research problem statement for community health nursing

Exploring Community Health Nursing Research Topics: A Comprehensive Guide for Nursing Students

Community health nursing is a dynamic and vital field within the nursing profession, focused on providing holistic care to populations within a defined community. This specialized branch of nursing goes beyond individual patient care, extending its reach to families, groups, and entire communities. This article will delve into community health nursing, explore its significance, and provide valuable resources for nursing students to engage in research, evidence-based practice (EBP) projects, capstone projects, research paper topics, research questions, and essay ideas.

What You'll Learn

Understanding Community Health Nursing: A Holistic Approach

Community health nursing emphasizes preventive care , health promotion, and disease prevention within a specific community. This holistic approach involves understanding the community’s unique needs, cultures, and challenges to provide targeted interventions that improve health outcomes. As nursing students, you will find this field to be a gateway to understanding the broader healthcare landscape and the interconnectedness of various factors that influence health.

PICOT Questions on Community Health Nursing

• P: Adult population in psychiatric care ; I: Implementation of daily RS questionnaire; C: Units without the daily survey; O: Reduction in utilization of restraint and seclusion; T: 6 months. Can the implementation of a daily RS (Restraint and Seclusion) questionnaire for adults in psychiatric care lead to a significant decrease in the utilization of restraint and seclusion within a period of 6 months?
• P: Pediatric population in school settings; I: Introduction of daily exercise regimen; C: Schools without daily exercise; O: Improvement in BMI and overall fitness; T: 1 academic year. Does introducing a daily exercise regimen in school settings for pediatric populations result in a noticeable improvement in BMI and overall fitness over the course of 1 academic year?
• P: Elderly population in assisted living facilities; I: Implementation of fall prevention program; C: Facilities without fall prevention program; O: Reduction in fall-related injuries; T: 1 year. Is there a significant reduction in fall-related injuries among the elderly residing in assisted living facilities after the implementation of a comprehensive fall prevention program within 1 year?
• P: Low-income pregnant women; I: Provision of prenatal education classes; C: Those without access to prenatal education; O: Increase in prenatal knowledge and healthier pregnancy outcomes; T: Throughout gestation. Can providing prenatal education classes to low-income pregnant women lead to increased prenatal knowledge and improved pregnancy outcomes when compared to those without access to such education?
• P: Diabetic population within the community; I: Establishment of a mobile diabetic clinic; C: No mobile clinic available; O: Enhanced diabetic management and reduced hospitalizations; T: 2 years. Does the establishment of a mobile diabetic clinic within the community lead to better diabetic management and a decrease in hospitalizations over a span of 2 years?
• P: Adolescent population in schools; I: Implementation of comprehensive sexual education; C: Schools with standard sexual education; O: Reduction in teen pregnancies and sexually transmitted infections (STIs); T: 3 years. Over a period of 3 years, does the implementation of comprehensive sexual education in schools result in a significant decrease in the rates of teen pregnancies and STIs among adolescents compared to schools with standard sexual education?
• P: Homeless population; I: Launch of mobile healthcare unit; C: No access to regular healthcare; O: Improvement in overall health status and decrease in emergency room visits; T: 1 year. Can the introduction of a mobile healthcare unit for the homeless population improve their overall health status and a noticeable reduction in emergency room visits within a year?
• P: Rural elderly population; I: Initiation of telehealth services ; C: Lack of telehealth services; O: Enhanced access to healthcare and better management of chronic conditions; T: 18 months. Does the introduction of telehealth services for the rural elderly population lead to increased access to healthcare services and improved management of chronic conditions over the course of 18 months?
• P: New mothers; I: Implementation of postpartum support groups; C: No postpartum support groups available; O: Reduction in postpartum depression rates and improved maternal well-being; T: 1 year. Can the implementation of postpartum support groups for new mothers lead to a significant reduction in postpartum depression rates and an overall improvement in maternal well-being within a year?
• P: LGBTQ+ youth; I: Creating safe spaces in schools; C: Absence of designated safe spaces; O: Decreased mental health challenges and higher academic achievement; T: Ongoing. Does creating safe spaces within schools for LGBTQ+ youth lead to a noticeable decrease in mental health challenges and a rise in academic achievement over an ongoing period?

Evidence-Based Practice Projects Ideas

• Evaluating the effectiveness of community-wide vaccination drives in reducing vaccine-preventable diseases.
• Assessing the impact of a smoke-free policy in public spaces on community members’ respiratory health.
• Investigating the outcomes of a nutrition education program in improving dietary habits among low-income families.
• Analyzing the effectiveness of a community-based mental health awareness campaign in reducing stigma and increasing help-seeking behavior.
• Exploring the outcomes of a diabetes management intervention using mobile health apps in urban communities.
• Studying the effects of a community gardening initiative on physical activity levels and nutrition awareness.
• Investigating the utilization and impact of telemedicine services in remote rural areas.
• Assessing the benefits of a community fitness program on cardiovascular health and overall well-being.
• Evaluating the effectiveness of a school-based anti-bullying campaign on students’ mental health.
• Analyzing the outcomes of a community-driven initiative to increase access to clean drinking water in underserved areas.

Nursing Capstone Project Ideas

• Developing a comprehensive disaster preparedness plan for a local community.
• Designing and implementing a culturally sensitive prenatal care program for immigrant populations.
• Creating a curriculum for training community health workers in identifying and addressing social determinants of health.
• Establishing a support network for caregivers of elderly individuals living at home.
• Designing a mental health first aid training program for community leaders and volunteers.
• Implementing a community-based program to promote physical activity among children with obesity.
• Creating a resource guide for LGBTQ+ youth to access healthcare services without discrimination.
• Developing a community-wide initiative to combat opioid misuse and overdose.
• Establishing a telehealth platform for remote health consultations in underserved regions.
• Designing a comprehensive sexual education curriculum for high schools to address varying cultural norms.

Nursing Research Paper Topics

• The impact of community health nursing interventions on reducing health disparities .
• Exploring the role of community health nurses in disaster response and recovery.
• Analyzing the effectiveness of school-based health clinics in improving student health outcomes.
• Investigating the barriers and facilitators of healthcare access in underserved rural communities.
• The role of community health nursing in promoting healthy aging and elderly care.
• Addressing mental health stigma through community-based interventions led by nurses.
• Analyzing the outcomes of community health education programs on reducing tobacco use .
• Exploring the relationship between community engagement and positive maternal-child health outcomes.
• The effectiveness of telehealth services in bridging healthcare gaps in remote areas.
• Investigating the impact of community health nursing in preventing and managing chronic diseases.

Community Health Nursing Research Questions

• How does the presence of community health nurses influence health outcomes in underserved urban neighborhoods?
• What are the key components of successful school-based vaccination programs , and how do they impact disease prevention?
• How do cultural competence and sensitivity affect the effectiveness of community health nursing interventions?
• What are the main challenges community health nurses face in addressing social determinants of health ?
• How does community engagement contribute to the sustainability of community health initiatives led by nurses?
• What strategies effectively promote mental health awareness and reduce stigma within communities?
• How do telehealth services improve access to healthcare for individuals in geographically isolated regions?
• What role do community health nurses play in detecting and managing chronic diseases ?
• How do community health interventions impact healthcare utilization patterns and costs?
• What are the outcomes of community health nursing programs focused on improving maternal and child health?

Essay Topic Ideas & Examples

• The Role of Community Health Nursing in Promoting Population Health.
• Addressing Health Disparities: The Impact of Community Health Nursing.
• Community-Based Approaches to Preventing Teenage Pregnancy .
• Telehealth: Bridging Healthcare Gaps in Underserved Communities.
• Cultural Competence in Community Health Nursing: Challenges and Strategies.
• Disaster Preparedness and Response: The Critical Role of Community Health Nurses.
• The Influence of Social Determinants of Health on Community Health Nursing Interventions.
• Community Health Education: Strategies for Promoting Healthy Lifestyles.
• Exploring the Connection Between Mental Health and Community Well-being.
• Innovations in Community Health Nursing: Harnessing Technology for Better Outcomes.

As nursing students, you are poised to become the next generation of community health nurses, armed with the knowledge and skills to impact the health and well-being of diverse populations positively. Community health nursing offers numerous opportunities for research, practice, and advocacy. By delving into PICOT questions, evidence-based practice projects, capstone projects, research paper topics, and research questions, you can deepen your understanding of this vital field and contribute to its growth. Don’t hesitate to seek our writing services if you need assistance with your community health nursing assignments or essays. We understand the demands of nursing education and are here to support you in your academic journey. Your dedication to improving community health is commendable, and together, we can pave the way for healthier, more vibrant communities.

Frequently Asked Questions (FAQs) About Community Health Nursing

• Is community health nursing the same as nursing? Community health nursing is a specialized branch of nursing that focuses on providing holistic care to populations within specific communities. While nursing is a broader field encompassing various specialties, community health nursing is distinct in its emphasis on preventive care and health promotion within communities.
• What are the qualifications of a community health nursing? To practice community health nursing, one typically needs a registered nurse (RN) license. Many community health nurses also hold a Bachelor of Science in Nursing (BSN) degree, and advanced practice may require additional education such as a Master of Science in Nursing (MSN) with a specialization in community health.
• Do community health nurses work in hospitals? While community health nurses primarily work in community settings like public health departments, schools, and clinics, they can also collaborate with hospitals to provide education, preventive care, and continuity of care to patients transitioning from hospital to home.
• Can a community health nurse become a doctor? Community health nurses can certainly pursue further education and career advancement, but the path to becoming a doctor is different. Becoming a doctor requires completing medical school and earning a medical degree (MD) or a doctor of osteopathic medicine (DO) degree, whereas community health nursing involves nursing education and training.

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Community Health Nursing Research Paper Topics

The field of community health nursing offers a vast range of community health nursing research paper topics . This is a critical area of study and practice focusing on the delivery of health care services to communities, promoting wellness, preventing diseases, and improving the quality of life across populations. It plays a pivotal role in the contemporary healthcare system by focusing on health promotion, disease prevention, and addressing health disparities in various communities. This piece will delve into a comprehensive list of research paper topics, an in-depth article on the scope and significance of community health nursing, and an overview of the services provided by iResearchNet to assist students in their academic pursuits.

100 Community Health Nursing Research Paper Topics

Community health nursing, a pivotal aspect of the healthcare system, is dedicated to promoting wellness, preventing diseases, and improving the quality of life across various populations. This vital field encompasses a wide range of research topics, reflecting its diverse and comprehensive nature. From health promotion and disease prevention to healthcare policy and global health, community health nursing research paper topics span a broad spectrum of issues that are crucial to understand and explore for the betterment of public health.

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1. Health Promotion:

• Strategies for promoting healthy eating habits in children.
• The role of community health nurses in promoting physical activity.
• Effectiveness of smoking cessation programs led by community health nurses.
• The impact of stress management programs on mental health.
• Strategies for promoting sexual health among teenagers.
• The role of community health nurses in promoting vaccination.
• Effectiveness of alcohol and drug abuse prevention programs.
• Strategies for promoting mental health in the workplace.
• The impact of community health nursing on reducing rates of obesity.
• Strategies for promoting healthy aging.

2. Disease Prevention:

• The role of community health nursing in preventing infectious diseases.
• Strategies for preventing chronic diseases in high-risk populations.
• The impact of early detection and intervention on disease outcomes.
• Strategies for preventing mental health disorders in the community.
• The role of community health nursing in preventing maternal and child health problems.
• Strategies for preventing occupational health hazards.
• The impact of environmental health initiatives on disease prevention.
• Strategies for preventing communicable diseases in schools.
• The role of community health nursing in preventing substance abuse.
• Strategies for preventing elder abuse and neglect.

3. Community Assessment:

• The importance of community assessment in public health planning.
• Strategies for conducting a comprehensive community health assessment.
• The role of community health nurses in community assessment.
• The impact of community assessment on healthcare delivery.
• Strategies for assessing mental health needs in the community.
• The role of community assessment in disaster preparedness.
• Strategies for assessing the health needs of vulnerable populations.
• The impact of community assessment on health promotion programs.
• Strategies for assessing environmental health risks in the community.
• The role of community assessment in healthcare policy development.

4. Vulnerable Populations:

• Strategies for addressing the health needs of homeless populations.
• The role of community health nursing in caring for refugees and immigrants.
• Strategies for addressing the health needs of LGBTQ+ communities.
• The impact of community health nursing on reducing health disparities among minority populations.
• Strategies for addressing the health needs of individuals with mental health disorders.
• The role of community health nursing in caring for individuals with disabilities.
• Strategies for addressing the health needs of individuals with chronic diseases.
• The impact of community health nursing on reducing health disparities among low-income populations.
• Strategies for addressing the health needs of individuals with substance abuse disorders.
• The role of community health nursing in caring for survivors of domestic violence.

5. Community-Based Interventions:

• The impact of community-based interventions on reducing rates of infectious diseases.
• Strategies for implementing community-based interventions for chronic disease management.
• The role of community health nurses in developing and implementing community-based interventions.
• The impact of community-based interventions on mental health outcomes.
• Strategies for implementing community-based interventions for maternal and child health.
• The role of community health nursing in community-based interventions for occupational health.
• The impact of community-based interventions on environmental health outcomes.
• Strategies for implementing community-based interventions for substance abuse prevention and treatment.
• The role of community health nursing in community-based interventions for elder care.
• The impact of community-based interventions on reducing health disparities.

6. Mental Health:

• Strategies for promoting mental health awareness in the community.
• The role of community health nursing in mental health care.
• Strategies for addressing the mental health needs of individuals with chronic diseases.
• The impact of community health nursing on reducing rates of suicide.
• Strategies for addressing the mental health needs of individuals with substance abuse disorders.
• The role of community health nursing in caring for individuals with anxiety and depression.
• Strategies for addressing the mental health needs of survivors of trauma.
• The impact of community health nursing on reducing rates of domestic violence.
• Strategies for promoting mental health among the elderly.
• The role of community health nursing in caring for individuals with post-traumatic stress disorder (PTSD).

7. Maternal and Child Health:

• Strategies for promoting maternal and child health in low-income communities.
• The role of community health nursing in maternal and child health care.
• Strategies for addressing the health needs of pregnant women with substance abuse disorders.
• The impact of community health nursing on reducing rates of infant mortality.
• Strategies for promoting breastfeeding in the community.
• The role of community health nursing in caring for children with chronic diseases.
• Strategies for addressing the health needs of adolescents.
• The impact of community health nursing on reducing rates of teenage pregnancy.
• Strategies for promoting child immunization in the community.
• The role of community health nursing in caring for children with developmental disabilities.

8. Elderly Care:

• Strategies for promoting healthy aging in the community.
• The role of community health nursing in elderly care.
• Strategies for addressing the health needs of the elderly with chronic diseases.
• The impact of community health nursing on reducing rates of elder abuse.
• The role of community health nursing in caring for the elderly with dementia.
• Strategies for addressing the health needs of the elderly living in rural areas.
• The impact of community health nursing on reducing rates of falls among the elderly.
• Strategies for promoting physical activity among the elderly.
• The role of community health nursing in caring for the elderly with mobility issues.

9. Healthcare Policy:

• The impact of healthcare policy on community health nursing.
• Strategies for influencing healthcare policy to address community health needs.
• The role of community health nursing in healthcare policy development.
• The impact of healthcare policy on health disparities.
• Strategies for influencing healthcare policy to address the needs of vulnerable populations.
• The role of community health nursing in healthcare policy implementation.
• The impact of healthcare policy on access to care.
• Strategies for influencing healthcare policy to address mental health needs.
• The role of community health nursing in healthcare policy evaluation.
• The impact of healthcare policy on health outcomes.

10. Global Health:

• The role of community health nursing in addressing global health disparities.
• Strategies for controlling infectious diseases in low-income communities.
• The impact of global health initiatives on community health nursing.
• Strategies for addressing the global health needs of refugees and immigrants.
• The role of community health nursing in global health initiatives.
• Strategies for addressing the global health needs of vulnerable populations.
• The impact of community health nursing on global health outcomes.
• Strategies for addressing global health needs through community-based interventions.
• The role of community health nursing in global health policy development.
• The impact of community health nursing on global health promotion.

Researching community health nursing is of paramount importance, as it encompasses a multitude of topics crucial for enhancing public health and reducing health disparities. From developing community-based interventions to addressing the needs of vulnerable populations and crafting effective healthcare policies, the scope of community health nursing research paper topics is vast and integral to the ongoing betterment of global health. We encourage students and researchers alike to explore these topics, contribute to this ever-evolving field, and help shape a healthier future for communities worldwide.

The Range of Community Health Nursing Research Paper Topics

Community health nursing is a crucial branch of nursing practice that focuses on the well-being of entire communities rather than individual patients. Nurses in this field work to improve the overall health of communities by promoting healthy lifestyles, preventing disease, and addressing various health-related issues that affect community members. This article will discuss the significance of community health nursing and the diverse range of research paper topics it offers, emphasizing the importance of health promotion, disease prevention, and community-based interventions.

Health Promotion

One of the primary responsibilities of community health nurses is to promote health within the community. This involves educating community members about healthy behaviors, lifestyle choices, and available resources. Community health nurses often lead campaigns to encourage healthy eating, regular exercise, stress management, and other behaviors that contribute to overall well-being. These efforts help to prevent the onset of diseases and other health issues. There are numerous research paper topics related to health promotion, such as the effectiveness of different health promotion strategies, the role of community health nurses in promoting mental health, and the impact of health promotion campaigns on the rates of chronic diseases.

Disease Prevention

Another critical aspect of community health nursing is disease prevention. Community health nurses play a vital role in preventing the spread of infectious diseases by administering vaccinations, educating the public about preventive measures, and implementing infection control practices. Additionally, they work to prevent chronic diseases by promoting healthy behaviors and lifestyles that can reduce the risk of diseases such as diabetes, heart disease, and cancer. Research paper topics in this area could include the role of community health nurses in preventing infectious diseases, the impact of community-based interventions on the rates of chronic diseases, and the strategies for preventing mental health disorders in the community.

Community-Based Interventions

Community-based interventions are strategies implemented in the community to address specific health issues. Community health nurses are often involved in the development, implementation, and evaluation of these interventions. They may work with other healthcare professionals, community organizations, and community members to design interventions that are culturally appropriate and tailored to the specific needs of the community. These interventions may focus on various health issues, such as mental health, maternal and child health, elderly care, and substance abuse. Research paper topics in this area could include the effectiveness of community-based interventions in addressing mental health needs, the impact of community-based interventions on maternal and child health outcomes, and the strategies for implementing community-based interventions for substance abuse prevention and treatment.

Community health nursing is pivotal in enhancing well-being, averting illness, and addressing various health-related concerns within communities. The myriad of research paper topics in this domain mirrors its multifaceted nature. From promoting health and preventing disease to orchestrating community-based interventions, there are numerous dimensions where community health nursing can create a profound impact. Researchers are urged to delve into these areas and contribute to the ongoing initiatives to bolster the health and well-being of communities globally. The term “community health nursing” encompasses a broad spectrum of subjects that can facilitate the formulation of effective strategies and interventions to cater to the distinct health needs of various communities. By undertaking research in this domain, we can gain a deeper insight into the challenges encountered by communities and devise innovative solutions to overcome these hurdles and foster health and well-being for all.

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Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

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A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

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• OJIN Homepage
• Table of Contents
• Volume 26 - 2021
• Number 2: May 2021
• Rebuilding Community-Based & Public Health Nursing Wake of COVID-19

Rebuilding Community-Based and Public Health Nursing in the Wake of COVID-19

Patricia Pittman is the Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University. As director of the Mullan Institute for Health Workforce Equity, Professor Pittman she leads an extensive research, action and education enterprise that focuses on advancing policies that enable the health workforce to better address health equity, including protection of labor rights of health workers. Her current portfolio includes directing two HRSA-supported Health Workforce Research Centers.

Dr. Jeongyoung Park is an Assistant Professor at the George Washington University School of Nursing and a faculty member at the Fitzhugh Mullan Institute for Health Workforce Equity (Mullan Institute). Dr. Park is a health services researcher at the intersection of nursing, health policy, and health economics. Her research interests include healthcare delivery and payment system changes, and its impacts on health workforce and patient outcomes.

• Figures/Tables

The COVID-19 pandemic has reset the table for a dialogue about health equity, public health, and the future of nursing. Experts anticipated that payment reforms would lead to a much-needed increase in community and public health nursing. Despite calls for the profession of nursing to take a leadership role in addressing the social determinants of health and health equity, data show that jobs for nurses in community-based clinics and public health have actually declined in the last decade. This article offers background on the ongoing decline in public health infrastructure in the United States, an analysis of workforce data on nursing jobs using the National Sample Survey of Registered Nurses from the years 2000, 2004, 2008, and 2018, and the National Association of County and City Health Officials from 2008 to 2019, as well as a discussion of why these findings are so troubling. We discuss policy implications for nurse educators related to curricula and clinical experiences, and for professional nursing organizations as they set goals to increase and improve nursing jobs in community clinics and public health settings. In conclusion , we note that the federal investments in community health centers and public health nursing provide a short window of opportunity to reverse the historic and ongoing decline and rebuild a stronger community and public health nurse workforce.

Key Words: Nursing, COVID-19, public health workforce, public health nursing, community health nursing

Among the many problems that the COVID-19 pandemic brought to the fore in the United States were two: health inequities and the crumbling public health infrastructure and workforce in most parts of the country. Both have become priorities for the new federal administration, and significant resources are now available to strengthen the nursing workforce in community-based and public health settings ( ARP, 2021 ).

It is well known that pre-pandemic, investment in the public health workforce has been declining for at least 15 years. It is well known that pre-pandemic, investment in the public health workforce has been declining for at least 15 years. This is one reason why the social determinants of health (SDOH) that drive healthcare and other inequities have not been adequately addressed ( Castrucci & Lupi, 2020 ). What is less well known is that participation by nurses has been falling faster than other professional groups within the public health workforce. This article discusses the reduced participation by nurses in both public health and community-based clinics, and discusses implications for the future.

Public health and community health nurses are not new to this country. Indeed, they were a central force in healthcare from 1910 to 1940, losing prominence only as the medical model of care and the rise of hospitals gained traction through the mid-20th century ( Pittman, 2019b ). Efforts to revitalize public health nursing have continued over time, especially by organizations such as the Association for State and Territorial Directors of Nursing (ASTDN) (now the Association of Public Health Nurses).

Figure 1 shows the range of activities public health nurses are engaged in, all of which are essential contributions to address health equity. Since the early 1940s, there has been a general convention that at least one public health nurse is needed per 5,000 population. In 2008, the ASTDN called for the formalization of this goal, and specifically for additional nurse supervisors, and a higher density of public health nurses in high poverty communities ( Keller & Litt, 2008 ).

Figure 1. Contributions of Community/Public Health Nurses

( Keller & Litt, 2008 )

Many predicted that value-based payment would provide an incentive for healthcare organizations to hire more nurses outside of hospitals... Following the 2010 Affordable Care Act ( Patient Protection and Affordable Care Act, 2010 ), experts hoped that progress was being made toward addressing healthcare inequities with this change to the healthcare infrastructure. Many predicted that value-based payment would provide an incentive for healthcare organizations to hire more nurses outside of hospitals, in areas such as public health and community-based settings ( Larson, 2017 ; Pittman & Forrest, 2015 ; Salmond & Echevarria, 2017 ). The rationale was that as hospitals assumed more risk under Accountable Care Organizations and other value-based payment programs, care would shift outside of the hospital to ambulatory settings and homes. We would invest in public health and upstream initiatives, such as coordination with social services, housing, and food security. ( Larson, 2017 ). Some chief nursing officers in hospitals were even calling for large health systems to create a chief nursing officer position for community-based nursing ( Pittman & Forrest, 2015 ).

...many argued that nurse leaders should emphasize the importance of recommitting to the foundational practice of public health nursing... At the same time, many argued that nurse leaders should emphasize the importance of recommitting to the foundational practice of public health nursing, as exemplified by Lillian Wald in the period of 1910 to the late 1930s ( Hassmiller, 2013 ; Pittman, 2019a ; Sullivan-Marx, 2020 ). This call became more compelling as researchers identified a surge in so-called diseases of despair (i.e., primarily behavioral health-related challenges) and noted that the centralized medical model based in hospitals was failing. The increased interest in SDOH, driven in part by the Robert Wood Johnson Foundation Culture of Health goal ( n.d. ), and the continued emphasis on deepening outcome-based payment in health reform, also highlighted the promise of models that function at the intersection of nursing and social work.

When the COVID-19 pandemic appeared in early 2020, nurses in critical care settings occupied the headlines. The reported shortage of critical care nurses renewed appreciation for the essential role hospitals play during a public health emergency. Nurses who were working in intensive care units under dangerous physical and emotional conditions were hailed as heroes and seen as the symbol of the entire profession. Nothing about this shift in the conversation was unfair or regrettable. However, as has happened numerous times in the last half-century, the fear of a nursing shortage in hospitals, for a time, pushed the issue of community and public health nursing aside, once again ( Pittman, 2019a ).

...the fear of a nursing shortage in hospitals, for a time, pushed the issue of community and public health nursing aside, once again. When the Biden Administration took office in 2021, priorities shifted and the implications of the COVID-19 pandemic for public health and health equity became center stage. On January 21st, one day after assuming office, President Biden issued an Executive Order that established a Public Health Workforce Program. This order would determine how to deploy personnel in future public health threats; establish a five-year budget requirement for a sustainable public health workforce, including Public Health Service Commissioned Corps; and establish a U.S. Public Health Job Corp that would conduct contact tracing, assist in vaccination outreach and administration, and assist with training to provide testing ( Biden, 2021 ).

Implicit in this measure was an acknowledgment that the prevention of community spread of COVID-19 could be improved. Beyond the perceived mismanagement and politicization of the pandemic by the former administration by many, the new policies reflected the notion that more could have been done to prevent the spread with a robust public health workforce in the community. Public health infrastructure had not been a priority for many years ( Taylor, 2018 ). Areas of weakness noted in the current pandemic included coordination between local, state, and federal roles; community education on the importance of public health prevention measures, surveillance through contact training, COVID-19 testing, and planning for the vaccine rollout ( Sullivan-Marx, 2020 ).

An example that demonstrates the importance of a robust infrastructure concerns the vaccine rollout. An example that demonstrates the importance of a robust infrastructure concerns the vaccine rollout. West Virginia and New Mexico were far more successful in quickly vaccinating their residents than others. These two rural states had maintained a stronger public health infrastructure than other states. They turned to their public health workforce, rather than the fragmented private sector pharmacy and healthcare delivery system, during the vaccine roll-out, taking vaccines to hard-to-reach populations ( Cunningham, 2021 ).

In March, Congress passed the American Rescue Plan Act (ARP) of 2021. The ARP provides a significant funds for the public health workforce through multiple mechanisms, including funding for local health departments. In keeping with the goals announced in the earlier Executive Order ( Biden, 2021 ), $7.66 billion in the new law is targeted to establish, expand, and sustain a public health workforce, including awards to state, local, and territorial public health departments ( ARP, 2021 ).

...it is important to understand whether payment reforms and the calls for nurses to address SDOH were indeed having an effect before the pandemic. As we contemplate the implications of this new opportunity for nurses and the profession of nursing, it is important to understand whether payment reforms and the calls for nurses to address SDOH were indeed having an effect before the pandemic. In order words, where does the nursing workforce stand today, and is it positioned to expand its role in community health and public health?

In this analysis, we question the progress made prior to the 2020 pandemic in terms of strengthening community-based and public health nursing and discuss the implication of the recent legislation ( ARP, 2021 ) for the future of community and public health nursing.

Analysis of Workforce Data

...not only did the expected expansion of nursing into community and public health settings not occur, but the trendlines were headed in the wrong direction. We analyzed the last four iterations (2000, 2004, 2008, and 2018) of the National Sample Survey of Registered Nurses (NSSRN), performed by the National Center for Health Workforce Analysis ( [NCHWA], 2018 ), and data from the National Association of County and City Health Officials ( [NACCHO], 2019 ) from 2008 to 2019. Our analysis included evaluation of the data in these documents over time and consideration of other trends. Using the NSSRN over time, we first conducted descriptive analysis on changes in nurse employment in community and public health settings, as well as in other primary care settings. We also examined county and city employment data over time to trace back a sub-set of community/public health nurses, i.e.,nurses in local health departments, and compared with trends of other occupations employed in local health departments. These findings revealed that not only did the expected expansion of nursing in to community and public health settings not occur, but the trends were headed in the wrong direction.

...current distribution of nurses is still weighted heavily toward hospital employment. As shown in Figure 2 , data from the most recent NSSRN (2018) revealed that the current distribution of nurses is still weighted heavily toward hospital employment (62.6%). Just 1.4 % of registered nurses (RNs) are employed in community/public health non-clinic settings (e.g., state health or mental health agency; city or county health department), and 1.6% are employed in public health/community clinic-based settings (e.g., rural health center, Federally Qualified Health Center [FQHC], Indian Health Service, TRIBAL Clinic), for a combined 3% of the nurse workforce.

Figure 2. Distribution of RNs by Employment Setting 2018 (n= 3,272,871)

[ View full size ]

*PH/CH not clinic-based includes State Health or Mental Health Agency, City or County Health Department. PH/CH clinic-based includes Rural Health Center, FQHC, Indian Health Service, TRIBAL Clinic, etc.

Source: Authors’ Analysis Based on the National Sample Survey of Registered Nurses, 2018 ( NCHWA, 2018 )

...RNs in both clinic and non-clinic-based community/public health jobs dropped dramatically. Analysis of NSSRN Over Time When we examined the NSSRN (2000; 2004; 2008; 2018) over time, we saw a clear and discouraging trend. As shown in Figure 3 , RNs in both clinic and non-clinic-based community/public health jobs dropped dramatically. RNs in non-clinic-based community/public health jobs fell as a percent of the total RN workforce from 3.2% (69,837) in 2000 to just 1.4 % (47,226) in 2018. There was a similar drop in clinic-based jobs, from 3.5% (76,127) to 1.6% (53,084). The Table provides the descriptive data used to compile Figure 3 .

Figure 3. RNs in Community/Public Health*, 2000-2018

Source: Authors’ Analysis Based on the National Sample Survey of Registered Nurses, 2000, 2004, 2008 and 2018 ( NCHWA, 2018 )

Table. Descriptive Data for Figure 3

Primary care settings (beyond the publicly-funded community clinics described above) cannot be traced back to the early NSSRN surveys (2000; 2004; 2008), so we examined two other categories: private medical practice and nurse-owned practices. The decline was less dramatic than in community health/public health, but we found a drop in nurses employed in private medical practice from 9.2% in 2000 to 6.9% in 2018, again with a slight increase in the absolute numbers (203,346 to 226,524). Nurse-owned practices remained flat at just .3% over time, even with the absolute numbers almost doubling from 5,978 to 10,655 ( NCHWA, 2018 ).

Other Trends Trends in additional non-hospital categories also challenged the predictions. For example, school -based nurses declined as a percentage of the total nurse workforce, from 3.8% to 2.9%, although their actual numbers increased by a little over 10,000 (83,269 to 93,344) ( NCHWA, 2018 ).

...the decrease of nurses was faster than any other occupation within public health. To understand why there are not more public health nurses, it is also worth looking at data on a sub-set of public health nurses: those working in local health departments. These nurses are a critical part of the governmental response to any public health crisis, including COVID-19. We analyzed county and city health employment data ( NACCHO, 2019 ) from the years 2008-2019. As shown in Figure 4 , the number of nurses declined from just over 33,000 to just over 21,000. This decline mirrors the NSSRN data presented in Figure 3 , but it also reveals another puzzling data point: the decrease of nurses was faster than any other occupation within public health. Behavioral health staff were falling but have had a significant uptick since 2016. Other staff, such as epidemiologists and preparedness staff, have increased slightly over time ( NACCHO, 2019 ).

Figure 4: RNs and other Occupations in Local Health Departments, 2008-2019

Source: Authors’ Analysis of 2019 National Profile of Local Health Departments, National Association of County and City Health Officials ( 2019 )

The question, then, is why public health nursing has been particularly hard hit during this period since the year 2000? Edmonds and colleagues ( 2020 ) warned against replacing public health nurses with less costly personnel in their Call to Action for Public Health Nurses, arguing that nurses’ “preparation, knowledge, clinical decision'making skills, and their ability to flexibly be deployed across a diverse range of activities in response to rapidly evolving public health needs” make them irreplaceable in public health ( Edmonds et al., 2020 , p. 324) However, the data above do not suggest substitution

At least part of the problem appears to be on the supply side. Local health departments seem to agree. In a 2017 survey of local health departments in California, 80% reported problems with recruitment or retention of nurses, and 46% reported a decrease in nurses on staff ( Taylor, 2018 ).This finding suggests that it is not simply a problem of low job availability or a lack of appreciation for nursing contributions in these settings. They indicated that they want more nurses.

At least part of the problem appears to be on the supply side. It is possible thatthe interest in career advancement and continued education has led the workforceto greater specialization. Specialization in nursing, as in medicine, could be drivingthe workforce away from primary care, community-based care, and public health,and into hospitals and specialty physician offices.

Competition from acute care settings may also be hurting community-based healthcare and public health. Competition from acute care settings may also be hurting community-based healthcare and public health. The same California survey ( Taylor, 2018 ) found that nurses reported that low compensation was a major reason for considering leaving their local health department jobs. Indeed, the most recent NSSRN (2018) showed that the mean annual salary for nurses in hospital settings was $76,506 versus $66,632 for those in public health departments ( NCHWA, 2018 ). More jobs without increased compensation may, therefore, be an insufficient remedy.

It is incumbent on nursing and health policy leaders in a variety of settings to do more.

Policy Implications

Current information suggests that the payment reforms and marketplace alone are insufficient to expand nursing in the community clinics and public health. It is incumbent on nursing and health policy leaders in a variety of settings to do more. In addition to remuneration issues, the supply of nurses graduating with a focus on community and public health may also be less than is needed for an expansion.

Implications for Nursing Education First, nursing program faculty should review curricula and bolster educational offerings in community-based healthcare and public health as appropriate. Program leaders need to identify role models in public health and offer community and public health practice settings for students to conduct clinical practice requirements. If nurses are prepared for this type of work, they may be more likely to rise within the ranks of public health departments, earn a higher salary, and report greater job satisfaction.

Non-traditional practice would teach students about unique and critical roles of public health workers from other backgrounds... Second, boards of nursing in some states still require a nurse preceptor for clinical hours. For public health nurses, allowing preceptors with various non nursing backgrounds would be beneficial. Such a policy could increase the availability of clinical sites and expose nursing students to the work of interprofessional teams before they graduate. Rather than seeing these occupations as a threat, Lillian Wald, the foundational public health nurse in the early 20 th century, saw the partnership with social work as critical to addressing community needs ( Pittman, 2019a ). Non-traditional practice would teach students about unique and critical roles of public health workers from other backgrounds, particularly social workers and community health workers.

Implications for Goal Setting Third and last, measurable goals would spur action. An example of this is evident from the Institute of Medicine report on the Future of Nursing ( [IOM], 2011 ), which set a goal of 80% of the nurse workforce attaining a bachelor of science level education by 2020. This measurable goal drove change in a positive direction, even if the goal was not fully attained. While public health nurses are but one component of the community and primary-based workforce needed, ASTDN has delineated an achievable set of goals for public health nursing. ( Spetz, 2018 ) Organizations that support primary care, community-based, and school-based nurses could do the same.

...measurable goals would spur action. The ASTDN goals are (1) one public health nurse per 5,000 population, (2) an additional 1:8 ratio for supervisors to nurses, and (3) more nurses in high-need communities. These goals suggest the need for 66,284 non-clinic-based community/public health nurses to meet the 1: 5,000 ratio, plus an additional 8,284 additional public health nurse supervisors as recommended by ASTDN. Based on the most recent estimate of 47,226 nurses in public health roles (NSSRN, 2018), we would need another 27,341 public health nurses to meet the first criterion of the ASTDN goal. More would be required to meet the needs of high poverty communities, depending on the criteria used to identify those communities.

One advantage of this type of goal is that nursing schools could estimate the number of new graduates per year specialized in public health needed in each region; public health departments could do the same. Federal health workforce program administrators could track how their programs contribute to this goal at a national and a local level. Examples of these programs are the Nurse Corps loan repayment program, which received additional funding under the American Rescue Plan Act ( Health Resources and Services Administration, 2020 ), and Title VIII, which funds various nurse education programs and received extra support under the Coronavirus Aid, Relief, and Economic Security Act ( 2020 ).

Events of the COVID-19 pandemic have reset the table for the healthcare workforce and specifically the profession of nursing. Even more clear is the danger of allowing our public health infrastructure to decay, as this analysis of nurses in the public health workforce alone suggests has happened.

Even more clear is the danger of allowing our public health infrastructure to decay... To attract more nurses to this field, public and private employers will need to address relative compensation issues. Nursing programs will need to produce more nurses who are interested in and prepared to practice in community and public health. Local, state, and federal public health workforce programs will need to set measurable goals by region and publicly track progress.

The combined emphasis on equity and the public health workforce of the current administration provides a window of opportunity to reverse the historic, ongoing declines briefly described in this article in community and public health nursing. Rebuilding a stronger nurse workforce will not only prepare the United States to meet the challenges of future pandemics, but also have a positive upstream impact on the SDOH-related inequities that are endemic.

Patricia Pittman, PhD, FAAN Email: [email protected]

Jeongyoung Park, PhD Email: [email protected]

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May 31, 2021

DOI : 10.3912/OJIN.Vol26No02Man07

https://doi.org/10.3912/OJIN.Vol26No02Man07

Citation: Pittman, P., Park, J., (May 31, 2021) "Rebuilding Community-Based and Public Health Nursing in the Wake of COVID-19" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 7.

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Journal of Community Health Nursing, Volume 41, Issue 4 (2024)

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Community-Engaged Research

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Community-Engaged Research (CEnR) seeks to incorporate community stakeholders and needs throughout the research process – it includes a large continuum of research processes with varying levels of community participation. Community-Based Participatory Research (CBPR) is one popular example of CEnR aims to share responsibility equitably amongst all partners and grants equal decision-making power to community and academic stakeholders.[1] 

Find the full PDF guide here .

The following six principles should guide all community-engaged research: [2]

• Avoidance of Harm: researchers should understand the broader context of this research and its potential consequences and actively avoid harming communities
• Shared Power in Decision-Making: equity should be prioritized in decision-making, and participatory governance structures must be established at the start of research
• Transparency: researchers should openly and transparently communicate with community partners throughout the research process
• Mutual Accountability: teams should collaboratively establish responsibilities and decision-making processes, prioritizing respect in all discussions
• Accessibility: researchers should provide equitable compensation to community partners and participants, along with allowing for flexibility and adaptation
• Capacity-Bridging: researchers should think of the sustainable value of their community partnerships and prioritize community capacity building

• Take time to speak to community members and leaders prior to defining your research questions and objectives. Come in with an idea of your research project, but be open to refining and rethinking it based on community feedback. University of Kansas’ “ Assessing Community Needs and Resources” toolkit provides detailed guidance on collaborative analysis of community needs. 
• Understand how your proposed research fits into the historical and contemporary contexts of the community. Be mindful of any harm your research could cause and keep in mind trauma and negative consequences associated with past research in this community. If the community has worked with researchers in the past, inquire of their experiences. This can prevent replicating collaborations that are exploitative. 
• If this is your first exposure to community-engaged research, consider exploring training and courses, such as CITI’s Community-Engaged and Community-Based Participatory Research courses. Also, contact colleagues who have conducted CBPR and learn how they have approach communities.
• Consider what community organizations or institutions are doing work related to your research interest. Research what groups have already collaborated with university researchers and utilize existing relationships. University of Chicago’s Office of Civic Engagement is a great starting point to explore existing community collaboration and resources. Explore Urban Institute’s Fostering Partnerships for Community Engagement Toolkit for further resources. 
• Reflect on your individual and institutional positionality as a researcher working within your selected community. Take  conscious action to trace your own motives for working in this community and your intentions.
• Build in extra time throughout the process and set a realistic timeline. Remember that community-engaged research generally requires a longer timeframe than other research projects of similar scope. [1] Be aware that communities have needs that they have to prioritize, and are responsible to address which may or may not influence the research process and progression. 
• Collaborate with community stakeholders to define desired outcomes and metrics of success and incorporate these into your research proposal.    Evaluation of your research should be defined collaboratively and in centering community voices. 
• Include community stakeholders in the various steps of research, creating opportunities for their feedback on the research process. Be open to changes to your research process based on their feedback.
• Host an event in collaboration with community partners to share your research findings. This event should be accessible and findings should be conveyed in plain language.  
• Develop partnership agreements and memorandums of understanding (MoUs) to clearly define the scope of your engagement. Have transparent conversations with community members to determine consensus on data sharing, research dissemination, and responsibilities. Community Research Collaborative provides a useful template for developing partnership agreements.
• Establish governance structures that aim for genuine participation. Strive to eliminate power hierarchies and prioritize equitable decision-making. Clearly delineate roles and responsibilities with community partners. 
• Ensure that your research truly benefits the community. Ask yourself what will the community gain from participation beyond the research partnership? Discuss with your community partners what the benefits will be and how you will achieve them as you partner in the research process.
• Create equitable compensation plans to ensure that your community partners are properly compensated for their time and labor. The Urban Institute’s Equitable Compensation Plan Toolkit   is a great starting point for thinking about this.

NORC Community-Engaged Research Framework:   details an evidence-based framework for effective community-engaged research and key principles

Urban Institute Community Engaged and Participatory Methods Toolkit:   offers several detailed toolkits for conducting community-engaged research, on topics including applying CEnR to various research methods, driving racial equity, and conducting trauma-informed research or participatory research with sensitive populations

University of Chicago Office of Civic Engagement:   offers resources on community engagement, further assistance in kickstarting research processes, and information on recent community partnerships with the university

UCSF Prevention Science Community Engaged Research Toolbox:   compiles public health-oriented and general resources on community-engaged research, including webinars, sample formal documents, and toolkits

Arnold School of Public Health:   offers comprehensive resources focused on topics such as CBPR, assessing community needs, evaluation, and effective leadership

University of Kansas Community Toolbox:   provides extensive resources on every stage of the community-engaged research process through this detailed, multi-chapter toolkit

[1]   https://healthycommunities.ucr.edu/what-community-engaged-research

[2] https://www.norc.org/research/library/community-engaged-research-framework.html

[3] https://vibrantcitieslab.com/wp-content/uploads/2022/03/NIHH-Community-Engagement-Guide-for-Conducting-Research-and-Evaluation.pdf

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The Research in Community and Public Health Nursing (RCPHN) is the official journal of the Korean Academy of Community Health Nursing.

RCPHN is a peer-reviewed journal published quarterly by the Korean Academy of Community Health Nursing.

RCPHN coverage includes theoretical, practical, and educational issues related to community and public health nursing. Articles include original research articles, reviews, and editorials. This journal aims to provide worldwide access to timely research and practice features of use to community health nurses, educators, school health teachers, occupational nurses, and administrators in the field of community and public health nursing.

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• v.17(1); 2022

The influencing factors of clinical nurses’ problem solving dilemma: a qualitative study

a Department of Nursing, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China

b Tongji University School of Medicine, Shanghai, China

c Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Problem solving has been defined as “a goal-directed sequence of cognitive and affective operations as well as behavioural responses to adapting to internal or external demands or challenges. Studies have shown that some nurses lack rational thinking and decision-making ability to identify patients’ health problems and make clinical judgements, and have poor cognition and response to some clinical problems, easy to fall into problem-solving dilemma. This study aimed to understand the influencing factors of clinical nurses’ problem solving dilemma, to provide a basis for developing training strategies and improving the ability of clinical nurses in problem solving.

A qualitative research was conducted using in-depth interviews from August 2020 to December 2020. A total of 14 participants from a tertiary hospital in Shanghai, China were recruited through purposive sampling combined with a maximum variation strategy. Data were analysed with the conventional content analysis method.

Three themes and seven subthemes were extracted: nurse’s own factors (differences in knowledge structure and thinking, differences in professional values, poor strain capacity); improper nursing management (low sense of organizational support, contradiction between large workload and insufficient manpower allocation); patient factors (the concept of emphasizing medicine and neglecting to nurse, individual differences of patients).

The influencing factors of clinical nurses’ problem-solving dilemma are diverse. Hospital managers and nursing educators should pay attention to the problem-solving of clinical nurses, carry out a series of training and counselling of nurses by using the method of situational simulation, optimize the nursing management mode, learn to use new media technology to improve the credibility of nurses to provide guarantee for effective problem-solving of clinical nurses.

Introduction

Nursing education in China can be divided into two main levels: vocational education and higher education. Vocational education includes technical secondary schools and junior colleges, while higher education includes undergraduate, master’s and doctoral education. Vocational education aims at training students to master basic nursing service skills and to be able to take the post to engage in daily nursing work (Sun & Zong, 2017 ). Higher nursing education started late, and undergraduate education has always followed the “three-stage” education model of clinical medicine (basic medical courses, specialized courses and clinical practice). Most courses are centred on subject knowledge, and all clinical practice takes the form of centralized practice (Li, 2012 ). The training goal of nursing postgraduates is gradually expanding from academic master to professional master. The curriculum mainly includes classroom teaching and clinical practice. The classroom teaching contents include public courses (political theory, foreign languages, etc.), professional basic courses (advanced health assessment, pharmacotherapy, pathophysiology, evidence-based nursing, medical statistics or clinical epidemiology), specialized courses (advanced nursing practice theory) and Academic activities . The goal of nursing doctoral training is to cultivate high-level nursing research talents, focusing on the cultivation of scientific research ability rather than clinical practice ability. The curriculum includes ideology and politics, basic theory, research methods, specialized courses, development frontier, scientific writing, etc (Luo et al., 2018 ). There are some problems in the training mode and curriculum, such as theory and practice are out of touch, traditional lecture-based classroom teaching makes students passively accept knowledge, students attach importance to theory over practice, knowledge input to ability output, professional study to humanities knowledge. Nursing students receive no theoretical and/or practical training in problem solving before entering the clinical setting, so there is not a starting point for these nurses to clinical dilemmas in their professional life.

With the development of medicine, people pay more attention to health and have higher requirements for nursing service ability (Yang, Ning, et al., 2018). The National Nursing Development Plan (National Development and Reform Commission, 2017 ) points out that it is necessary to strengthen the construction of nurse teams, establish nurse training mechanisms and improve the professional quality and service ability of nurses. However, in the face of increasingly complex and changeable clinical environment, nurses are still lacking in problem-solving thinking and ability, and often fall into the dilemma of problem solving (Li et al., 2020 ).

Typical decision theory approaches to the identification of problem solving in nursing have viewed the process as a series of decision formulations that include: decisions about what observations should be made in the patient situation; decisions about deriving meaning from the data observed (clinical inferences); and decisions regarding the selection of action to be taken that will be of optimal benefit to the patient (McGuire, 1985 ). Information processing theory describes problem solving as an interaction between the information processing system (the problem-solver) and a task environment, which can be analysed as two simultaneously occurring sub-processes of “understanding” and “search” (VanLehn, 1989 ). Individuals collect the stimulus that poses the problem in the understanding process, forming the internal representation of the problem, transforming the problem stimulus into the initial information needed in the search process, and then producing mental information structures for the understanding of the problem, which making individuals distinguish the nature of the problem and clarify the goal of the problem. The mental information structures drive the search process that enables the individual to find or calculate the solution to the problem. This process starts with the nurse identifying the clinical problem and continues until the decision is made to resolve the problem (Taylor, 2000 ). Clinical problem solving requires nurses to have a variety of cognitive strategies, which involves nurses’ knowledge, experience, and memory process. Nurses must recognize the current problem and use all available knowledge and experience to transform the problem into their internal problem representation, and then set goals and search for strategies that can achieve the goal (Mayer & Wittrock, 1992 ). In today’s complex clinical environment, nurses need to be able to solve problems accurately, thoroughly, and quickly. Nurses who can solve problems efficiently have fewer medical errors (Babaei et al., 2018 ), and the level of nursing skills and empathy are higher (Ay et al., 2020 ; Bayindir Çevik & Olgun, 2015 ). To cultivate nurses’ problem solving thinking and ability, it is necessary to better understand the influencing factors of problem solving dilemma. However, these cannot be obtained by observing nurses’ behaviour in their work, and cannot be obtained through quantitative research either. Exploring the thinking process involved in nurses’ work through qualitative interviews is an effective way to understand the influencing factors of nurses’ problem solving. Given this, this study used qualitative research methods to deeply analyse the influencing factors of clinical front-line nurses’ problem solving dilemma, to provide a basis for making relevant strategies to cultivate nurses’ thinking and ability of problem solving.

Study design

A qualitative study based on in-depth interviews was conducted to obtain influencing factors of nurses’ problem-solving dilemma.

Settings and participants

Purposive sampling combined with a maximum variation strategy was used to identify and select information-rich participants related to the research phenomenon. Maximum variation was achieved in terms of participants’ gender, education level, professional title, marital status, seniority, and administrative office, respectively. The study was conducted between August 2020 to December 2020 in a tertiary hospital in Shanghai, China. The inclusion criteria were a nurse practicing certificate of the People’s Republic of China and within the valid registration period; having been engaged in clinical nursing work for at least 1 year and still engaged in clinical nursing work; clear language expression, able to clearly describe the solution and feelings of clinical problem solving; informed consent to this study and voluntary participation. The exclusion criterion were on leave during the study period (personal leave, maternity leave, sick leave, etc.); out for further study or came to the hospital for further study; confirmed or suspected mental illness and psychotropic medicine users. Purposive sampling continued until thematic saturation was reached during data analysis.

Data collection

Face-to-face, a semi-structured interview was used to collect information. All interviews were conducted in the lounge to ensure quiet and undisturbed by a female postgraduate nursing student with the guidance of her master tutor. Initially, an interview guide was developed based on literature review and expert consultation including about five predetermined questions: What thorny problems have you encountered in clinical work or have a great impact on you? How did you solve it? Why take such a solution? What is the biggest difficulty encountered in the process of problem solving? How does it affect you? How do you feel in the process of problem solving? Before the interview, the consent of the interviewee was obtained and then the researcher fully explains to the interviewees and starts with a friendly chat to allay the interviewees’ worries. During the interview, the researcher listened carefully and responded in time, always maintaining a neutral attitude, without any inducement or hint, if necessary, giving encouragement and praise to support the expression of the interviewees, and to record the interviewees’ facial expressions, physical movements and emotional responses in time. At the same time, a recording pen was used to ensure that the interview content was recorded accurately and without omission. The interview time for each person was 30 to 40 minutes.

Data analysis

After each interview, the researcher wrote an interview diary in time to reflect on the interview process and transcribed the interview content into words within 24 hours, then the researcher made a return visit by phone the next day to confirm that the information is correct. The seven-step method of Colaizzi’s phenomenological analysis method ( Table I ) was adopted to analyse the collected data(Colaizzi, 1978 ). Two researchers collated the original data, independently coded, summarized this information as themes, and organized a research group meeting once a week to discuss and reach a consensus.

7 steps of Colaizzi’s phenomenological analysis method.

Ethical considerations

This study was approved by the Ethics Committee of the Shanghai Pulmonary Hospital, Affiliated to Tongji University, project number: K16-252. Before the interview, the researcher explained the purpose and significance of the study to each interviewee in detail and obtained the informed consent of them on a voluntary basis and all of the interviewees signed informed consent forms. To protect the privacy of each interviewee, their names are replaced by numbers (e.g., N1, N2), and the original materials and transcribed text materials involved are kept by the first author himself, and all materials are destroyed after the completion of the study.

There was no new point of view when the 13th nurse was interviewed, and there was still no new point of view when one more nurse was interviewed, the interview was over, 14 nurses were interviewed. Three themes and seven subthemes were extracted. The characteristics of the participants ( N = 14) are provided in Table II .

Participant characteristics (N = 14).

Nurses’ own factors

Differences in knowledge structure and thinking.

Differences in the structure of prior knowledge and way of thinking will affect nurses’ processing of clinical data, thus affecting their clinical decision-making. The nurses made a wrong judgement of the condition because of the solidified thinking that postoperative nausea and vomiting symptoms were side effects of narcotic drugs and the lack of overall control and understanding of the patient’s condition.

There was a patient who came back after surgery with nausea and vomiting, the first thing that went through my mind, is the drug side effects, so I didn’t pay much attention, as is often the case, the most common cause of postoperative nausea and vomiting is anesthetic drug side effects, but later found to be cerebral infarction, this kind of situation I find it hard to recognize.

Differences in professional values

Professional values of nurses are accepted codes of conduct internalized by nursing professionals through training and learning (Pan, 2016 ). Negative professional values are easy to lead to problem solving dilemma. Some nurses think nursing is just a service.

The work is difficult to do, everything is the nurse’s fault, the nurse must apologize and put up with the patient’s scolding, nursing is a service industry, sometimes I am really wronged.” There are also nurses who believe that nursing work can reflect their personal value, and solving problems successfully will bring them a sense of achievement.

Although the nursing work is very intense, I live a full life every day. I feel a sense of accomplishment and pride that I can solve the problems of patients and discharge them smoothly through my work.

Poor strain capacity

Nursing work is patient-centred holistic nursing, the current clinical situation is complex and changeable, requiring nurses must have good strain capacity, and can “be anxious about what the patient needs, think what the patient thinks, and solve the patient’s difficulties.”

All patients are self-centered, and they don’t care whether you (the nurse) are busy or not. For example, once I gave oral medicine to a patient, a patient in the same ward was in a hurry and asked me to help him call his son. I was busy handing out the medicine and did not help. As a result, the patient was very dissatisfied and complained to the head nurse.

The 20-bed patient went through the discharge formalities but was still lying in the hospital bed. when the new patient arrived and she didn’t leave, I went to urge her to leave the hospital, she suddenly got angry and scolded me, I don’t know what to do.

Improper nursing management

Low sense of organizational support.

Organizational support is an important resource for clinical nurses in the process of problem solving (Poghosyan et al., 2020 ). Low sense of organizational support will hinder nurses’ problem solving.

The style of leadership and the atmosphere of the department are very important. in a department I rotated before, the leader was too strict to listen to your explanation, and the atmosphere of the department was not good. I couldn’t find help when I encountered problems. When I have a conflict with a patient, the leader will only criticize me, which makes me feel helpless.

Sometimes there will be a conflict with patients due to the bed turnover problem, and the patient will not listen to your explanation and turn around to complain, the nurse will be responsible for such things. In severe cases, even violent incidents will be encountered and the personal safety can not be guaranteed.

Insufficient allocation of manpower

Although the total number of nurses has increased substantially, there is still a shortage of human resources under the rapidly increasing workload (Guo et al., 2021 ).

When I was on the night shift and I encountered the critical moment of rescuing patients, I had to call an anesthesiologist, a doctor on duty, a nurse on duty simultaneously, an observation of the patient’s condition to prevent accidents was needed, I also have to race against time to give the patient ECG monitoring and oxygen inhalation. When the doctor came, he also criticized me that the first-aid equipment was not in place (crying).

According to the normal nurse-patient ratio, each nurse takes care of eight patients, and now there are not only eight patients, but also with extra beds and a fast turnover, and sometimes a nurse is responsible for more than 12 patients

Patient factors

The concept of emphasizing medicine and neglecting to nurse.

There is a deviation in society’s cognition of the profession of nurses, which believes that nurses are the “legs” of doctors, and nurses’ work is to help doctors run errands, give injections and give fluids. This concept not only leads to nurses’ lack of due respect, but also hinders nurses’ professional identity, and has a great negative impact on nurses’ problem-solving (Gao et al., 2015 ).

The patient did not dare to tell the doctor something he was not satisfied with, but complained directly to the nurse. For example, if the patient did not want to do some tests, he would scold the nurse. The nurse explained to him that he would not listen. But when the doctor came, he smiled and refused to admit that he cursed nurses, and he would frame the nurse. 90% of the patients would be willing to listen to the doctor.

Sometimes the patient says he was not feeling well, and I know the patient’s condition. I will give her some reasonable explanations, but the patient does not accept it. She is satisfied only when the doctor come to see her. In the final analysis, the patient just don’t believe us. No matter how much I explain to her, it is not as effective as the doctor’s glance at her.

Individual differences of patients

There are differences in patients’ personality characteristics, cultural background, views on nurses and state of an illness, these individual differences are also the reasons for nurses’ problem-solving dilemma (Chan et al., 2018 ).

Some cancer patients are in a period of anger, and it is very difficult to communicate with him. When I see him angry and lose his temper, I will not talk to him and just leave.”

Patients have different cultural levels and different social backgrounds. Sometimes I can’t talk too deeply. If patients are a little more educated, it will be easier for us to communicate with them, and some patients can’t understand anything we say.”

Multiple factors affecting clinical nurses’ problem-solving dilemma

The reasons for nurses’ failure in problem solving are mainly in the process of understanding the problem, the search process driven by the psychological information structure, and the problem or loss of balance in the process of implementing the plan. In the process, the three factors of nurses, management and patients all played an important role. Nurses’ knowledge structure and thinking loopholes led to the deviation of nurses’ internal representation of the problem (Jonassen, 2005 ). Poor professional values and low sense of organizational support can lead to nurses’ negative orientation and attitude towards problems (Poghosyan et al., 2020 ; X. Wang et al., 2018 ). The manpower allocation of nurses, patients’ emphasis on medical treatment over nursing care, and individual differences mainly increase the complexity and difficulty of nurses’ problem-solving task environment as external factors. The three factors work together on the problem-solving of clinical nurses, which leads to the dilemma of problem-solving.

Implementing situational simulation training to improve the comprehensive quality of nurses

At present, the overall quality and ability of nurses cannot meet the requirements of systematic, effective and rapid problem-solving. It is necessary to strengthen the construction of nurses to improve nurses’ problem-solving ability. Some studies have shown that situational simulation class can improve students’ knowledge, experience, psychological quality and other abilities (Mohammad, 2020 ). It is suggested that nursing educators should explore targeted situational simulation teaching and strengthen the relationship between classroom teaching and clinical practice through situational simulation, and to build a novel, perfect and clinical knowledge network for nurses. Secondly, emergency situational simulation teaching should be carried out to enable nurses to experience emergency situations from different angles, so as to improve their thinking, skills and timeliness in dealing with emergencies (Zhang et al., 2019 ). The content of professional values training should also be added to the situational simulation class in order to cultivate nurses’ positive, accessible and stable professional values and promote their positive orientation and attitude when facing problems (Skeriene, 2019 ).

Optimize nursing management and improve nurses’ working experience

Through interviews, it is found that nursing management factors have caused nurses’ problem-solving dilemma to a certain extent, which needs to be optimized according to the specific problems existing in nursing management to help nurses deal with the problems and solve the dilemma effectively. The total number of registered nurses in China exceeded 4.7 million in 2021, an increase of 1.46 million from 3.24 million in 2015, an increase of 45% (Deng et al., 2019 ]. However, there is still a large workload and underallocation of manpower, which may be due to the unreasonable distribution of human resources between time periods and departments. Hospitals and nursing managers can use the hospital information system to evaluate the nursing workload, and allocate nursing human resources reasonably according to the evaluation results (H. Yang et al., 2019 ), so as to avoid nurses falling into the dilemma of problem solving due to long-term overloaded work. In addition, it is necessary to create a harmonious departmental atmosphere for nurses, create a supportive departmental environment (Aghaei et al., 2020 ), and strictly ensure the safety of nurses’ practice and put an end to the occurrence of violence. Timely and strong organizational support can reduce the painful feelings of nurses caused by adverse events (Stone, 2020 ). and help them to solve problems actively.

Using new media to improve the image and credibility of nurses

There is a bias in social cognition of the profession of nurses, and some negative media reports mislead patients, resulting in social stereotypes of nurses (L. Q. Wang et al., 2021 ). It is necessary to make full use of new media to objectively introduce the nursing profession to the public, publicize outstanding nursing figures and typical deeds, make the public realize the important role of nurses in health care, and create an atmosphere of understanding and supporting nurses in the whole society to enhance the image and credibility of nurses and help nurses deal with problems and solve difficulties effectively (Falkenstrom, 2017 ).

Limitations and strengths of the study

The limitation is that the transferability of this study’s results may be limited as a result of including a small number of participants and the participants all worked in the same hospital in Shanghai. More participants in different cities and hospitals could have increased the variety of the descriptions and experiences. The strength is that the use of purposive sampling facilitated inclusion of participants from a range of demographic groups. The use of maximum variation strategy facilitated that the participants covered different gender, education level, professional title, marital status, seniority and department, which helped to increase the representativeness of sample.

Implications for practice

This study provides an in-depth exploration of the problem solving dilemmas of clinical nurses in China and provides valuable insights into the continuing education of nurses. These insights shine a light on areas that warrant further investigation and need to be improved in continuing education of nurses. It is of great significance to improve nurses’ problem-solving ability, improve nurses’ professional quality, effectively solve patients’ medical treatment and health problems, and improve patients’ experience of seeking medical treatment.

Through the semi-structured interview, it is found that the problem-solving dilemma of clinical nurses is affected by many factors. Nurses themselves should be confident, self-improvement, constantly learning and enterprising to improve their own ability, and be good at using new media to improve nurses’ image and credibility. Hospitals, nursing administrators and nursing educators should take corresponding measures to improve the knowledge structure of nurses, cultivate nurses’ positive professional values and adaptability, and give full organizational support to nurses. optimize the allocation of nursing human resources to provide a strong guarantee for nurses to deal with problems solving dilemma.

Biographies

Yu Mei Li : associate chief nurse, master degree, master supervisor, engaged in nursing of tumor patients.

Yifan Luo : nurse, master degree, engaged in clinical nursing.

Funding Statement

This work was supported by the Graduate Education Research and Reform Education Management program of Tongji University [2021YXGL09].

Disclosure statement

No potential conflict of interest was reported by the author(s).

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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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Community Nursing: Roles and Impact

Heart disease, diabetes, cancer, and strokes are among the leading causes of death in the United States, according to the Centers for Disease Control and Prevention (CDC). However, in many cases, early medical intervention can prevent these conditions from becoming fatal or even developing in the first place.

However, not everyone has easy access to medical care, and those who do have access don’t always receive the ongoing support they need to make informed decisions about their health. These barriers do not just affect individuals — communities may face inequitable care and access fueled by prejudice, socioeconomic inequality, and the social determinants of health (SDOH).

The field of community nursing tackles these issues on medical and social levels. A career in this socially conscious sector of health care often requires the right education and skills , but there are many rewarding community nursing roles for nurses who want to use their talents to uplift entire populations.

What Is Community Nursing? Common Duties and Job Requirements

Also referred to as community health nursing, community nursing focuses on the health needs of entire communities and populations. The professionals who work in this specialty are often referred to as community health nurses .

Typical responsibilities of community health nurses include:

• Assessing the health needs of the populations they serve
• Teaching community health education classes with a focus on disease prevention
• Identifying, screening for, and providing care for health problems their communities commonly face
• Advocating for legal and policy reforms that benefit their communities
• Acting as liaisons between the people they serve and health care providers, especially when there are language or cultural barriers
• Coordinating with other leaders in their communities to create and run health programs

Instead of carrying out these duties in hospitals and other traditional health care settings, community health nurses often work in schools, pharmacies, workplaces, and community clinics. Members of a community can often seek help from a community health nurse at little to no cost.

Basic Requirements for Becoming a Community Health Nurse

Community health nurses are usually registered nurses (RNs). Becoming an RN involves earning an associate degree in nursing or a Bachelor of Science in Nursing (BSN), passing the NCLEX-RN exam, and earning a state-issued nursing license. However, some entry-level roles may be open to licensed professional nurses (LPNs) and licensed vocational nurses (LVNs).

Because working within a community can require creative problem-solving, research, education, and clinical skills, community health nurses often gain experience in traditional health care settings before getting into the field. Later in their careers, many community health nurses earn professional certifications and advanced degrees such as a Master of Science in Nursing (MSN). These advanced training opportunities can prepare nurses to work with high-needs populations and fill high-level administrative positions.

Community Nursing Roles: Duties, Salaries, and Other Career Information

While many professionals work under the title of community health nurse, there are many other career opportunities for nurses interested in this specialty. Each community nursing role comes with its own unique responsibilities and career opportunities. Some require extra training and education beyond a BSN and RN licensure.

Public Health Nurse

Public health nurses typically work for local, state, and federal government agencies such as public health departments or the Centers for Disease Control and Prevention (CDC). Their duties often align with more general community health nurse duties, but in many cases, their efforts are heavily focused on disease prevention and health education.

A public health nurse’s duties typically include:

• Analyzing public health data to identify issues such as increased mortality, hospitalization, or overdose rates
• Providing immunizations, primary care treatment, and other disease prevention services
• Educating people about health resources in their communities
• Teaching health classes through local partners such as hospitals, community clinics, and schools
• Helping public health officials monitor environmental risk factors such as pollution

Because public health nurses often work for government agencies, they typically perform these duties for people located in an agency’s jurisdiction, such as a city or county. However, they’re also instrumental in providing health care services to houseless communities and individuals, older adults, and other underserved groups.

Education, Training, and Salary Potential

To become public health nurses, many experienced RNs earn certifications from professional organizations such as the National Board of Public Health Examiners (NBPHE) and the American Nurses Credentialing Center (ANCC), part of the American Nurses Association (ANA), both of which offer training programs specifically for public health nurses. To prepare for high-level administrative positions, professionals also pursue degrees like an MSN with a specialty in public health.

The median salary for public health nurses was about $73,040 as of August 2024 according to Payscale. The highest-paid professionals can make more than $112,000.

Occupational Health Nurse

Occupational health nurses focus on the health care needs of workers. While they can work directly for private corporations in every industry, occupational health nurses also work for health and safety consulting services that serve multiple companies.

Occupational health nurses’ responsibilities include:

• Tending to workers who have been injured on the job
• Responding to health-related emergencies before emergency service personnel arrive
• Educating workers about common chronic health issues in their industry and providing guidance on preventive care
• Referring workers to specialists
• Helping employers identify common health and safety hazards and devising strategies to minimize risks
• Teaching health and safety courses as well as emphasizing the importance of safety protocols
• Running on-site health clinics for workers and their families

Occupational health nurses’ specific duties vary depending on their industries. For example, those who serve manufacturing companies might educate employees about environmental hazards such as fine particles and chemicals. Those in office-oriented industries might screen employees for issues associated with sedentary lifestyles, such as heart disease.

Because occupational health nursing is often a private-sector community nursing role, there are multiple paths to becoming one. However, most positions require RN licensure and some nursing experience. Some nurses gain experience in acute care settings where they deal with injuries that might be common in some industries. Skills learned in other clinical settings can be equally valuable.

Additionally, occupational health nurses may need to be familiar with Occupational Safety and Health Administration (OSHA) and workers’ compensation policies. Some employers offer on-the-job training in these subjects. Occupational health nurses can hone their skills and seek more advanced, potentially higher-paying, positions by earning certifications through organizations such as the American Board for Occupational Health Nurses.

Occupational health nurses made a median salary of about $80,470 per year as of April 2024 according to Payscale. The most experienced nurses made around $101,000. However, it’s important to remember that an occupational health nurse’s salary can vary widely based on their industry.

School Nurse

In addition to caring for sick or injured students, school nurses can help students manage their daily medications and cope with chronic illnesses. They can also serve their communities in a number of other meaningful ways.

School nurses’ responsibilities typically include:

• Designing and overseeing student health education and safety campaigns
• Running immunization programs
• Assisting visiting specialists while screening students for physical and developmental issues
• Connecting parents to health care and education resources, especially in schools in underserved communities
• Assisting with and reporting cases of suspected abuse and neglect
• Educating teachers about meeting their students’ health and psychosocial needs

Because school nurses work closely with teachers, children, parents, and others who may not have much medical knowledge, the ability to communicate clearly with diverse groups is a key skill.

School nurses can be LPNs, LVNs, or RNs, though the level of licensure a school nurse needs is determined by state regulations. Depending on the state where they work, nurses may also have to seek approval from a local government agency to work in schools.

Future school nurses often gain initial experience by working in pediatrics. Many seek certification and further training through the National Board for Certification of School Nurses (NBCSN). School nurses made a median yearly salary of about $51,530 as of July 2023, Payscale reports, with the highest earning making about $72,000.

Health Education Specialist

Health education specialists teach communities about health-related topics. This can include informing the general public about current health issues, patients about managing chronic illnesses, and community health professionals about helping the people they serve. Hospitals, nonprofits, and government health agencies often employ health education specialists to teach community-oriented classes and educate individual patients.

Education specialists’ responsibilities can also include:

• Helping public officials identify a community’s health needs
• Designing and evaluating education programs
• Connecting underserved communities to health care resources
• Advocating for improved public health policies
• Helping run health screening programs

Though health education specialists aren’t always nurses, their medical knowledge and patient care skills can make them great candidates for health education roles.

Health education specialists typically need at least a bachelor’s degree. Nurses who want to pivot into this community nursing role often earn BSNs and work as RNs in patient care positions that require some amount of patient education. Some pursue health education certifications from organizations such as the National Commission for Health Education Credentialing (NCHEC) or pursue MSNs through programs that offer health education concentrations.

According to the U.S. Bureau of Labor Statistics (BLS), health education specialists made a median yearly salary of about $62,860 as of May 2023. The highest-paid 10% of professionals made more than $107,920.

Psychiatric-Mental Health Nurse

Psychiatric and mental health RNs assess patients, monitor their progress, and help their colleagues develop and carry out long-term treatment plans. Advanced practice registered nurses (APRNs) who specialize in psychiatric care can even prescribe medications and provide therapy. They can work in in-patient and out-patient settings and for community mental health centers.

Psychiatric nurses can also perform community-oriented duties such as:

• Facilitating support groups for patients and their loved ones
• Teaching classes about mental health and self-care at schools, workplaces, and in the community
• Teaching managers, teachers, and other professionals how to identify and help with mental health issues
• Helping health care professionals integrate physical and mental health care programs
• Working with government, law enforcement, and social service agencies to develop policies and programs to handle mental health crises

According to the U.S. Health Resources and Services Administration (HRSA), 122 million Americans live in mental health professional shortage areas. RNs and APRNs who provide direct and community-focused mental health services are instrumental in building up the country’s mental health workforce and helping people find accessible support.

Nurses can become psychiatric nurses by becoming RNs and finding employment in a mental health facility. To take on more advanced psychiatric community nursing roles, RNs often earn MSNs through programs that offer psychiatric nursing concentrations. After graduation, students typically have to pass a state APRN licensing exam. Many pursue the Psychiatric-Mental Health Nursing Certification (PMH-BC) through the ANCC.

As of August 2024, Payscale reports that RNs in the psychiatric specialty made a median yearly salary of about $75,580. The top 10% of earners made over $104,000.

Community Health Administrator or Coordinator

Organizations that offer community health services often need dedicated administrators to run them. These professionals can work for any number of private, nonprofit, and government health organizations.

While specific duties are often determined by the type of organization an administrator works for, common duties include:

• Overseeing personnel
• Managing budgets
• Forming partnerships with other organizations
• Researching gaps in community care
• Implementing evidence-based education and community health care programs
• Coordinating between multidisciplinary teams including doctors, counselors, and human services specialists
• Seeking funding from government grants and private donors
• Handling public relations matters such as speaking to the press and writing press releases

Some community health administrators are in charge of just a few of these duties. For example, one administrator might be in charge of financial matters, while another is in charge of clinical services such as ensuring staff follow evidence-based nursing processes . This may include creating training and staff assessment programs as well as helping local nursing schools coordinate practicum placements.

Like other nursing administrator positions, community nursing administrative positions often require an MSN and years of experience as a nurse. While many MSN programs offer leadership and administration concentrations, future community administrators may want to take courses in public health, nursing education, and informatics.

While not focused specifically on community nursing, the ANCC offers a Nurse Executive Certification credential. Administrators in multiple nursing specialties often earn this certification before pursuing high-level administration roles.

Nursing administrators made a median annual salary of about $96,540 as of May 2024 according to Payscale, with the highest earners making up to $144,000. However, these figures include all nursing administrators, not just those who oversee community services.

Job Outlook for Community Nursing Roles and Related Career Paths

The BLS predicts that employment in the community health sector will grow by 14% between 2022 and 2032. This is equivalent to about 8,000 job openings per year. While not all of these jobs are nursing positions, this growth indicates that community health could be an excellent sector for health care professionals of all kinds to consider.

While the BLS doesn’t provide job outlook data specifically for community nursing roles, it does track many related positions. Between 2023 and 2033, the BLS expects employment for:

• Licensed practical and licensed vocational nurses to grow by 3%
• Registered nurses to grow by 6%
• Health education specialists to grow by 7%
• Medical and health services managers to grow by 28%

For context, the BLS expects employment in all sectors of the economy to grow by an average of 4% between 2023 to 2033.

Become an Advocate for Healthier Communities

Along with being direct care experts, community nurses in all specialties often take a holistic approach to their field. In addition to meeting their patients’ immediate medical needs, they must figure out how to support them in the long term through education, compassion, and advocacy. The University of Tulsa’s online RN to Bachelor of Science in Nursing (RN to BSN) program is designed to help RNs develop those skills and apply them in communities of all kinds.

Built on the Roy Adaptation model , TU’s curriculum emphasizes collaboration and adaptability — two skills needed to enact impactful, long-lasting change. With classes on nutrition, applied research, and population health, students learn how to implement evidence-based interventions for community-wide issues. Learning these skills can help nurses become informed members of any community-based health care team and lay the foundation for future leadership roles.

To find out if TU’s flexible RN to BSN program is right for you, reach out to a member of our admissions counseling staff today.

Recommended Readings

How Global Health Nursing Supports Population Health

Strategies for Interdisciplinary Team Nursing

What Is an Occupational Health Nurse?

American Nurses Credentialing Center, Nurse Executive Certification (NE-BC®)

American Nurses Credentialing Center, Psychiatric-Mental Health Nursing Certification (PMH-BC™)

Centers for Disease Control and Prevention, Leading Causes of Death

Health Resources and Services Administration, Health Workforce Shortage Areas

National Association of State Boards of Education State Policy Database, School Nurse Qualifications

National Board for Certification of School Nurses, Certification

National Commission for Health Education Credentialing, Certification Exams

Payscale, Average Nurse Administrator Salary

Payscale, Average Occupational Health Nurse Hourly Pay

Payscale, Average Psychiatric Nurse (RN) Hourly Pay

Payscale, Average Public Health Nurse Hourly Pay

Payscale, Average School Nurse Salary

U.S. Bureau of Labor Statistics, Community Health Workers

U.S. Bureau of Labor Statistics, Health Education Specialists

U.S. Bureau of Labor Statistics, Licensed Practical and Licensed Vocational Nurses

U.S. Bureau of Labor Statistics, Medical and Health Service Managers

U.S. Bureau of Labor Statistics, Registered Nurses

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