The present study explore the future challenges of nursing from the perspective of experts. The future changes of Iranian nursing from the perspective of experts were classified into three areas including the challenge of centralized governance, the incompatibility of professional development with social demands, and the challenge of human resource management.
The first category was nursing governance. Governance capacity requires institutions, mechanisms, and policies and procedures to properly design and implement nursing and health policies (WHO, 2020). The participants stated that the position of nursing policy is incoherent and turbulent. Therefore, strengthening nursing governance in Iran is necessary. Strengthening the leadership and management capacity of nursing in the Middle East is an undeniable necessity. Hence, the World Health Organization has considered the creation and strengthening of a department or directorate in the Ministry of Health of these countries as a necessary task (WHO, 2016b). According to the organization, 53% of the 76 countries in 2020 had national programs to develop nursing leadership (WHO, 2020). A successful example of strengthening nursing leadership is the University of Technology Sydney, which was attended by more than 300 participants from 14 countries and 85% of managers in the leadership model had major career advancement (Homer, Copeland, & Rumsey, 2012). Therefore, the Ministry of Health should pay more attention to train the country's senior nursing managers.
Nursing policy and legislation are challenged in terms of the adoption of supportive laws, as well as the participation of nursing leaders, in the macro policies of the health system (Cheraghi, Ghiyasvandian, Aarabi, 2015). Two of the nursing supporting laws by the Islamic Consultative Assembly include the approval of the Nursing Services Tariff in 2007 and the participation of nurses in the "Comprehensive and Public Health Services System" in the Sixth Development Plan, neither of which has been implemented so far. The adoption of WHA54.12 in 2000 by the World Health Organization on the development of health systems by involving nurses and midwives in the framing, planning, and implementation of health policies at all levels indicates the international community's attention to the role of nurses(Fyffe, 2009). However, the All-Party Parliamentary Group on Global Health in 2016 notes that nursing leaders have not been sufficiently involved in decision-making and policy-making processes at the local, national, and international levels(APPG, 2016). Therefore, the nursing leaders in Iran should be further supported by the country's health authorities.
Nursing governance should closely monitor and evaluate various nursing activities. Nursing education activities in Iran are supervised by the Nursing Board (Cheraghi, Ghiyasvandian, Aarabi, 2015); however, monitoring and evaluation of clinical nursing services are done by the deputy of curative affairs. Therefore, it seems that despite measures such as issuing licenses for nurses' professional qualifications, the need for developing the supervisory role of the Deputy of Nursing over clinical services remains a serious challenge.
The last subcategory was cooperation and communication with other institutions of the health system. The inter-professional cooperation with other institutions and deputies of the Ministry of Health is one of the essential concerns for the development of nursing services. Nursing can be expanded into national and international programs such as primary health care, universal health coverage, and the development of home care by promoting this role. However, the inter-professional cooperation faces organizational, professional, and cultural challenges (Dahl & Crawford, 2018). Therefore, steps can be taken to expand national and international health systems programs by strengthening this role of nursing.
The next influential dimension for the future was the inadequacy of professional development with social demands. Demographic transition, its associated disability, long-term condition, and individuals at end of life increase the need for community-based nursing (Shahshahani, Salehi, Rastegari, & Rezayi, 2010). Futurists predict the expansion of diverse nursing specialties to control future changes (Grossman & Valiga, 2020). Two examples of Iran's efforts to expand community-based nursing include postgraduate community nurse education since 1986(Heydari, Rahnavard, & Ghaffari, 2017) and the establishment of chronic disease clinics in 2015(Deputy of nursing, 2016). However, nursing services in Iran have been, so far, provided mainly in the third level and hospitals, and the activities of Iranian nurses have not met the needs of society. One of the most important reasons for this failure has been the lack of a suitable position for community health nurses in the country's health centers.
Another challenge is home care. In many European countries, long term care services tend to take care of the home (WHO, 2012). Home care in the future should be more patient-centered, more integrated, with quality technology and specialized services (Van Eenoo et al., 2018). In 2016, the Deputy of Nursing announced the regulations for establishing a counseling center and providing nursing care at home (Deputy of nursing, 2016). Home care faces three cultural, infrastructural, and treatment-oriented challenges of the health system of Iran (Heydari, Rahnavard, & Ghaffari, 2017). Despite the improvements in the home care program, it seems that there is no coherent plan for the future of home care. Home care should be able to reduce referrals to hospitals.
Another serious challenge of the health system of Iran is not having intermediate centers. These care centers provide transitional services as a link between home care and hospital care. The most important intermediate centers include hospice, nursing homes, LTCFs, consult clinics. European countries have increased the number of care homes in the last ten years (Eurofound, 2017). However, home care centers in the health system of Iran is not very widespread. The Ministry of Health has also emphasized the need to establish these centers. The need for such centers in Iran is serious due to the increase in the elderly population and the Disability to care for these people and the lack of need for acute hospital care.
In the present study, experts emphasized the importance of using communication technologies such as health information technology, telemedicine, and mobile applications and the need for electronic nursing reporting. According to Wright and Honey’s study, clinicians considered the use of telerehabilitation and teleconsultations technology to be effective in increasing their efficiency (Jane Wright & Michelle Honey, 2016). McCarth et al. also stated that electronic nursing documentation is effective in reducing rates of documentation errors, falls and infections, and saving time (McCarthy et al., 2019).
The third dimension of the future of nursing was the challenge of human resource management. The first subcategory was nursing education tailored to the needs of the community. According to experts, nursing education in the Iran should be adjusted according to the needs of society. In 2019, Schwartz outlined five general trends influencing the future of nursing education, including the elderly population and the burden of disease, the increasing prevalence of mental disorders, the complexity of patient care, and the need for inter-professional teaming, internationalization, and technological growth (Schwartz, 2019). Therefore, nursing education in Iran should be modified based on these changes due to the serious changes and the burden of diseases in Iran.
The empowerment of nursing managers was another subcategory. According to experts, there are 14,000 nursing managers in Iran, but the ability of nursing managers in Iran, like other countries in the world, is a serious challenge. Despite their managerial responsibilities, nursing managers are selected as managers mainly based on clinical experience and expertise (Roche, Duffield, Dimitrelis, & Frew, 2015). On the other hand, nursing managers should spend 70% of their time on clinical tasks and less time on administrative tasks based on the Garling Inquiry (Garling, 2008). It seems that strategies such as improving training, support, and succession planning are effective in empowering nursing managers in Iran.
The next subcategory is the recruitment and retention of nurses. The World Health Organization has identified the shortage of nurses as the most important challenge in human resource management (ICN, 2006). Recruitment and retention of nurses in Iran face challenges, such as shortage of nurses, nursing development and improvement programs, job satisfaction, exhaustion, and burnout as well as factors affecting nurse retention(Zamanzadeh, V., Valizadeh, L., & Neshat, H., 2020). This challenge will be greater than other countries in the world due to the high estimation of the elderly population by 2030, as well as the current shortage of nurses and economic challenges and lack of expansion of nursing services in the community.
The specialized nursing was another topic of concern for experts on the desirable future of nursing. There are different approaches to develop these roles in different countries. However, the development of nurse roles faces cognitive, structural, organizational, and cultural barriers. In different countries, clinicians primarily worked in acute care settings, such as inpatient wards, intensive care units, and hospital-affiliated clinics (Bryant-Lukosius, 2010). Recently, the use of clinical nurses has expanded to outpatient care, long-term care, home care, and a variety of clinical specialties including oncology, cardiology, intensive care, gerontology, and mental health (Kilpatrick, et al., 2013). Recently, the Deputy of Nursing developed a roadmap for specialized nursing roles in Iran in collaboration with Isfahan University of Medical Sciences. Therefore, it seems that with the development of nursing in the community, and the creation of outpatient services, long-term care centers, as well as home care, and the need for specialized nurses will increase.