In the study by the World Health Organization, disagreement on community health nursing performance was mentioned as one of the important challenges ( 6 ). In their study, Kemppainen et al. ( 13 ) considered the lack of clarity in the nurses' job descriptions and activities in the field of health promotion as a barrier. In another systematic review study, the lack of a clear definition of the nurses' role in PHC has been mentioned as an important challenge in achieving universal health coverage ( 24 ).

Another challenge lies in the field of community health nursing policymaking. What was mentioned in the studies shows the impact of the structure and policies of the health system on not creating an appropriate position for community health nurses in the field of community-based and community-oriented health services. Many countries have given nurses the opportunity to provide primary health care to develop the quantity and the quality of health care in their communities. At present, in the Iranian health system, changes are taking place without considering the needs of care seekers and the costs of health care increase with the rise in the elderly population and the higher percentage of chronic diseases in the community ( 23 ). A study conducted in Oman also showed that community health nursing is not considered as much important as hospital-based nursing by the policymakers ( 55 ). In the study by Yuan, the lack of community health nurses' participation in health policymaking and planning is one of the major challenges in providing community health nursing services ( 9 ). According to the WHO, one of the most important challenges is the lack of public commitment and the policymakers' incapability to execute regional and global policies for community health nurses ( 6 ).

Another important challenge is management. One of the challenges in this area is the lack of motivational mechanisms for encouraging community health nurses. In a WHO study, the environment and the non-supportive conditions of community health nurses are stated as challenges and the use of motivational strategies to attract and retain competent community health nurses is regarded as a solution ( 6 ). The study of Kemppainen et al. ( 13 ) showed that in the organizational culture, the presence of health managers who support nurses in providing health services is an effective factor in nurses' health promotion practice. Another challenge in this area is the health system managers' lack of knowledge of community health nursing, which is consistent with the study conducted by WHO ( 6 ). Therefore, considering the emergence of global health threats, it seems necessary to clarify the concept of community health nursing.

Infrastructural challenges are another type of challenge according to this study. Currently, the focus of the health system on disease-oriented approaches rather than prevention is an important reason for the huge amount of money spent in the treatment sector, and causes issues in the allocation of resources to the community health nurses in the field of health promotion. The results of the study by Yuan also regarded the lack of sufficient funding for the provision of community-based nursing services as a significant challenge ( 9 ). Moreover, an Omani study reported community health nurses' limited access to equipment and lower funding for implementing the program ( 55 ), which is in line with the study of Kemppainen et al. ( 13 ). Other studies in other countries have shown that the amount of nurse salaries at the community level and in the society is lower than in medical centers, and these underpaid nurses who provide services at the community level are pushed to work in the treatment sector ( 56 , 57 ). Another challenge in this area is poor interdisciplinary cooperation. The World Health Organization also considers poor interdisciplinary cooperation with other professions as one of the major challenges of community health nursing ( 6 ). Investing in interdisciplinary teamwork is considered as a way to overcome the challenges of nursing in providing primary health care ( 24 ).

Cultural issues are regarded as another important challenge. People's distrust of non-physician experts' capabilities is a challenge in this area. A Chinese study also showed the lack of public trust in community health nursing services ( 9 ). However, according to the study by the WHO, non-physician staff are also able to provide similar care to patients ( 58 ). The findings of another systematic review study aimed at investigating the impact of replacing physicians with nurses in PHC in the care procedure, patient outcomes and cost analysis showed that the care provided by nurses had similar or better health outcomes compared to the care provided by physicians ( 36 ). According to the WHO, if the health system wants to address the health needs of the community, it must use nurses and midwives ( 59 ). The existence of a communication channel for community health nurses is essential to raise public awareness through the media ( 47 ). The study of Heydari et al. ( 18 ) also emphasized on preparing the community and raising public awareness in order for them to receive community-oriented nursing services. Therefore, it is necessary to explain the important role of nurses in providing health services to the public.

Considering that all the challenges mentioned in these studies can also be applied to Iranian community health nursing in Iran, it is possible to take an important step toward solving these challenges in the country's health system by implementing the proposed strategies.

Limitations

This integrated review has several limitations. The authors' knowledge of the challenges of community health nursing and the solutions is limited to the data documented in the articles. Therefore, if the challenges are not fully described or reported by the authors, they will not be reflected in the results. Only credible articles in English and Farsi were reviewed; as a result, the articles and the related data from initial research and gray literature published in other languages may have been omitted. The authors did not seek to evaluate the quality of the studies and did not compare them with similar ones. However, our integrated review is an attempt to combine the results of the studies and the research approaches. Finally, these results are more related to community health nursing challenges in Iran. Future research should address the challenges of community health nursing at a global level.

Considering the results of the present study, it can be concluded that the challenges of community health nursing in Iran, including the lack of an appropriate position for community health nursing, nursing education ignoring community-oriented care, and inappropriate infrastructure are inter-wound issues dependent on each other that affect community health nursing practice. Therefore, in order to solve these challenges, it is suggested that the policy makers and the managers of the health system modify the structure of the health system so as to move from a treatment-oriented approach toward a community-oriented one, develop supportive laws and job descriptions for community health nurses, and create an organizational chart for community health nurses at the community level. It is also recommended to use motivational strategies to attract community health nurses and support them in establishing community health clinics, and to cover community-based services and care under insurance. Moreover, nursing education administrators should modify nursing students' curriculum with the aim of focusing on community-based education. In addition, in order to solve the challenges in this field, community health nursing leaders should try to increase cross-sectoral and inter-professional cooperation, promote the profession, and make the capabilities of community health nurses recognized by other professions and the public.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author Contributions

The data analysis and manuscript were prepared by AH with support from SJ, MR. All authors critically reviewed and contributed to the manuscript and approved the final version.

This article was a part of a nursing PhD dissertation approved by Ahvaz Jundishapur University of Medical Sciences (No. 1398.874) which was financially supported by the Nursing Care Research Center in Chronic Diseases of Ahvaz Jundishapur University of Medical Sciences (NCRCCD-9837).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank the library staff of Ahvaz Jundishapur School of Nursing and Midwifery for their contribution to the study and their support in searching through resources and articles.

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Keywords: community health nursing, nursing problems, challenges, solutions, Iran

Citation: Hosseinnejad A, Rassouli M, Jahani S, Elahi N and Molavynejad S (2022) Community Health Nursing in Iran: A Review of Challenges and Solutions (An Integrative Review). Front. Public Health 10:899211. doi: 10.3389/fpubh.2022.899211

Received: 18 March 2022; Accepted: 06 June 2022; Published: 27 June 2022.

Reviewed by:

Copyright © 2022 Hosseinnejad, Rassouli, Jahani, Elahi and Molavynejad. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Simin Jahani, jahanisimin50@yahoo.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Competency assessment for community health nurses: a focus group expert panel discussion

Ramlah kisut.

1 Department of Nursing Services, Ministry of Health, BB3910, Bandar Seri Begawan, Brunei Darussalam

Hajah Dayang Jamilah Haji Awang Sulaiman

Hanif abdul rahman.

2 Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah, Institute of Health Sciences, Universiti Brunei Darussalam, BE1410, Gadong, Brunei Darussalam

3 Research Scholar, School of Nursing, University of Michigan, Ann Arbor, USA

Khadizah H. Abdul-Mumin

4 Adjunct Senior Lecturer, School of Nursing and Midwifery, La Trobe University, VIC3086, Bundoora, Australia

Associated Data

The datasets generated during and analyzed during the current study are not publicly available due to institutional data sharing policy but are available from the corresponding author on reasonable request.

General Practice setting in the Primary Health Care Services are the utmost visited by the public. It is important that the nurses’ competencies in this area be assessed to ensure provision of safe and quality services.

Aim/objective

To explore perceptions and experiences of competencies assessment tool for community health nurses working at the General Practice setting in the Primary Health Care Services.

An exploratory qualitative study utilizing focus group discussions were conducted on purposive sample of 12 officers with expertise in competency assessment and community health nursing from higher nursing education institutions, the Nursing Training and Development Centre, the Nursing Board and the Community Health Nursing Services in Brunei Darussalam. The existing competencies assessment tool was revised, the participants were divided into two groups of expert panel review team and two focus group discussions were held with each team. The focus group discussions encompassed components and methods of assessment; methods of grading; and overall organization and structure of the revised competency assessment tool.

Four themes emerged: 1) International equivalent core competencies components; 2) Multi-methods approach to assessment; 3) Definitive guidelines as framework for assessment; and 4) Understanding and acceptability of the competency assessment tool.

Conclusions/implications to practice

The expert panel reviews provide practical input that were inculcated in the preliminary developed competencies assessment tool. Identification of eligible assessors were recommended based on standardized criteria, and socialization and training held to set direction and guidance for implementing the utilization of the competencies assessment tool. Further studies are deemed important to critically evaluate and validate the preliminary competencies assessment tool for development of a more robust assessment instrument.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00898-y.

Introduction

Healthcare systems across the globe are equally and primarily aiming at providing quality and safe health care to the public. It is important for the front-facing healthcare providers, for example such as nurses [ 1 ], midwives, and social workers to have the appropriate competencies at least at a minimum standard to enhance healthcare provision which is of quality and safe care.

The worldwide perspectives of professional nursing competencies are focused on providing safe and quality service. It is the responsibility of each professional nurse to be competent in delivering the skills sets required to improve and sustain the quality of patient care, hence increasing patient satisfaction [ 2 ]. Substantial evidence also pinpointed the importance for health care organizations to give attention to professional competencies for nurses to maintain safety and quality service [ 3 ]. Medical errors, negligence, or malpractice built from incompetence can risk patients’ lives [ 4 ]. For all these reasons, there is a need for valid and reliable instruments to assess the competencies of nurses in the practice setting. Many attempts to define competence and competencies have been published in the literature but there are still confusion and lack of clarity surrounding the concept [ 5 ]. Competencies can be described as a combination of observable and measurable knowledge, skills, abilities, and personal attributes that constitute an employee’s performance. Whatever the agreeable definition is, the ultimate goal is that the employee can demonstrate the required attributes to deliver safe and quality care [ 6 ].

Background of the study

The importance of competencies standard.

In the healthcare system, core competency standards are the standards and requirements usually set by the relevant healthcare profession regulatory body to inform standards of practice of the specific profession intended for the provision of safe and quality care to the public as consumers of the healthcare system. Such healthcare professions extend beyond nursing and include for example midwifery, social workers, physicians, optometrists [ 7 ], and other medical professions [ 8 ]. Core competency standards are important for these healthcare professions for monitoring of safe practice and provision of quality patients’ care.

In the nursing profession, nursing regulatory body is responsible for nurses’ competencies in providing safe and quality care to patients. Having competent nurses in the healthcare services increase trust and confidence of the public [ 9 – 11 ]. Being competent in providing patients’ care also uphold the high reputation of nursing profession [ 12 ]. Poor and unsafe patient care may occur if nursing practices do not met expectations laid in the core competency Standards [ 13 , 14 ].

Context of the study

Nursing profession in Brunei Darussalam (henceforth: Brunei) is the largest that contributed to at least 70% of the total healthcare workforce [ 15 ]. There are different rank of nurses working at various clinical sites in the three level of healthcare system of Brunei – Primary, Secondary and Tertiary. The first level of health care system provision in Brunei is the Primary Health Care that comprised of 14 primary health centers and 16 maternal and child clinics. There are about 300 CHNs working in 14 PHC across Brunei. To work as CHNs, they are required to have at least an education background of general nursing. Whereas, those who work in maternal and child clinics are required to have midwifery or community health nursing qualifications. Maternal and child health (MCH) nursing, or midwifery, or Community Health Nursing qualifications are additional advantage. Some CHNs work at the General Practice (GP) setting in the PHC providing care in the outpatients’ departments (OPDs), Chronic Diseases Clinics (CDCs), and nurse-led clinics. Other CHNs work at the MCH setting providing maternal and child health care, and Women’s Clinics. Both GP and MCH settings are integrated in the PHC. This paper specifically focuses on the CHNs in the GP setting.

Core competency standards in Brunei

Similar to other countries, in Brunei Darussalam (henceforth: Brunei), there also exists core competency standards for Registered Nurses developed by the Brunei Nursing Board (BNB) [ 16 ], the national regulatory body that governed nursing practice. However, the core competency standards are more generic but not specific to nurses working in a specific setting. One of the aims documented in the core competency standards is:

“to assess clinical performance competency and measure the professions’ fitness to continue practice in Brunei Darussalam”.

Aligned with the core competency standards for Registered Nurses, a generic competency assessment tool (GCAT) was also developed by the Brunei Nursing Training and Development Centre (Pusat Latihan Perkembangan Kejururawatan [PLPK]). However, the GCAT is generic and only purposely designed for assessing newly employed nurse, for a one time use when they were first employed. CAT for continuous assessment of core competency standards for Registered Nurses are not available yet. Nurses in Brunei are assessed based on evaluation of the Key Performance Indicators (KPIs) assigned by the Department of Nursing Services via the Head of Nursing in each department across the primary, secondary and tertiary level of healthcare. This KPIs are integrated feature in the yearly performance appraisal tool (PAT) designed by the Department of Public Services which are generic for all civil servants’ regardless of their professions. The PAT may only be suitable for assessing and evaluating generic skills, which pose challenges to the nursing profession as it is not specific to nurses’ skills and competencies.

Another CAT was developed in 2016 by a Primary Health Centre (PHC) [ 17 ], which is specific and initially used biennially for assessing core competency standards of the community health nurses (CHNs) working at General Practice in the PHC. It is identified that this CHNs CAT was developed in response to the PHC accreditation assessment by the Joint Commission International. Since then, there is no further evidence of regular and continuous use of this CHNs CAT.

Limitations of the existing CHNs CAT

The development of the CHNs CAT were not based on a systematic process of instrument development and validation, and the core competencies assessed may risk the bias views of the former developer(s). The tool has never been reviewed and evaluated, hence, reliability and validity of the CATs have yet to be established. Assessment of core competency standards should not be a one off, but a regular and continuous process so that standards are consistently maintained throughout nursing practices. This concurs with the international health care accrediting agencies such as Joint Commission International [ 6 ] which highlighted the requirement for periodic performance evaluation to assure ongoing competencies of nurses.

In terms of the feature and contents of the CHNs CAT, analysis uncovered that the instrument only predominantly contains a set of basic nursing procedural skills to be assessed by checking the ‘DONE’ or ‘NOT DONE’ column (See Table  1 for examples of skills assessed). Other higher level of core competencies such as that recorded in the BNB [ 16 ] are not found. These include legal and ethical framework of practice, professional practice, leadership and management, continuous professional and personal development, and education and research. There is no scale that differentiate achievement of a CHN to another. The method of assessing was only through observation methods instead of diverse methods of evidence, to name a few the CHNs CAT do not use such as reflective accounts, critical incidence analysis, peer review, evidence-based practice and acknowledgement from patients and colleagues at work.

Examples of what were assessed in the existing CHNs CAT

Needs and significance of the CHNs CAT development

In view of the limitations of the CHNs CAT that assessed only generic, basic and practical nursing skills, being the Head of the Community Health Nursing Services in Brunei, the primary author takes the lead for evaluation, development, implementation and validation of the CHNs CAT as a pilot or trial. The similar process may further be adapted in the development of CAT in other nursing clinical areas. This paper presents the first two of the four-part tasks which are the instrument evaluation and development.

It should be noted that the role of nurses in GP setting has expanded over the years [ 6 ]. With the evolving and expansion scopes of nurses working in the GP setting of the PHC, CHNs CAT need to be developed in alignment with the expanded scope of practices (SoP) and consistent with the actual regulated practices. Reviewed of literature evident that nurses practices either below or beyond their SoP that cause either loss of or inadequate skills that eventually will compromise nursing practices in the General Practice setting of the PHC [ 18 ]. Hence, this study is significant in various ways: 1) consideration of development of a credible and reliable CHNs CAT that is appropriate and able to accurately assess competencies of CHNs working at the GP setting in the PHC; 2) in a longer term, this study can inform development of similar standardized CAT for assessing core competency standards of nurses in many different clinical settings in Brunei.

This study aimed to explore expert panel perceptions and experiences of CHNs CAT for CHNs working at the General Practice setting in the PHC Services in Brunei Darussalam. The objectives were:

• To evaluate the competencies required for CHNs working at the GP setting in the PHC Services
• To determine how would the competencies be assessed
• To develop preliminary CHNs CAT

Research design and methods

This study was qualitative and exploratory underpinned by instrument evaluation and development process, utilizing focus group discussions to collect in-depth data on expert panel’s perceptions and experiences of competencies assessment tool for CHNs working at the General Practice setting in the Primary Health Care Services.

Ethical considerations

This study is conducted in line with the principles underpinning the Declaration of Helsinki [ 19 ]. Ethical clearance was provided by the joint committee of the Pengiran Anak Puteri Rashidah, Institute of Health Sciences Research Ethics Committee (IHSREC), Universiti Brunei Darussalam and Medical and Health Research and Ethics Committee (MHREC), Ministry of Health (ERN: UBD/PAPRSBIHSREC/2O19/18). Written permission to evaluate and re-developed the existing CAT was granted by the Director of Health Services and Director of Nursing Services. Participants were assured that their participations were voluntary and they could withdraw from the study without penalty at any time throughout the study prior to completion of data analysis. Written informed consent was obtained from all participants once their enquiries were answered and they were fully satisfied with the information about the study. Confidentiality was ensured where the study was done in private room free from distractions and access of others. Participants’ anonymities were also ensured where participants were coded using a personal identification number (PIN code). They were requested to refer to this code and were not allowed to call real names during the FGDs. The research and any publications will not report participants’ details that can easily identified their affiliations.

Preparation prior to data collection

Defining chns cat.

A working definition for CHNs CAT was formulated to ensure all the study participants have the same idea on the CHNs CAT, hence, guide them in the evaluation and development. CHNs CAT is defined as an instrument or a tool for assessing and evaluating CHNs competencies that encompassed their knowledge and skills which should be performed at a minimum standard.

Identification of literature for instrument evaluation and development

The research team conduct literature search on evidence-based core competencies standard where four international regulatory documents were initially gathered to facilitate expert panel review. Table  2 illustrated the key documents.

International regulatory documents

Data collection

Expert panel review.

Expert panel or working group was formed. Participation and selection as expert panel were by invitation where letters were sent to the Dean and Directors of the higher nursing education institutions, Head of Brunei Nursing Board, Head of Nursing Administration of the Community Health Nursing Services, and Head of the Nursing Training and Development Centre for nomination of at least an expert in developing CAT for CHNs at the General Practice setting in the Primary Health Care Services. The mixture of different participants ensured a diverse range of stakeholders within the specialization of either community health nursing or competency assessment. The participants were selected using purposive sampling guided by coherent inclusion criteria (Table  3 ). Participants whom do not met these criteria were excluded.

Inclusion criteria for the study

Through FGDs the expert panel critically review, analyse, compare, evaluate and synthesize the existing CHNs CAT with the current empirical evidences from the authoritative regulatory documents. The components and/or domains on competencies standard of CHNs in the existing CHNs CAT was compared with those in the international regulatory documents. The expert panel further suggested appropriate recommendations for development of the preliminary revised CHNs CAT. The expert panel also added another three international regulatory documents that further facilitate evaluation and development of the preliminary revised CHNs CAT:

• International Council of Nurses (ICN), Nursing Care Continuum Framework and Competencies [ 9 ]
• The Nursing Council of Hong Kong, Core competencies for Registered Nurses (General) [ 23 ]
• Jordanian Nursing Council, National Standards and Core Competencies for Registered Nurse [ 11 ]

It is expected that expert panel review tasks will be conducted only by one expert panel group throughout the instrument evaluation and development to ensure consistencies in the development of the preliminary revised CHNs CAT. Six participants initially volunteered in the expert panel review. However, due to other administrative commitments, it was not possible to get the same expert panel to wholly complete the tasks, hence invitation was extended, and another six participants further volunteered which formed the second group of expert panels. The change in the planning was observed as opportunistic as it considers the diverse views [ 24 ] from the two expert panel groups. They comprised of nursing academics from the higher nursing education institutions, nursing managers of Community Health Nursing Services from the PHC Services, nursing authorities from the Nursing Board and competencies evaluators and trainers from the Nursing Training and Development Centre.

Four FGDs, two for each team were held with the expert panel review team. The first FGD was to collect analysis, evaluation, perceptions and experiences related to the revised competencies assessment tool from the first expert panel review team, and a second one was conducted to finalize their collective agreement. The third FGD was held with the second expert panel review team to determine if there were any further divergent feedbacks which may be overlooked by the first team, and the last one was to finalize all feedbacks from the second team for development of a preliminary revised CHNs CAT. The FGD encompassed components and methods of assessment; methods of grading; and overall organization and structure of the revised competency assessment tool.

The revised CAT was emailed to the expert panel a week before the FGDs to allow them preparation prior to the FGDs. The FGDs were also guided with a pre-designed open-ended question so that the FGDs would not side track. All FGDs were audio recorded with consent from the participants to ascertain accurate and consistent account of the FGDs for transcriptions.

Table  4 presented summary of the critique of the existing CAT by the two expert panel group. The domains and performance indicators were identified and refined which resulted to construction of a revised version of the preliminary CHNs CAT.

Critique of the existing CHNs CAT

Data analysis

All FGDs were transcribed verbatim. The transcriptions were then checked for accuracy against the audio recordings. Two members of the research team (first and last authors) systematically analyzed the transcripts to identify both deductive themes based on the focus group guide and inductive themes that emerged during coding. Transcripts were read and re-read to identify potential themes. Emerging themes were then coded by hand independently by each team members, then coding was compared with discrepancies resolved through discussion to enhance reliability of the findings.

Participants’ characteristics

Participants were six nurse managers from Community Health Nursing Services, two academics from the higher nursing education institutions, two authorities from the Nursing Board and two senior nurses with capacities as competencies evaluators and trainers from the Nursing Training and Development Centre. Nine of the participants were female (75%) and the rest were male (25%). All of these individuals have expertise in both competency assessment and Community Health Nursing services. Their details and main expert field is presented in Table  5 . They have more than 10 years of clinical work experiences in community health nursing setting of the PHC and are well versed with the core competencies of a CHN. For confidentiality purpose, gender, exact age and qualifications, and workplace are not reported.

Expert Panel Characteristics

Findings from the expert panel review

Table  6 showed some examples of the results derived through the process of deductive and inductive coding of the FGDs transcripts that eventually lead to the finalization of themes. Quotes that exemplified the inductive coding are presented in the final themes. Four final themes emerged from the expert panel review process of refining and finalizing the preliminary CHNs CAT: 1) International equivalent core competencies components; 2) multi-methods approach to assessment; 3) Definitive guidelines framework for assessment; and 4) Understanding and acceptability of the competencies assessment tool.

Examples of deductive and inductive coding

Theme 1: international equivalent core competencies components

This theme described the expert panel affirmation for the core competencies components to be equivalent of the international standards. All of the expert panel pointed out that the core competencies components should be benchmarked that equivalent to the international standards. The expert panel justified that this is to ensure that the CHNs will achieve the minimal core competencies standards which should be arranges into key components. The World Health Organization (WHO) is the most commonly referred international organization as the governing body for the CHNs core competencies.

“ … the competencies tool should follow competency framework from WHO. It should be at the international standards so that performances of our community health nurses should be at par with other countries … The core competencies should be divided into five clusters and under each cluster there should be list of competencies to be achieved” (P04, Expert Panel Group 1, FGD 1)

Majority of the expert panel also pointed out that benchmarking of the core competencies standards should be comparable with the requirement of the International Council for Nurses competencies framework [ 9 ]. They also pinpointed that the core component of competencies also needs to reflect role of PHC nurses in General Practice or also called Out-Patient Department (OPD) setting, and should be consistent with the core competencies standards set by the Nursing Board for Brunei.

“ … the components of the competencies should mirror the ICN competencies framework but also must matched with NBB (Nursing Board for Brunei) requirements. Comparing these both together, the core competencies components should be put into domain. For examples, ethical responsibilities, leadership or continuous professional development, and so on. Then it will be easy to arrange the competencies either skills or knowledge under each domain” (P02, Expert Panel Group 1, FGD 1)

Arranging core components into key areas or domains was agreeable by the expert panel to provide clarity of the knowledge or skills set under the domains. Five core competency standards (Legal and ethical framework for practice; professional practice, leadership and management; continuous professional and personal development, and education and research) established by Nursing Board for Brunei [ 16 ] were commonly suggested by majority of the expert panel.

“ … The ICN core competency standards are extended version. But core competency standards from NBB are succinct. We should use the five main components and arranged list of competencies under these five main components accordingly” (P01, Expert Panel Group 1, FGD 1)

“ … It would be more appropriate if we adopt competency standards from local context … so it would be meaningful as we also teach our student using these core competency standards.” (P05, Expert Panel Group 1, FGD 1)

Theme 2: multi-method approach to assessment

This theme explained the expert panel assertion that the assessments grading system should not be rigid to observations only but diverse encompassing other methods such as audit, certificate of training and chart review. It was notified by some of expert panel that method of assessment in the revised CAT need more clarification in terms of appropriate methods of assessment that will accordingly assessed and measure specific competencies performance.

“How do we assessed a specific skill required by the specific core competencies components? We cannot depend on 100% observations only. Assessing through discussion with others may be subjective too. The main point is the appropriateness of the competencies assessment, it should assess what it should measure. For examples achievement of skills require direct observations, demonstration of knowledge require evidence of assignments, and research may need evidence such as published manuscripts or evidences of changes in practices … ” (P10, Expert Panel Group 2, FGD 3

The expert panel believed that evidences of competencies should be included or submitted at the end of assessment period to ensure validity of the assessment conducted. The expert panel provided examples of evidences such as certificate of attendance or participation, audit result, chart review or other relevant documentation supporting the achievement of the core competencies. Quality improvement activity was also suggested by half or the expert panel to diversify methods of assessment. Other expert panel members also recommended that Objective Structured Clinical Examination (OSCE) as on the best way to assess competency albeit time consuming.

“ … I think OSCE is a good way to assess competency but we may not able to afford it … It need time and lots of resources in preparation for the session” (P12, Expert Panel Group 2, FGD 2)

Many participants favour the use of different methods of assessment over single method;

“ … apart from the stated methods, can we add quality improvement activity as one of the assessment methods? . . . it can save much of our time to assess some of the components by just providing evidences of participation or contributions such as certificates, letter of acknowledgment or participation, and so on. This should be submitted to support the competencies assessment. This is to make sure that the community health nurses truthfully achieved the performances which were assessed.” (P6, Expert Panel Group 1, FGD 2)

Theme 3: definitive guidelines as framework for assessment

This theme represented the expert panel emphasis on the importance of a distinctive grading system that can differentiate the performance of newly employed nurses from the experienced nurses. All of the expert panel were on favor of a scoring or grading system for the competencies assessment.

“The grading system or scoring system for competencies assessment is very good. It gives high marks to high performer nurses and low marks to low performer nurses. It is good because it differentiates how a nurse is more competent than the others, and remedies can be planned to improve competencies.” (P09, Expert Panel Group 2, FGD 3)

However, about three quarter of the expert panel recommended that in view of the multiple methods of assessment, explanations should accompany the grading system as a framework that guide the grading or scoring system. They commented that development of such framework will be useful because the General Practice or OPD is usually a very busy setting, hence, if the CAT is unclear, the purpose of doing competency assessment will be defeated by time constraint, work overload, inadequate staffing and lack of knowledge on how to use the CAT among assessors and the nurses to be assessed.

“ … the use of different methods of assessments on the same competencies is very good. The direct observations may be complemented by collections of reflective diaries, which further can be strengthen by providing certificate of attendance that sharpen the skills being assessed. However, how do we know the assessor is choosing the right method of assessments for a particular performance in the core competencies component, while other assessor may also use different method for that same performance?” (P12, Expert Panel Group2, FGD 3)

A few of the expert panel argued that due to the scale nature (1 to 5) of the grading system, there may be issues in segregating how the score be awarded to an experienced nurse from the new nurses.

“ … I am not a 100% supportive of the grading system … an assessor may not have adequate knowledge on how to rate the performance … again the different methods of assessment that can be employed … also because the scale is only 1, 2, 3, 4 and 5. How would you rate based on this scale to an experienced nurse and how would you differently rate a new graduate nurse?”(P11, Expert Panel Group 2, FGD 3)

The concern about the possibilities of inconsistencies among assessors were also highlighted by a quarter of the expert panel as assessment can be subjective reliant on the individual assessor.

“ … different nurse managers may have different way of interpreting their competency assessment findings so at the end of the day we may have discrepancy of the score given” (P08, Expert Panel Group 2, FGD 3)

“ … some nurse managers may be very lenient, but some may strictly adhere to their high level of expectation … … this again all depend on their individual interpretation of the performance standards.” (P05, Expert Panel Group 1, FGD1)

Theme 4 – understanding and acceptability of the competencies assessment tool

This theme illustrated the expert panel concern about the users’ understanding of the CAT comprising the nurse assessing and the nurse to be assessed in order to ensure that expected performances are similarly perceived by both parties. Majority of the expert panel pointed out that competency standards should be appropriately assessed by an experienced or senior nurse. They further highlighted that assessment needs to be done regularly as an ongoing activity in order to monitor and maintained the standards of practice.

“ … The competencies assessment should not be a one-off activity … looking at the number of components, we must set interval period for the assessment to be conducted … are we going to make it annually or every 3 years … ” (P07, Expert Panel Group 2, FGD 4)

More than half of the expert panel felt that the CAT acknowledged their understanding of the CAT addressing that it will be useful to assist nurse managers in determining whether or not a community health nurse is competent in a particular standard. Having said that, the expert panel also proposed several recommendations to be put in place before the implementation of the CAT. It was perceived that the CAT can be utilize properly with adequate information and guidance along with adequate training, particularly on what are the expectations on the competency standards nurses have to achieve and how to utilize the CAT.

“ … I can see that this CAT can be useful to ensure nurses are competent though it may be very tough to conduct the assessment if nurse managers are not fully informed about the assessment. The CAT must be clear in every aspect so that the nurse who assessed and the nurses to be assessed equally understand expectations laid on by the CAT. A briefing and training on how to use the CAT would be a good start before using the CAT in practice … ” (P03, Expert Panel Group 1, FGD 2)

Three quarters of the expert panel expressed their acceptability of the CAT and stated that the revised CAT would be more applicable and useful than the existing generic annual performance appraisal for civil servant. They raised the issue of time constraint and increase workload, if the CAT would be additional to the performance appraisal.

“ … I can foresee the difficulty face by nurse managers if the CAT is used in addition to annual performance appraisal establish for civil servant. It will be extra work for nurse managers and some of us may not have enough time to do them both at one time” (P08, Expert Panel Group 2, FGD 3)

This study was conducted to explore expert panel perceptions and experiences on the existing CHNs CAT including its components, methods of assessment, grading system and its overall structure and organization. This study evident that it is fundamental to identify a comprehensive core competencies domain and the list of core competencies for CHNs in the general practice setting of the PHC Services. This was pinpointed by the expert panel in their critique of the existing CHNs CAT as shown in Table ​ Table6 6 and theme 1 of the study findings. As emphasized by the WHO [ 6 ], the role of nurses in GP setting has expanded over the years [ 6 ]. Identification of a set of clear competencies domains ensure that CAT assessed the scope of practices (SoP) within the country they practice, hence, consistent with the actual regulated practices [ 18 ]. The findings are consistent with qualitative research exploring the relevance of existing Australian Competency Standards for Registered Nurses that is capable of assessing the specific community health nursing practices. CHNs must be better equipped with knowledge, skill and ability to deal with these complexities in order to provide safe and the best care possible.

It is important to highlight that competencies are acquired and developed steadily and progressively overtime, which should not be a ‘one off’ or ‘once-only’ activity. Assessment should be continuous, on-going and perform at regular interval [ 8 ]. This is particularly true in a way that it allows time for assessors to adequately observe, monitor and evaluate the performance rather than jump into conclusion at 1 hour observation for instance. The issue of ‘once-only’ assessment and a ‘tick-box’ approach in competency assessment should be given attention as there is empirical evidence to show that these strategies may not be able to adequately assess competence [ 8 , 24 , 27 , 29 ].

Review of the CATs internationally also suggested that the core competencies standards should be expanded to include higher level of knowledge and skills such as research, leadership and management [ 30 ]. Our study demonstrated that the seven-core competency generic nurses standards framework advocated by the ICN [ 9 ] appropriately aligned with the five-core competency generic nurses standards domains established by the Nursing Board for Brunei [ 16 ]. Comparison of the two generic competencies standards with other international countries showed that the contents are all similar and relevant [ 11 , 23 , 31 , 32 ]. Likewise, the specific core competencies standards for CHNs in the preliminary revised CHNs CAT concurs with Brunei Nursing Board [ 16 ] and the rest of the international regulatory documents.

The alignment of the preliminary revised CHNs CAT with the local and international document coincide with the expert panel view that implied CAT should be developed based on benchmarking with international regulatory bodies and other countries. It is viewed that benchmarking ensure that core competencies of the CHNs in Brunei are at least at the international standards. This is expressed by the expert panel in theme 1. This may possibly due to the fact that community health services worldwide are facing similar current global challenges. These include growing number of chronic diseases, ageing population and shortage of healthcare professionals [ 33 ]. Aside from this, another possible reason is due to the global mobility and migration of nurses that requires them to acquire competencies which are globally adaptable [ 34 ].

The findings presented in this study delineated the process of instrument evaluation and development undertaken by the expert panel that include critical analyses and evaluations of the existing CHNs CAT, which were further revised, refined and finalized by the expert panel through the process of FGDs. This process was conducted systematically and is considered rigorous in terms of face and contents validity [ 35 ]. Future studies should consider quantitative design encompassing pilot testing of the CAT and performing the psychometric properties for determining reliability and validity of the preliminary CHNs CAT. The systematic process in instrument development which was first advocated by Benson and Clark [ 36 ] and evident in many of the developed instruments include the implementation and psychometric properties testing for determining instruments’ reliability and validity. It is anticipated that the CHNs CAT for the general practice setting of the PHC Services would set the basis for assessment to determine the competence level of CHNs from entry into practice and throughout their professional nursing careers instead of a one-off activity.

Concern over the inconsistencies of perceptions of the CAT from the FGDs with the expert panel are also consistent with findings from the literature [ 29 ]. Traditional approach of competency assessment is distorted with ambiguity and inconsistency. Such concern may be justified because competencies assessments are subjective to individuals whom may either be lenient or have high expectations. In addition, interpretations of assessors are subject to clarity of the core competencies to be assessed. The expected core competencies must be communicated to the CHNs and their assessors so that they have similar understanding of the competencies, hence the competencies performance and assessment are conducted as expected [ 37 , 38 ].

In term of acceptability to use in practice settings, time constraint, work overload, inadequate staffing and lack of knowledge on how to rate competence are the identified obstacles that may lead to hesitancy to use the preliminary CAT. These findings are similar to a study conducted by Figueroa, et al. [ 39 ] in determining the compliance of nurses to national core competency standard. The use of multi-methods and multi-assessors approaches in conducting assessment may solve this issue. Holanda et al. [ 40 ] indicates that using these approaches may reduce inconsistencies among assessors as well as reduce time taken to do the assessment. Although evidences on the most effective method is limited, there is general agreement in the literature that competency assessment should use more than one assessment methods that include such as self -assessment, direct observation, Objective Structured Clinical Examination (OSCE), and simulation [ 24 , 29 ]. The multi-methods competencies assessment and multi-assessors of core competencies acknowledged uniqueness of individual nurses through diverse approaches. Other widely used method is patient-centered competency model which addressed patient as an assessor to add greater reliability and validity to the assessment process [ 29 ].

This study pinpointed that usability and acceptability of using the preliminary CHNs CAT additional to the existing generic civil servant’s performance appraisal may be viewed as task duplications by assessors, in particular, nurse managers which is highlighted in theme 4. The use of multiple competency assessment tools to meet mandatory evaluation of performance and regulatory requirements may put extra burden for the assessing nurses and the nurses being assessed alike. This may at the end highly likely resulted to the ‘tick-box’ approach which defeat the purpose to adequately assess nurses ongoing ability to competently undertake their daily nursing duties [ 40 ]. In an equilibrium, being specifically competent of nursing practices denotes safety and quality measures in nursing care whilst annual appraisal will only look at the general performance of aptitude and attitude nursing staff.

The preliminary CHNs CAT

The revised version of the preliminary CHNs CAT was refined and finalized as Draft 1 Preliminary CHNs CAT (see supplementary materials ) after three major revisions following the expert panel review from the FGD. Upon suggestion from the expert panel review, the preliminary CHNs CAT now contents glossary of the terms used in the CAT, a concise introduction of the document, components of the competencies, method of assessment, grading system and a step-by-step guide on how to use the document. The expert panel equally agreed for the importance of culturally specific and context specific CHNs CAT, hence the inclusion of the additional three documents.

The expert panel also aligned the requisites identified in the international regulatory bodies with the core competencies standards of the Brunei Nursing Board [ 16 ] in the preliminary CHNs CAT. The whole process of developing the CHNs CAT is not completed yet. Instrument development should include pilot testing the CAT and analysis of the psychometric properties of the CHNs CAT for its reliability and validity. The next tasks for the primary author is to continue on implementation, validation, and reevaluation and redevelopment of the CHNs CAT accordingly. It is planned that these will be done in the near future.

This study had provided two distinct inputs. First, the valuable insight in the refinement of a preliminary developed CAT and second, the identification of issues that may affect the acceptability and the implementation process of the revised CAT. The expert panel had given substantial contributions in the revision process of the existing CAT leading to preliminary development of a new CAT. The study highlighted the significant of using a multi-method and multi-assessors’ approach in the assessment. These include direct observations of the nurse’s practice, an interview to ascertain nursing care in different scenarios and evidences provided by the nurse (including self-assessments, exemplars or examples of practice, documentation, and reports from other nurses and other health professionals). Adequate information and training of using the preliminary new CAT, and providing clear explanations of terms used in the preliminary new CAT are some recommended solutions concerning the utilization and acceptability of the CAT. It is also suggested that competencies assessments should be periodic, regular assessment instead of a ‘once-only’ assessment. It is found imperative to paid attention to multiple competency assessment tools which may put extra burden to the nurses.

Strengths and limitations of the study

This study reviewed the existing CHNs CAT for nurses working at the General Practice setting in PHC through the review of expert panel groups that have background in community health nursing. The FGDs with the expert panel evident that challenges remain in establishing components or domains of competencies, list of competencies and assessments approaches in terms of methods and assessors. Further FGDs may deem required to establish a more comprehensive list of assessment items. Further quantitative analysis is also required to assess the psychometric properties of the preliminary new CAT to evaluate the tool critically, hence development of a more robust assessment instrument.

Implication to practice, policy and research

The World Health Organization (2010) emphasize that it is imperatively important to ensure nurses are competence to perform their jobs. The American Joint Commission on Accreditation of Healthcare Organization (AJCAHO) (2010) claimed that in order to provide quality patient care, the individuals delivering patient care services must be competent enough to do so. AJCAHO standards also require leaders to ensure the competence of staff members to be continually assessed, maintained, demonstrated and improved [ 8 ]. Therefore, taking safety and quality of care into consideration, it is vital to utilize reliable and validated tool to assess competency. Policy makers may enforce the preliminary revised CHNs CAT for implementation.

There is no single best method that can be used to assess competence. The combination approach is recommended to ensure adequate assessment of competence. Methods of assessment identified in the literature include return demonstration, skill assessment inventories (via self, peers, supervisors, and clients), portfolio development and review and observation of daily work [ 25 , 41 ]. Thus, this reflects that using ‘one size fits all’ approach poses a significant limitation to competency-based assessment in the clinical setting which demonstrated that one single method will not be able to adequately measure competence. Future research should include this area to consistently improve the preliminary revised CHNs CAT.

It is worth mentioning that the revised CAT is intended to assess and evaluate competency standard at staff nurse level. Knowing the importance of assessing and evaluating competencies of other level of nurses, it is imperative to develop similar tool with different core competencies standards in the future studies.

Acknowledgements

The authors would like to express sincere appreciation to all the participants who have joined and supported the project.

Abbreviations

Authors’ contributions.

RK, JS and KHA contributed to the conception or design of the study. RK and KHA were involved in acquisition of data/or interpretation of data. All authors participated in writing, drafting and revising the manuscript, and agreed to be accountable for all aspects of the work and any issues related to the accuracy or integrity of any part of the work. All the authors read and approved the final manuscript.

No funding was received for this undertaken project.

Availability of data and materials

Declarations.

The study protocol was designed and performed according to the Declaration of Helsinki. Ethical clearance was provided by the joint committee of the Pengiran Anak Puteri Rashidah, Institute of Health Sciences Research Ethics Committee (IHSREC), Universiti Brunei Darussalam and Medical and Health Research and Ethics Committee (MHREC), Ministry of Health (ERN: UBD/PAPRSBIHSREC/2O19/18). Written informed consent was obtained from all participants.

Not applicable.

The authors do not have conflict of interest to declare.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Ramlah Kisut and Khadizah H. Abdul-Mumin contributed equally to this work.

Contributor Information

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Hajah Dayang Jamilah Haji Awang Sulaiman, Email: [email protected] .

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Reflections on the Experience of Community Health Nurses in Palliative Care: A Qualitative Approach

Affiliation.

• 1 Department of Community Health Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India.
• PMID: 34511804
• PMCID: PMC8428882
• DOI: 10.25259/IJPC_65_21

There is a major demographic shift with increase in non-communicable diseases even in low- and middle-income countries. Many self-limiting illnesses are burdensome to people when they have limited access to health care system and poor family support. The aim of the study explores experiences of community health nurses in palliative care delivery in a primary health care setting. The study was conducted in Community Health Nursing Department, College of Nursing, CMC, Vellore. A qualitative research using a grounded theory approach was done which included in-depth interviews and focus group discussions from community health nursing faculty. This study used a deductive and inductive approach that stressed the process rather than the meaning of the studied phenomenon. The in-depth interviews lasted for 45 min-1 ½ h for each participant; focus group discussions were held in two sessions lasting for 2 ½ h. The group interviews were transcribed to verbatim. All transcripts were read multiple times to ensure correctness of the transcription by the authors to get an overall impression of the material before the initial coding. Authenticity, credibility, critical appraisal and integrity were demonstrated throughout the study. This study enlightens the experiences of the health care providers on palliative care delivery at the primary care setting and explores barriers, challenges and facilitators for delivery of good palliative home care. Totally, 15 subthemes were grouped under five major themes; community support, family support, acceptance of services, barriers and gaps in care. The in-depth interviews provided an insight into the experiences of the participants on successful collaborative services, caregivers fatigue and the barriers in providing services in the home care setting. Focus group discussion showed that a holistic approach to patient care in primary care setting is possible by community health nurses and a collaborative care from the secondary and tertiary care settings will bring down the non-compliance to the therapeutic regimen.

Keywords: Community health nurses; Palliative care; Primary health care; Qualitative study.

© 2021 Published by Scientific Scholar on behalf of Indian Jounal of Palliative Care.

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