Health issues have changed dramatically over the past years due to ageing, old age, increase in life expectancy, and chronic diseases. Patient care in hospitals has now shifted towards community-based care, and health systems focus on disease prevention, health promotion, and rehabilitation (1). According to global statistics, non-communicable diseases are currently responsible for more than 53% of diseases in Iran (2). Also, Iran’s population is ageing like other countries in the world, and Iran’s older adult have become more older adult than the rest of the world and Asia these years, and by 2050, one out of every three Iranians will be older adult (age of 65 years old or older) (3, 4). This increasing trend has consequences on the social and economic sectors, including the resources of the healthcare sector (2). Based on this, the location and nature of nursing care have changed in response to a variety of factors and have moved from hospitals to primary care centers and social places (such as school, work, play place, etc.) (1, 5). CBN play an important role in providing primary health care (6). Nurses can provide healthcare services based on the preferences of the patient, family, and health system (7). The most important fields in which CBN can play its roles include preventive care, health promotion, education, chronic disease management, children’s and older adult health, and health policymaking (8). Many countries have established community nursing programs aligned with their healthcare systems. CBN has been significantly developed in the health systems of all countries around the world (9). For instance, in the United States, community-based nursing is an integral part of the public health infrastructure (10). In some European countries (Ireland, Sweden), CBN has replaced doctor-based and hospital-based approaches by providing health services to community members and families (11). The status of CBN in some less developed and developing countries as Indonesia, Nepal, Cameroon, Senegal, Uganda and Guyana, shows a lack of commitment and low capacity (12). In countries like Japan and China, CBN is also focusing on assessing community health needs, providing health care and health promotion (13, 14). The history of CBN in Iran dates back many years, and community-oriented curricula are taught in nursing schools, but CBN still has many obstacles and has not been able to play its role effectively in Iran’s health system (15). Now in Iran, comprehensive urban health centers are managed by graduates and associates of family health, environmental health, professional health, and CBN do not have a specific place in Iran’s health system (16, 17). Although nursing in Iran has a long history, community-based nursing still has many challenges and has not been able to play its role effectively in Iran’s health system. This study aims to analyze the state of community-based nursing to identify the challenges facing of the development of CBN in Iran.

In the present study, 12 interviews were analyzed. In the process of analyzing interviews, after removing duplicate codes and merging similar codes, 4 main categories were obtained (Table 2).

The first main category that was obtained from the analysis of the participants’ interviews was the lack of a clear place for CBN in the Iranian health system. Not having a well-defined job position in the health system has caused CBN to not be able to perform its activities with the tasks that it is responsible for.

According to the participants in the study, nursing in Iran is limited to hospitals and medical centers, and we have fewer nurses in society. Therefore, to improve these situation, they suggested that we should recruit nurses in health centers.

Another challenge that was identified was the inappropriate image of nursing in society. The inappropriate image of nursing harms participant’s views and leads to less acceptance of nursing in society. Meanwhile, the media plays an important role in introducing nurses to the public. Disruption and lack of attention of the media, presenting an image of nursing that is away from the reality and is one of the most important factors affecting the social image of nursing in the society.

Lack of awareness of the role of nurses in society was one of the subcategories identified in this class. According to the interviewees, most people and officials do not have enough knowledge about the role and importance of CBN.

Another issue that was identified was the inconsistency of nursing education with the needs of the community. In this study, the participants emphasized the necessity of moving colleges towards community-oriented and problem-oriented education and training human resources based on the needs of society. In this regard, they emphasized the necessity of revising nursing education programs.

Participants also stressed this point in the interview:

The study participants also believed that CBN plays a very important role in improving community health and empowering people.

Nurses can take care of patients at home. However, home care in Iran is very expensive and insurance still does not fully cover home nursing services.

Therefore, proper pricing of home nursing services is more important. The high cost of home care services and the lack of insurance coverage for these services have created many challenges for people to receive home care services.

According to the results obtained from this study, it was found that barriers were identified for the development of CBN in Iran, which can affect its expansion. One of the identified barriers is not determining a well-defined place for CBN in Iran’s health system. CBN has been taught in Iran’s nursing schools for more than four decades, but it has not found a well-defined place until now (19). For this reason, CBN has not been able to grow and expand effectively in society. It was found in a study by Shahshahani et al. that although there are many nursing positions confirmed by the nursing authorities in Iranian hospitals and community settings, according to the statistics of the Ministry of Health, almost the majority of nurses are working in hospital departments (20), so one of the basic challenges of CBN development in Iran, the definition of job position is appropriate to be the first contact level of people with nurses in the community, and this is while the study conducted by Barasteh et al. shows that nurses are currently providing services in hospitals (21).

The next obstacle identified in this study was the high cost of home nursing care in Iran. Most insurance services in Iran do not cover nursing services at home. This budget is expensive for families and makes them go to hospitals and medical centers for services. Due to the lack of a relevant organization in Iran to regulate the costs of nursing services at home, the desired prices are usually determined based on the agreement between the client and the particular nurse. These agreements can be made based on the working hours of the nurse, the specific needs of the individual and other factors (22). Meanwhile, the insurance coverage of nursing services at home can bring more material benefits; the results of one study showed that home healthcare services can reduce treatment costs (23). In terms of cost-effectiveness, various studies show that providing community-based care through community health nurses instead of hospital care leads to improving health and quality of care, management of chronic diseases, patients’ access to community-based services, and patient satisfaction, which in turn, leads to a reduction in emergency visits and hospitalizations, and ultimately. Reduction in treatment costs (7, 24).

Another barrier identified in this study was the inappropriate image of nursing in the society. The image of nursing is tied to the identity and role of the nurse (25). One of the long-term barriers to the nursing profession is the public image of the profession. Usually, people think about people based on their appearance, and how they dress, react, communicate, or behave. They give an opinion and make a visualization or a mental image, and people interact with that organization or people based on this image, positively or negatively (26). Many reasons can cause an inappropriate image of nursing in society. In this study, the role of the media is mentioned. According to some existing studies, the image of nursing in the media does not match the reality of what nurses do professionally. In a study aimed at determining the image of nursing in the press, Sanchez Gross et al. states that what is portrayed in the press about the nursing profession is mostly a secondary role and dependent on other professions, lacking authority and lack of ability in this process (27). In a study conducted by Pawłowski et al. it was shown that The media’s expression about the nursing profession has an important effect on forming the image of this profession in society. For example, aggressive expressions from website operators about the nursing profession or even messages. The direction loaded in them by the fans of the websites leads to a negative impact on nursing in public opinion. Nurses talking about the difference between what they say and what they do can lead to the development of the nursing profession (28). Therefore, to improve the public image of the nursing profession, monitoring and taking care of the production of the media, on the one hand, and the more prominent presence of nurses in the media to introduce the reality of their profession, on the other hand, will be a helpful solution in hearing the voices of nurses correctly (29).

In this study, it was found that people’s lack of knowledge about nurses can affect the image of nursing. Accordingly, in the research conducted by Van Irsel in 2016 in the Netherlands, he emphasizes that CBNs should show themselves more outside the profession increases public awareness of the reality of the complex roles involved in this field and ensure the delivery of care (30).

Another obstacle identified in this study was the mismatch of nursing education with the needs of society. In the study conducted by Buck many experts, nursing education should be changed to acquire the skills that nurses need to meet the needs of society and the health system (31). One of the goals of the educational system for this purpose is the necessity of reforming the educational system according to the needs of society and changing the educational approach from hospital-oriented to society-oriented (7). The study conducted by Heydari et al. shows that in Iran, nurses do not get the necessary preparation to work in society at the undergraduate level (19). The establishment of a CBN education program in the form of lectures in the first months of university, introduction of textbooks, and simulations about social and home care significantly affected their attitudes and beliefs towards CBN because the traditional curriculum has made students consider social activities and home care unimportant (32). Therefore, nursing educators and planners should continually review the content of CBN education based on the needs assessment of students and graduates of community health and according to the needs of the community (33).

The results of this study show that there are several barriers to the development of CBN in Iran, which can be solved with appropriate measures by health policymakers and nurses. Based on this, first, a suitable place for CBN in Iran’s health system should be defined, and then nurses should receive adequate and regular training to attend these centers and society.

On the other hand, most of the costs of home nursing services must be paid by insurance companies. Also, by improving the quality of nurses’ performance and informing the public about nursing services, the social image of CBN can be improved.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by data collection began after receiving the code of ethics (IR.IUMS.REC.1399.976) from the Iran University of Medical Sciences. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

SO, SG, HP, and NS: conception and design, critical revision of the article, and final approval of the article. SO and NS: analysis and interpretation and co-writing the article. SO: data collection and overall responsibility. All authors contributed to the article and approved the submitted version.