The Role of Nursing Consultant in Iran: A Qualitative Study.

BACKGROUND: Nursing consultation is one of the important roles of nurses and is very effective in improving care results. But this role is unknown in Iran and there are no respective organizational positions. The purpose of this study is to examine the factors affecting the position of this role.
MATERIALS AND METHODS: This study, as a qualitative research was conducted from April to December 2017 using content analysis approach. We performed semi-structured in-depth interviews with 23 participants who were selected using purposeful sampling and were asked to describe the factors affecting the organizational position of nurse consultant.
RESULTS: The mean (standard deviation) age of the participants was 44.5 years (10.68). 279 meaning units, 39 codes, 6 subcategories and two categories were obtained in this essay. The two main categories include necessity for nursing consultation role with two subcategories (nursing consultation role as one of the main roles in nursing, and the need for nursing consultation in healthcare system in Iran), and the obstacles of nursing consultation role with four subcategories (healthcare system problems, problems associated with physicians, problems associated with nurses and problems associated with patients' culture).
CONCLUSIONS: Considering the importance of nursing consultation role in improving the health of the patients, the policymakers should take into account the consultant role of nurses and they should understand the importance of and the need for this role. As such, we hope that managers and policymakers create a role position by removing the obstacles and considering the necessity of this role.

Introduction

The increased number of patients suffering from chronic diseases has increased the financial, social, and psychological burden of patients, families, and the healthcare system.[12] On the other hand, patients with chronic diseases play an important role in managing their health.[3] Moreover, given the completely different understanding of the patients of their disease and its management, appropriate education and consultation should be provided for each individual separately.[4] Nurses have to provide nursing consultation to encourage individuals in doing self-care, which in turn can increase their self-esteem and accountability.[5]

Nursing consultation role is one of the most important and professional roles of nurses[6] that was first established in England in 2000.[78] It is essential to consider nursing consultation role as a valuable resource and asset in the formation of future care models.[9] In spite of global trends for creating and improving advanced roles of nursing,[101112] there is no specialized nursing roles such as nurse specialists, nurse practitioners, or consultant nurse in Iran. Although nursing education role has recently begun in Iran, consultation role is still unknown to many nurses, physicians, graduate students, and even some of faculty members. Currently, some nurses may informally and incompletely provide some consultation services to patients, but there is no definite organizational position for nurse consultants. Gregorowski conducted an action research in the United Kingdom (UK) to develop the role and prepare nurse consultants as well as organizational support in accepting this role.[7] Baldwin also conducted a study to evaluate the role and function of nurse consultants together with their organizational position in Australia.[13] Some of the studies conducted in Iran with regard to the development of nursing roles and organizational position are as follows: Examining the challenges of development of role in nursing. Ahmadian's study argues that there is no certificate of professional competence for a specialist nurse position and only the variety of master's degree branches is rising with specialization approach.[10] Similarly, evaluating masters theses in nursing, Moshtaghi points out that most of the theses are concerned with nurses' caring role and rarely address specialist nursing roles.[14] Irajpour, who is working on a project aimed at developing nursing sciences and nursing specialization, also refers to the importance of different specializations in nursing and is trying to give a true position to specialization in Iran.[15] In a study by Ravanipour, some standards have been mentioned for nursing professionalization which include ethics and human values, resources and structure, social position reform, and educational and organizational structure reforms.[16] As shown by studies in Iran, the specialization position for nursing has been important from the viewpoint of researchers. On the other hand, no study was found evaluating the position of nurse consultant. Additionally, researchers that examined the effect of nursing consultation on various diseases are not familiar with nursing consultation role and use group education and psychosocial counseling or support instead of nursing consultation.[1718]

Given that nursing consultation role is very effective in improving care results and reducing costs and, as this role has no organizational position in Iran, the researcher decided to examine the factors affecting the position of this role in Iran's healthcare system.

Materials and Methods

This study is a qualitative research that uses conventional content analysis approach and its data have been obtained from interviews. This article is part of doctoral dissertation in which 23 participants (including seven faculty members, three physicians, four nursing managers, four postgraduate students and five nurses) were interviewed in Isfahan. Using purposeful sampling method, the participants were selected with the maximum variation in terms of age, gender, and work experience. The participants were those who were partly familiar with nursing consultation role and interviews continued until saturation was reached. The inclusion criteria are having experience or study about the subject matter (nursing consultation role), willingness to participate in the study, enough time to conduct an interview, and at least 2 years of work experience. The exclusion criteria include reluctance to continue cooperation in the study. In-depth, semi-structured face-to-face interviews were conducted with participants in the study from April to December 2017. The purpose of the study was explained and the duration of the interview was 40 to 55 minutes. The participants were asked to express their opinions on the position of nurse consultant in Iran, and some of the questions were: “How can nurse consultant position be defined in Iran?”, “How can nursing consultation services be provided in Iran?”, “Is any organizational position needed for nursing consultation?”, and “What are the problems in this way?” In general, they were asked to express their ideas and suggestions in this regard.

A code was assigned to each participant for the interview and after completing the interview, the recorded tape was carefully listened to by the researcher. Then, each interview was transcribed into text. OneNote software was used for coding, organizing codes, and analyzing qualitative data; data analysis was also performed using the content analysis method of Elo and Kyngas.[19] As such, semantic units containing words, sentences, or paragraphs were selected in the text. These semantic units were extracted based on the similarity to each other as a code; then, the similar codes were put in a subcategory. Finally, subcategories were put in a category with regard to the greatest differences and based on the highest similarity they had with each other, and categories were obtained.

Trustworthiness of data (including credibility, dependability, confirmability, and transferability) were examined using Lincoln and Guba's views (2007).[20] In-depth interviews were conducted with different people. The location of the interview was also selected according to the preference of the participants that made them talk more comfortably and provide more accurate interviews. The evaluation was performed by the members and four interviews were performed by the participants (including three faculty members and two graduate students) and codes, subcategories, and categories were reviewed and commented on. The peer review was also performed by colleagues and codes, subcategories, and categories were examined by the supervisor and one of the colleagues to evaluate the credibility of the results. To examine the data dependability, every detail of the research was expressed and recorded. For confirmability, the opinion of other colleagues and faculty members, who were familiar with the methods of analyzing qualitative research and were not involved in the research, were asked. For transferability, the study results were presented to other nursing managers, faculty members, and postgraduate students and their opinions about the result of the study were obtained.

Ethical considerations

This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (393305). In order to conduct the study, the researcher explained the objectives of the research and informed consent was obtained. The time and place of the interview were also determined according to the participants' preference.

Results

The mean (SD) age of participants was 44.50 (10.68) years. Demographic data is given in Table 1. According to the conducted interviews and after content analysis, three categories were considered, including prerequisites of nursing consultation role, necessity of nursing consultation role, and obstacles of nursing consultation role. In this essay, 279 meaning units, 39 codes, six subcategories, and two categories were revealed. Two categories, including necessity of nursing consultation role and obstacles of nursing consultation role, were addressed. The subcategories of the main categories are listed in Table 2.

Table 1

Demographic data of the participants in this study

Profession	Age	Gender	Specialty	Work experience
Faculty member (Ph.D.)	53	Female	Medical- surgical nursing	28
Faculty member (Ph.D.)	56	Female	Medical- surgical nursing	26
Faculty member (M.S)	66	Female	Medical- surgical nursing	37
Faculty member (Ph.D.)	55	Male	Medical- surgical nursing	30
Faculty member (Ph.D.)	55	Male	Medical- surgical nursing	29
Faculty member (Ph.D.)	54	Female	Community health nursing	19
Faculty member (Ph.D.)	40	Male	Psychiatric Nursing	12
Physician	50	Female	Cardiovascular	21
Physician	31	Female	Medical	5
Physician	46	Male	Psychiatrist	18
Nursing manager: Head of Nursing Department in health deputy	56	Male	Medical- surgical nursing	28
Nursing manager: Head of nursing professional association	55	Male	Medical- surgical nursing	20
Nursing manager: health education center	52	Male	Medical- surgical nursing	24
Nursing manager: health education center	45	Female	Community health nursing	18
Postgraduate student (Ph.D.	40	Female	Medical- surgical nursing	18
Postgraduate student (M.S)	26	Female	Medical- surgical nursing	2
Postgraduate student (M.S)	33	Female	Community health nursing	11
Postgraduate student (M.S)	31	Female	Geriatric nursing	9
Nurse	48	Female	Head nurse in CCU	22
Nurse	31	Female	Nurse in CCU	4
Nurse	47	Female	Head nurse in Medical ward	12
Nurse	39	Female	Nurse in Medical ward	8
Nurse	43	Female	Nurse in Medical ward	8

Table 2

Categories and subcategories of results of this study

Categories	Subcategories
The necessity of nursing consultation role	Nursing consultation role, one of the main roles in nursing The need of Iran’s Healthcare System for nursing consultation
Obstacles of the nursing consultation role	Healthcare system problems Problems associated with nurses Problems associated with physicians Problems associated with the patient culture

The necessity of nursing consultation role

Nursing consultation role, one of the main roles in nursing

Most literature has emphasized the results of nursing consultation in improving the health of patients with chronic diseases, and has described this role as one of the main and most important roles of nursing.

In this regard, one faculty member pointed to this: “Consultation is one of the eight roles of a nurse i.e., in addition to other roles, such as educational, research and support role, consultation role is also important. Especially in diseases that require long-term follow-up, such as chronic diseases, one of the roles that can suitably help patients to manage themselves is the nursing consultation role” (Faculty Member, 3).

Another faculty member revealed: “One of the main roles of a nurse is the consultation role that has been considered even for nurses with bachelor degrees. This role is very important especially in chronic diseases. It is through this role that the nurse evaluates patients, extracts their problems and, with the help of the patients themselves, can provide a solution through which the patients themselves can solve the problems properly” (Faculty Member, 5).

One of the nursing managers also said: “The problems and challenges of patients with chronic diseases, due to special conditions of the disease, are costly and time consuming for the health system and hospitals. However, since a nurse spends more time than a physician with a patient, she is more effective and one of the main roles of the nurse is the consultation role” (Nursing Manager, 3).

As the participants in this study also said, given the fact that nursing consultation is one of the main roles in nursing and as patients will benefit greatly from the services of this role, it is more reasonable to consider this role appropriately.

The need of Iran's healthcare system for nursing consultation

The patients with chronic diseases have many problems and needs. Currently, the patients' only references are physicians, and they may not have enough time to listen to the patient's problems and provide solutions. Accordingly, the lack of nursing consultation seems to be a serious problem. One nurse said: “The patients need consultation very much; they really need it, and our physicians really cannot afford to provide it; they just diagnose and treat; thus, nurses have to do that” (Nurse, 1).

In the same way, another nurse had this idea: “Wherever there is a patient, the nurse can offer consultation and help him somehow” (Nurse, 3).

Similarly, all three of the specialist doctors who participated in this study referred to this and stated that the need for nurse consultant is felt and can be very helpful for patients. (Physicians 1, 2 and 3).

According to the experiences of the researcher and many participants, patients with chronic diseases need psychological, social, and cultural support, and there are many questions and problems that they have and do not know where to go to find answers; the nurse consultant can play a role here. Thus, this role needs to be considered more.

Obstacles of the nursing consultation role

Healthcare system problems

Unfortunately, as mentioned, our country's healthcare system and health policymakers do not have enough knowledge of nursing and, therefore, no proper position has been considered for its specialized roles including the consultation role. The focus of policy in Iran is on medical system and treatment instead of care. The opinion of one of the nurses was as follows: “Our healthcare system is not health-centered” (Nurse, 5).

One of the faculty members, regarding the inadequate healthcare system performance, revealed this opinion: “Our health system is such that the patient is not seen at all. You do not see him as a key member of the team. In the Ministry everywhere it is said that the patient is very important but, in fact, neither in the healthcare system nor anywhere else is the patient seen. In fact, we do not see this role for the patient as an active role. Only stereotypical instructions such as 'you have to take your medicines' are provided to patients” (Faculty Member, 1).

Another faculty member had also the same idea in this regard andreferred to the inadequate position of nurses in the health system: “no place beyond the hospital has been defined for the nurses; in the hospital, it is only care which has been defined, and it training also has recently been formal. Our managers should think about consultation and it is possible. The system's need is important” (Faculty Member, 2).

A postgraduate student mentioned the health system's problem as follows: “Formality is the healthcare system that needs to be reconstructed” (Postgraduate Student, 4).

“The lack of postgraduates and insurance coverage” has been described as an obstacle by a nursing manager (Nursing Manager, 2).

Therefore, Iran's healthcare system itself has been considered as an obstacle and, thus, policy-makers should be provided with enough information with regard to the importance and position of nursing consultation role.

Problems associated with nurses

Lack of self-confidence and, in some cases, even insufficient knowledge was one of the problems related to nurses. Moreover, they had no motivation and sometimes were reluctant to specialize their work. In this regard, one nurse said: “Nursing job motivations are low and nurses do not believe that consultation is one of their roles” (Nurse, 4).

One of the nursing managers mentioned problems associated with nurses as follows: “There is a lack of self-confidence about our (nurses) abilities in the field of specialized roles, including the role of consultation” (Nursing Manager, 1).

One of the postgraduate students also highlighted the problems of nurses, which would be an obstacle of the role development: “Sometimes, nurses think that this (consultation role) is not very important, and valuable, while others (e.g., you who is working on this issue as a researcher) who look at them from outside, can discover its importance” (Postgraduate Student, 2).

Another student said: “Some of our nurses do know but do not act. They do not talk, or do not involve themselves in consultation or other specialized works; or they may say that for me, with this salary, this is an extra job” (Postgraduate Student, 3).

Problems associated with physicians

Medical patriarchy (physician's dominance) governing the health system can be one of the main obstacles to the development of nursing and the creation of specialized roles including nursing consultation role. But, unfortunately, this issue is defended by the health policy.

A faculty member in this regard said: “There is a problem in the administration related to hospitals. One of the problems is medical patriarchy. At the meetings I attend as a supervisor, I have to explain my role to others and defend it. In meetings, when it is our turn, physicians decide, but when it comes to physicians, the nurses cannot express their opinions” (Faculty Member, 4).

A postgraduate student also explained this obstacle as follows: “Some physicians make the patient dependent on them and do not create self-control. Patient is only the executor of orders” (Postgraduate Student, 1).

Problems associated with the patient culture

In spite of the urgent need of patients with chronic diseases to receive consultation and problem-solving strategies, they may deprive themselves from these services for cultural reasons.

In this regard, a faculty member said: “For nursing consultation role, the health-related culture of people should be high so that they can ask for this role. We have needs and demands. Needs may not lead to consultation. We should make demands” (Faculty Member, 6).

Another faculty member had this opinion in this regard: “I think that the culture of our people can be very influential. We prefer to keep our problem secret. Maybe we do not like, psychologically, to talk about our status and, therefore, do not speak with nurse consultants” (Faculty member, 7).

The participants in this study, however, pointed to obstacles that are important in creating and providing nursing consultation role; the obstacles that should be considered especially by health policymakers.

Discussion

In this study, the obstacles and necessity of nursing consultation role have been addressed for creating a suitable position for this role. Shiu introduced the obstacles and facilitators for the development of advanced nursing roles in Hong Kong as such: community awareness of advanced nursing roles and organizational support.[11] Some studies also highlighted problems related to culture, organizational support, and policies that are consistent with the results of the present study.

With regard to the first category of this study, that is, “necessity of nursing consultation role “and its subcategories, that is, “consultation role, one of the main roles in nursing, and Iran's health system's need for nursing consultation,” there are many points in the literature, suggesting that nursing consultation role is one of the main roles in nursing.[6] Increased need of patients for nursing consultation also seems to give rise to the concept of nursing consultation role, which adds to the independence of patients and motivates people's health-related activities and treatment follow-up.[21] Also, given the need of patients and healthcare system for nursing consultation, it can be said that nursing consultation can prevent complications, reduce mortality, and improve the quality of life in general.[22] This shows that nursing consultation is a need and necessity for the health system of Iran; but, unfortunately, it does not exist in Iran and needs to be considered by policymakers. Moreover, there was no trace of facilitators for the development of nursing roles in international papers, which can be due to the fact that in advanced countries, these issues have been emphasized and paid homage in previous years.

With regard to the second category, that is, “the obstacles of nursing consultation role “and includes “health care system problems, physician problems, nurses' problems and problems associated with patient culture”, similar cases have been mentioned in some literature. In this regard, Stevenson believes that the main challenge on this role is that it is not being accepted by the physician colleagues; feeling free in the new job position, negative organizational culture, and lack of managerial support are mentioned by him as the obstacles to nursing consultation role.[23] Nonacceptance of the role by other colleagues, tendency to routine works and time constraints are among other problems of nurse consultants mentioned by Deschodt.[24] In contrast, in many studies, nurses have received adequate support of the organization, physicians, and nurse colleagues. For example, in Mitchel and Doody's study, some physicians provided appropriate support for the nurse consultants, or even clinical autonomy and independent performance have been reported in the work of nurse consultants, and their positions have been reported to similar to those of physicians (physician as equal partners).[2526] In some studies, nurses have been seen less as an obstacle, and nurse consultants have been satisfied with their job, suggesting that job motivation and satisfaction of nurses in advanced countries is higher than in Iran. The high levels of satisfaction of nurse consultants with their role in other countries has been reported to be due to the independence of the patients and the importance of role for them.[71322] With regard to patients' culture and demand for more services, Stichler argues that patients are aware of their need for help, but resist to make required changes for meeting their goals. The patients may consider a predetermined plan by which they are thoroughly examined and provided with solutions to their problems and, hence, ask the consultant to accept it. Instead of actively participating in choosing a solution, patients often like someone provide them with a list of solutions. In addition, some patients are reluctant to receive care plans, or do not want to accept the truth.[27] Given that Stichler's study belongs to the early years of developing advanced nursing roles, perhaps there has been a lack of demand in patients. This obstacle still exists in the current study. In contrast, Gerish argues that patients have expressed their satisfaction with nursing consultation service.[28] Therefore, the obstacles mentioned in some studies seem to be in line with the results of the present study, while other studies have mentioned fewer obstacles that, to some extent, can be due to cultural differences as well as progress of nursing and health policy in other countries.

One of the limitations of the study was that it was difficult to interview some nurses or nursing managers because of the lack of enough time. The problem of access to the full text of some articles was another limitation of this research. Addressing an important issue such as nursing consultation role can be considered as a high strength in this study.

Conclusion

Given that participants believed that nursing consultation role is a nursing principle and consider it necessary in the health system of Iran, it can be concluded that providing services in the form of nursing consultation is a necessity in Iran. However, there are barriers to this issue; thus, considering the importance of nursing consultation role in improving the health of the patients, it seems that this role needs to be more valued in nursing profession. This role should be taken into account by policymakers, and they should understand the importance of and the need for this role. Policymakers should know that the creation of this role is achievable. As such, we hope that managers and policymakers will create a role position by removing the obstacles and considering the necessity of this role. Owing to the specialized nature of the nursing consultation role, nursing profession will be improved in Iran, if this role is appropriately established. Moreover, nurses can provide specialized services and their motivation and capabilities will increase.

Financial support and sponsorship

Isfahan University of Medical Sciences

Conflicts of interest

There are no conflicts of interest.