Barriers and Opportunities in the Implementation of Clinical Nurse Specialist Roles in Iran's Healthcare System: A Qualitative Exploration

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Although clinical nurse specialists play a crucial role in decreasing hospital readmissions, enhancing quality of life, and alleviating the financial strain on the healthcare system, integrating their role into the Iranian healthcare system presents both a challenge and an opportunity. The aim of this study, using a qualitative approach, was to explore the barriers and challenges associated with implementing Clinical Nurse Specialist (CNS) roles in the Iranian healthcare system. Methods This qualitative study was conducted using the directed content analysis approach. A purposeful sampling method with maximum variation was performed among the nurses holding a master's degree or higher. Data were collected using 19 in-depth semi-structured interviews and analysis process was conducted using the Graneheim and Lundman method, utilizing MAXQDA software version 10. Results The analysis revealed three main categories in the structural dimension, two main categories in the process dimension, and one main category in the outcome dimension. In the structural dimension, the main categories identified were human resources, organizational structure, and facilities. In the process dimension, the main categories included the interactive processes involved in the implementation of care and treatment, as well as diagnosis and treatment. In the outcome dimension, the primary category was health status Conclusions The successful integration of CNS roles into Iran’s healthcare system requires addressing the multifaceted barriers identified in this study. By drawing on international experiences and tailoring strategies to the unique socio-cultural and organizational context of Iran, policymakers and healthcare leaders can unlock the potential of CNSs to improve healthcare quality, reduce costs, and enhance patient satisfaction. The findings of this study serve as a foundation for developing evidence-based policies and practices that support the optimal utilization of highly qualified nursing professionals in Iran. Barriers Opportunities Clinical Nurse Specialist Iran Introduction In recent years, global healthcare systems have experienced substantial transformations due to various factors, including aging populations, remarkable advancements in medical technologies, increased disease complexity, and rising public expectations for higher-quality healthcare services. Amidst these evolving dynamics, nurses, as the largest segment of the healthcare workforce, play an indispensable role in ensuring, maintaining, and improving public health. Among them, Clinical Nurse Specialists (CNSs) hold a pivotal position, contributing to advanced patient care, education, research, and quality improvement initiatives within healthcare systems( 1 ). The Iranian healthcare system, however, faces significant challenges that hinder the delivery of high-quality nursing services. These challenges include shortages of human resources, excessive workloads, resource limitations, and structural inefficiencies in healthcare delivery( 2 ). Within this context, the need for leveraging the expertise of CNSs to provide advanced care and elevate the quality of healthcare services has become increasingly evident. International evidence has demonstrated the effective integration of CNS roles in reducing healthcare costs, improving patient outcomes, and enhancing patient satisfaction. For instance, countries such as Canada, and Australia have successfully incorporated CNS roles into their healthcare systems, yielding substantial benefits ( 3 , 4 ).In contrast, the Iranian healthcare system has yet to fully utilize the potential of highly trained nursing professionals with master’s and doctoral degrees. Although these professionals possess the knowledge and expertise required for advanced clinical practice, their roles remain underdeveloped and under recognized. Research within Iran highlights multiple barriers to the implementation of CNS roles, such as limited awareness and acceptance of the CNS role among healthcare managers, inadequate resources, and insufficient specialized training for nurses( 5 , 6 ) Moreover, a lack of coordination and collaboration among healthcare team members has been identified as a critical obstacle, further limiting the effective deployment of CNSs in Iran's healthcare system( 7 ). While international studies underscore the contributions of CNSs to cost-effective, high-quality care, research in Iran has predominantly focused on quantitative approaches, such as surveys, to identify structural barriers to CNS role implementation. Although these studies have provided valuable insights into external and systemic factors, they often fail to capture the deeper, more complex cultural, social, and organizational dynamics that influence the integration of CNSs. Consequently, there is a significant gap in the literature regarding the qualitative exploration of these multifaceted barriers( 8 – 10 ).Given the socio-cultural and organizational complexities of the Iranian healthcare system, a qualitative research approach is essential to understand the nuanced and often hidden factors affecting CNS role implementation. Qualitative methods are uniquely equipped to explore the experiences, attitudes, and perceptions of key stakeholders, including CNSs, healthcare managers, and other members of the healthcare team( 11 ).Such insights are critical for identifying both personal and structural barriers that hinder the effective integration of CNS roles. This study aims to address this gap by employing a qualitative approach to explore the barriers and challenges associated with the implementation of CNS roles in Iran’s healthcare system. By drawing on the perspectives of CNSs, healthcare managers, and other stakeholders, the research seeks to provide a comprehensive understanding of the factors that influence the integration of this role. The findings will offer evidence-based insights to inform policy-making and the development of strategies to optimize the utilization of highly qualified nursing professionals in Iran. Given the pressing challenges facing the Iranian healthcare system and the proven potential of CNSs to enhance healthcare outcomes, this study is both timely and critical. By identifying the specific barriers and opportunities for the effective integration of CNS roles, the research will contribute to advancing nursing practice and improving the overall quality of healthcare services in Iran. Methods 2 − 1. Study design This study utilized a qualitative content analysis approach, grounded in the naturalistic paradigm, which posits that reality is subjective and constructed through individual experiences and interactions( 12 ). The philosophical foundation aligns with the interpretivist perspective, emphasizing the exploration of participants’ experiences to derive contextually rich insights( 13 ). Data collection and analysis followed the Donabedian model, which served as the theoretical framework. According to this model, structure pertains to the context in which services are offered, process relates to the way services are delivered, and outcome reflects the effects of services on patients' health status( 14 , 15 ). The study was conducted from February 2020 to September 2021 at Baqiyatallah University of Medical Sciences in Tehran. A purposive sampling method was employed to select participants from various professional roles, such as nursing volunteers, head nurses, hospital managers, physicians, nursing faculty members, policymakers, and nursing board members. The inclusion criteria for nurse participants included agreeing to participate in the study, holding a minimum of a master's degree, and having at least five years of work experience in intensive care units or general practice clinics. The research adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist (Supplementary File 1) ( 16 ) to ensure rigorous methodology and comprehensive reporting. 2–2. Participants Maximum variation sampling was utilized to ensure that participants from diverse backgrounds (e.g., age, sex, work experience, executive experience, clinical experience in ICU or general wards, and employment in public or private hospitals) were included. Sampling continued until data saturation was reached, following Francis's suggestion, which states that three consecutive interviews revealing no new information indicate data saturation( 17 ). Exclusion criteria involved a lack of interest in further participation in the interview, although no participants met this criterion. 2–3. Data collection Nineteen in-depth, semi-structured face-to-face interviews were conducted outside of participants' working hours. The interviews followed a flexible format, starting with an open-ended question to establish trust and explore participants' experiences regarding the differences between the roles of master’s-level and general nurses. Additional questions were customized based on the Donabedian model, focusing on the structure, process, and outcome aspects of clinical nurse specialist roles. Probing questions, such as "Can you elaborate on that?" and "When you say..., what do you mean?" were used to clarify and deepen responses (Supplementary File 2). Interviews were audio-recorded with participants' written and verbal consent. After transcription, the interviews were re-read multiple times to gain a comprehensive understanding of the data. Each interview served as a unit of analysis. Meaning units (e.g., words, sentences, or paragraphs with related aspects) were identified, condensed, and categorized. Codes and categories were finalized through consensus among the research team, with clear definitions and labels assigned to each category. 2–4. Data analysis The analysis process was conducted concurrently with data collection, utilizing constant comparison as the methodological approach. The data was analyzed using guided content analysis, a method suitable for validating or developing a theory or framework ( 1 ).The MAXQDA software version 10 was employed for data analysis ( 18 ). Both authors, S.H and L.K, coded the data, and the final analysis was confirmed through discussion. 2–5. Rigor The COREQ checklist was used to guide the study( 16 ) (Supplementary File 1). We implemented Lincoln and Guba's recommendations ( 19 ) to enhance trustworthiness in our study. For credibility, we engaged in prolonged engagement and member checking. To promote transferability, we utilized rich descriptions and detailed description of the research processes and an audit trail were maintained. For dependability, Interviews were conducted by the same interviewer, using consistent questions, locations, and timing to ensure reliability. Confirmability was ensured through reflexivity and methodological transparency. These measures bolstered the trustworthiness and rigor of our research. Findings 3 − 1. Participants characteristics The study included 19 participants, all of whom held master's or doctoral degrees in nursing and had previous clinical experience. The majority of the participants were male, and their ages ranged from 36 to 56 years. The participants had diverse backgrounds, serving as nursing faculty members, board members, and department heads. In terms of clinical experience, they had been involved in clinical activities for varying durations, ranging from 9 to 30 years ( Table 1 ). Table 1 characteristics of the study participants Participant Number Age (years) Sex Educational Level Work Experience (years) Interview duration (minutes) Occupation 1 50 Female Phd Nursing 20 24 University faculty 2 36 Male Master of Nursing 10 28 ICU nurse + Cardiac perfusionist 3 45 Female Master of Nursing 15 44 ICU nurse + General nurse 4 45 Female Phd Nursing 9 39 University faculty 5 48 Male Master of Nursing 10 21 ICU nurse + Supervisor 6 41 Male Phd Nursing 26 38 Dean of the School of Nursing + Board of Nursing 7 50 Male Phd Nursing 26 40 Director of Intensive Care Unit + Board 8 46 Female Master of Nursing 20 35 Hospital nursing director 9 37 Male Master of Nursing 26 37 General nurse + Wound Expert + Researcher 10 47 Male Phd Nursing 27 69 University faculty 11 50 Female Phd Nursing 18 47 University faculty 12 54 Female Phd Nursing 20 23 Board of Nursing + Palliative Care Policymaker 13 47 Male Physician 30 23 University faculty + Doctor Head of the hospital's intensive care unit 14 50 Male Phd Nursing 24 34 Director General of the Office of Health Promotion and Clinical Nursing Services, Deputy Director of Nursing, Ministry of Health + Board of Nursing 15 53 Male Phd Nursing 28 37 Head of the Nursing Science Development Working Group 16 49 Male Physician 20 19 Head of the Hospital Intensive Care Unit 17 56 Male Phd Nursing 29 42 Deputy Director of Nursing, Ministry of Health and Treatment + Board of Nursing 18 45 Male Master of Nursing 15 49 General nurse 19 51 Male Phd Nursing 12 25 Dean of the Faculty + ICU nurse Data analysis was conducted using Donabedian’s directed content analysis method, which provides a robust framework for identifying the challenges faced by specialist nurses across three dimensions: structure, process, and outcome. The analysis revealed three main categories in the structural dimension, two main categories in the process dimension, and one main category in the outcome dimension. In the structural dimension, the main categories identified were human resources, organizational structure, and facilities. In the process dimension, the main categories included the interactive processes involved in the implementation of care and treatment, as well as diagnosis and treatment. In the outcome dimension, the primary category was health status (Table 2 ). Further details of each main category, along with their corresponding subcategories, are elaborated in the subsequent sections of the manuscript. Table 2 Sub-categories and categories of the study Sub-categories Categories Structural dimension Clinical Nurse Specialist's Demotivation Poor culture building Inefficient management in attracting human capital Human Resources Barriers Weakness in the policy-making system Incomplete implementation of legal regulations Ineffective organization Ineffective specialized curriculum Organizational structure Barriers Inappropriate allocation of financial resources Inappropriate educational facilities Lack of specialization in the clinical environment Facility/Amenity Barriers Sub-categories Categories Process dimension Weakness of the professional evaluation system Ineffective inter-professional and intra-professional interactions Interactive process during care and treatment Poor participation in treatment decisions Clinical exploitation Diagnosis/Treatment Sub-categories Categories Outcom dimension Inefficiency of the results monitoring system Health status (morbidity/mortality) 1. structural Barriers Based on the Donabedian model and informed by the experiences and statements of the participants, the implementation of the specialist nurse role is contingent upon the establishment of necessary infrastructures. Without these foundational elements, the effective adoption of this role remains unattainable. Accordingly, three main categories—human resources, organizational structure, and facilities and amenities—were identified and extracted as structural barriers. 1–1. Human Resources as Structural Barriers In organizations, including healthcare systems, all employees—such as managers, supervisors, experts, and staff at various levels—are collectively referred to as human resources( 20 ). Human resources represent the most critical asset of any organization. According to the participants, the low motivation of specialist nurses, poor culture building, and inefficiencies in the management system for attracting human capital were identified as key obstacles in this domain. 1-1-1. Clinical Nurse Specialist's Demotivation Apathy was highlighted by most participants as a significant barrier preventing nurses from pursuing higher levels of knowledge and professional development. (P.9), with 26 years of work experience as a Wound Care Expert, stated: "If you have a capable senior nurse manager, it's better than a nurse manager with 30 years of experience who does routine work, because that doesn't create any motivation for promoting her nurses... Motivation is created when you, a group of senior managers, are seen by these people (high academic degrees)." 1-1-2. Poor Culture Building Participants emphasized that effectively implementing and utilizing the role of clinical nurse specialists requires significant efforts in building a culture. They noted that cyberspace and media platforms should raise societal awareness of the importance of this role. Public education and awareness campaigns should highlight the contributions of clinical nurse specialists in advancing the health system, such as delivering cost-effective services within the framework of comprehensive and universal health coverage, prioritizing health promotion and prevention over treatment, and adhering to primary healthcare principles. In this context, (P.10), a faculty member with 27 years of experience, remarked: "Whenever something is going to happen, the first thing that needs to be anticipated is to create a culture; that is, we must first make our friends, respected colleagues in nursing, and the public aware that nursing includes various areas, such as its preventive role, which can be useful." 1-1-3. Inefficient Management in Attracting Human Capital Inefficient management in attracting and retaining human capital was identified as a structural weakness within the health system. Participants pointed to ongoing challenges, including inadequate staffing levels, which place excessive workloads on available nurses. (P.3), who has 15 years of experience in the ICU, commented: "The number of nurses is so low that whatever staff they give me is not enough to provide services, and each nurse has to care for a large number of patients." 1–2. Organizational Structure Barriers Organizational structure refers to the set of rules and regulations that define the division of tasks among individuals and employees to achieve common goals( 21 ). Four subcategories were identified as structural barriers: weaknesses in the policy-making system, incomplete implementation of legal regulations, inefficient organization, and ineffectiveness of specialized curricula. 1-2-1. Weaknesses in the Policy-Making System Collaboration and coordination among decision-making bodies were recognized by participants as crucial for the successful establishment and utilization of clinical nurse specialists. (P.7), with 26 years of work experience and an executive position,highlighted: "We currently have a disconnect between the Health Department of the Ministry of Health and the Nursing Department. The relationship between the Deputy Health and the Deputy Nursing in the Ministry of Health has been severed. The relationship between the Deputy Education and the Deputy Nursing has been severed. Well, it is natural that we cannot have clinical nurse specialists due to the lack of coordination between the components of the health system." 1-2-2. Incomplete Implementation of Legal Regulations Participants emphasized the necessity of fully implementing the approvals and guidelines required for clinical nurse specialists to effectively function in the Iranian health system. However, many noted a lack of comprehensive planning in this regard. (P.11), a faculty member with 18 years of experience, stated: "We do everything in the intensive care unit now, but we had people who had no problem removing the endotracheal tube 20 times. But when the patient had trouble removing the endotracheal tube, they ask you and say: Who said to remove it? In that case, there is no executive or legal guarantee to protect us, and we are easily convicted." 1-2-3. Ineffective Organization Proper organization, including clear job descriptions, well-structured organizational charts, and the recruitment of specialist nurses, was identified as essential for the effective provision of care by clinical nurse specialists. Despite the presence of nurses with advanced degrees, participants reported a lack of defined roles within clinical settings. (P.15), with 28 years of experience and head of the Nursing Science Development Working Group, noted: "When you look at hospital charts, they have a position called nurse. In this position, you can get an associate's degree, bachelor's degree, master's degree, or doctorate in nursing; it doesn't matter." 1-2-4. Ineffectiveness of Specialized Curricula Participants criticized current nursing education for failing to address the needs of specialist nurses and the future demands of community health. They stressed the importance of designing specialized educational programs based on systematic needs assessments. (P.17), with 29 years of experience and serving as Deputy Director of Nursing at the Ministry of Health, explained: "Our education system, the Education Office of the Ministry of Health, designs its courses, which, of course, could be based on a general needs assessment. Unfortunately, they did not work on this issue because education is a process that starts with a needs assessment and continues until individuals graduate." 1–3. Facility and Amenity Barriers Welfare facilities and amenities significantly influence employees’ working conditions, address their challenges, and ensure their mental and physical well-being( 22 ). Three subcategories were identified as barriers: inappropriate allocation of financial resources, inadequate educational facilities, and lack of specialization in the clinical environment. 1-3-1. Inappropriate Allocation of Financial Resources Participants emphasized the need for adequate resource allocation to support the employment of clinical nurse specialists. (P.5), with 10 years of work experience and an executive position, observed: "Although it is good to employ nurses with master's and doctoral degrees in specialized departments, it is not at all the case that these people are different from undergraduate nurses in terms of salary and services they receive." 1-3-2. Inadequate Educational Facilities Despite being integral members of healthcare teams, nurses often lack access to up-to-date knowledge due to their demanding workloads. This gap hampers their professional development. (P.3), with 15 years of ICU experience, remarked: "It is enough for a graduate nurse to only work in the hospital and not be active in congressional discussions and educational issues. After a while, this person is no different from ordinary nurses. That is, if we have a graduate nurse who has only worked in the clinic, due to being busy working consecutive shifts, they are separated from education and access to knowledge and are reduced to the level of a specialist. This is a danger that actually threatens our specialized nursing." 1-3-3. Lack of Specialization in the Clinical Environment An appropriate clinical environment was identified as critical for providing specialized training to nurses. Participants expressed concerns over the lack of environments tailored to specific nursing specializations. (P.1), with 20 years of experience as a faculty member, explained: "You can't say I won't change my resources and clinical environments to specialize as a nurse. Suppose you study at a university with a military approach but have no clinical environment for military practice. That's unacceptable." 2. Process Barriers Process barriers in clinical settings arise due to the employment of nurses without professional qualifications, lack of task segregation, and inadequate communication among treatment team members. These challenges significantly affect the effective provision of care. Two main categories were identified: the interactive process during care delivery and the process of diagnosis and treatment. 2 − 1. Interactive Process During Care Delivery The interactive process refers to the coordination and interaction between treatment team members to provide comprehensive care for patients( 23 ). Effective communication, as a core concept in nursing, is essential for high-quality care. Barriers identified in this category included weaknesses in the professional evaluation system and ineffective interprofessional and intraprofessional interactions. 2-1-1. Weaknesses in the Professional Evaluation System Participants highlighted the importance of implementing a system to assess the professional qualifications of clinical nurse specialists upon employment and to evaluate their caring behaviors regularly. (P.14), with 24 years of experience and serving as Director General of the Office of Health Promotion and Clinical Nursing Services, Deputy Director of Nursing at the Ministry of Health, stated: "In the specialized field, we should not repeat the mistake we made in general nursing. That is, we should not think that everyone with a master's degree in nursing can be a specialist. In addition to a master's degree, one must have a certificate of professional competence, and this certificate needs to be reviewed and renewed every 3–4 years." 2-1-2. Ineffective Inter professional and Intra professional Interactions Participants emphasized that quality patient care requires effective communication among all treatment team members, including physicians, general nurses, and clinical nurse specialists. However, barriers such as resistance to the specialist nurse role were identified. (P.15), with 28 years of experience and Head of the Nursing Science Development Working Group, remarked: "There is no doubt that the biggest challenge that specialist nursing roles face is that they have a problem with the term 'specialist nurse' to the point where they fear that specialist nurses will replace doctors in the hospital. What is more interesting is that we also have a problem among nurses themselves. When a graduate comes to work on the ward, the other nurses say, 'So what did they teach you in your postgraduate studies?'" 2–2. Diagnosis and Treatment Participants reported significant weaknesses in utilizing the diagnostic and therapeutic roles of clinical nurse specialists to enhance patient care. Two subcategories were identified: poor participation in therapeutic decision-making and clinical exploitation. 2-2-1. Poor Participation in Therapeutic Decision-Making The Iranian health system does not involve clinical nurse specialists in treatment planning. Participants noted that leveraging the expertise of specialist nurses could enhance patient care quality. (P.1), with 20 years of experience and serving as a university faculty member, explained: "Specialist nurses in the intensive care unit do not interfere in the diagnosis and treatment process, and in practice, their duties are limited to the area of care and do not include medical interventions. Nurses are defined everywhere in the world as planners, especially in specialized areas." 2-2-2. Clinical Exploitation In clinical settings, participants reported that clinical nurse specialists are often subservient to physicians, performing tasks beyond their defined responsibilities without proper recognition or compensation. (P.13), with 30 years of experience and serving as Head of the hospital's intensive care unit, stated: "In the clinical setting, nurses do things they have no responsibility for simply because doctors, without even giving orders, say that nurses have to do it. Nurses comply because they fear punishment if they don't, despite not being paid for these services." 3. Consequence Barriers Health is defined as a state of complete physical, mental, and social well-being( 24 ). The absence of adequate planning and infrastructure for deploying clinical nurse specialists has resulted in a lack of recognition and an incomplete evaluation of their activities and contributions. Within this category, the subcategory of an ineffective monitoring system was identified as a key consequence barrier, affecting health outcomes such as morbidity and mortality rates. 3 − 1. Inefficiency of the Results Monitoring System Participants noted that master's and doctoral-level nurses, serving as clinical nurse specialists within the Iranian healthcare system, contribute to expediting patient recovery and discharge. Their efforts positively impact patient and family satisfaction while reducing hospital complications. However, the absence of a structured results monitoring system prevents the assessment of their true impact. (P.12), with 20 years of experience and serving as a Palliative Care Policymaker, emphasized: "We need to constantly measure the outcomes of clinical nurse specialists. If my efficiency and outcome, for example, quality improvement, improves, then it is clear that the creation of the clinical nurse specialist role has been successful." Discussion The findings of this study reveal significant barriers and challenges to the implementation of Clinical Nurse Specialist (CNS) roles in Iran’s healthcare system. By employing the Donabedian model, the structural, process, and outcome dimensions of these challenges were explored. The results provide valuable insights into the socio-cultural, organizational, and professional dynamics that hinder the effective utilization of CNSs in healthcare settings. In this discussion, we compare the findings with previous research, highlight the implications for practice and policy, and suggest strategies for overcoming the identified barriers. Structural Barriers The structural barriers identified in this study, including human resource issues, organizational inefficiencies, and facility-related shortcomings, align with the findings of previous studies( 25 ).For instance, Jokiniemi et al (2021) highlighted that organizational structure and resource allocation play pivotal roles in the successful integration of CNS roles( 26 ). Similarly, Kilpatrick, Carter and Bryant-Lukosius emphasized that supportive infrastructure are essential for CNS implementation( 27 – 29 ). In the Iranian context, participants reported demotivation among CNSs, poor culture-building efforts, and inefficient management in attracting qualified personnel. This is consistent with Sadati, who identified a lack of awareness and acceptance of the CNS role among healthcare managers as a significant obstacle( 30 ).To address these issues, targeted strategies such as increasing public and professional awareness through media campaigns and educational initiatives are essential. Additionally, organizational reforms that prioritize the recruitment, retention, and professional development of CNSs should be implemented. Providing competitive salaries and clear career progression pathways can help mitigate the demotivation and attrition of highly qualified nurses. Process Barriers Process-related barriers, particularly those involving interprofessional and intraprofessional interactions, were prominent in this study. Weaknesses in communication and collaboration among healthcare team members were frequently cited by participants. Sievers et al. (2006) emphasized that interprofessional communication is critical for delivering high-quality care and optimizing the roles of specialized professionals like CNSs( 31 ). However, in the Iranian healthcare system, the lack of professional evaluation systems and poor participation of CNSs in treatment decision-making processes limit their effectiveness. Participants also noted that CNSs are often excluded from critical care planning and are subjected to clinical exploitation, reflecting systemic undervaluation of their expertise. Addressing these barriers requires the establishment of robust frameworks for interprofessional collaboration. Regular training programs focusing on team-based care and communication skills can enhance the integration of CNSs into healthcare teams. Moreover, formal recognition of CNSs as key contributors to patient care planning should be institutionalized through policy changes. Outcome Barriers The study also highlighted inefficiencies in monitoring the outcomes of CNS roles. Participants reported that the lack of a results monitoring system prevents the accurate assessment of CNS contributions to patient outcomes, such as reduced morbidity and mortality rates. This finding aligns with Donabedian’s (1992) assertion that outcome evaluation is a critical component of healthcare quality assessment( 32 ).Similar challenges were reported by Negarandeh et al (2023), who noted the absence of systematic outcome measurement in Iranian healthcare settings( 33 ). To overcome this barrier, it is essential to develop and implement standardized metrics for evaluating the impact of CNSs on patient outcomes. Integrating these metrics into existing healthcare information systems can facilitate ongoing monitoring and quality improvement. Furthermore, regular audits and feedback mechanisms should be established to ensure the accountability and continuous professional development of CNSs. Implications for Policy and Practice The findings of this study underscore the urgent need for evidence-based policy interventions to support the integration of CNS roles in Iran. Policymakers should prioritize the development of clear regulations and guidelines that define the scope of practice, responsibilities, and competencies of CNSs. Additionally, investing in the professional development of CNSs through specialized training programs and international collaborations can enhance their capacity to meet the growing demands of the healthcare system. From a practical perspective, healthcare managers should foster a culture of collaboration and mutual respect among team members. Creating opportunities for CNSs to participate in decision-making processes and providing them with the necessary resources and support can enhance their contributions to patient care. Finally, addressing structural issues such as inadequate resource allocation and organizational inefficiencies will require a coordinated effort involving all stakeholders in the healthcare system. Limitation One limitation of the study was the lack of access to contact clinical nursing professionals working in other countries. Another limitation of the study is the gender imbalance among the participants, with the majority being male. This gender disparity may have implications for the generalizability of the study's findings, as the experiences and perspectives of female participants may differ from those of male participants. Future studies should strive for a more balanced gender representation to ensure a comprehensive understanding of the topic. It is worth noting that despite these limitations, the study still provides valuable insights into the barriers to CNS role implementation in Iran. Conclusion While this study offers valuable insights into the barriers to CNS role implementation, it is not without limitations. The qualitative design, though suitable for exploring complex phenomena, limits the generalizability of the findings. Future research should consider using mixed-methods approaches to validate and build upon these findings. Additionally, longitudinal studies that track the implementation of CNS roles over time can provide deeper insights into the effectiveness of proposed interventions. Abbreviations PhD Doctor of Philosophy CNS Clinical nurse Specialist COREQ Consolidated Criteria for Reporting Qualitative Studies MAXQDA Software for Qualitative Data Analysis Declarations Ethics approval and consent to participate This study was assessed and approved by the ethics committee belonging to Baqiyatallah University of Medical Sciences (BUMS) with the ethical ID: IR.BMSU.REC.1399.288. All procedures involving human participants were conducted in full accordance with the ethical guidelines and regulations outlined in the Declaration of Helsinki. Informed consent to participate was obtained from all participants after providing them with detailed information about the study's objectives, methods, and confidentiality measures. Participation was voluntary, and participants could withdraw from the study at any time without facing any consequences. To maintain confidentiality, participants' identities were protected, and they were referred to using codes (e.g., P1, P2, P3, etc.) instead of their actual names. Consent for publication Not applicable Availability of data and materials The data will be available to anyone upon request. Competing interests The authors declare no conflict of interest Funding No funding source Authors' contributions Study concept, design and supervision: Seyed Tayeb Moradian, Amir vahedian azimi, Jamileh mokhtari nouri, Abbas Ebadi; acquisition of data: Saeed Hashemi, analysis and interpretation of data: Saeed Hashemi, leila karimi; drafting of the manuscript; Saeed Hashemi, leila karimi and Amir vahedian azimi; critical revision of the manuscript for important intellectual content, statistical analysis and administrative, technical and material support: Seyed Tayeb Moradian, Amir vahedian azimi, Jamileh mokhtari nouri, Abbas Ebadi , leila karimi and Saeed Hashemi Acknowledgements: The authors would like to express their gratitude to all the participants who generously shared their valuable experiences in this study. 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What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol health. 2010;25(10):1229–45. Kuckartz U, Rädiker S. Analyzing qualitative data with MAXQDA: Springer; 2019. Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative content analysis: A focus on trustworthiness. SAGE open. 2014;4(1):2158244014522633. Swanson RA. Foundations of human resource development. Berrett-Koehler; 2022. Chew X, Alharbi R, Khaw KW, Alnoor A. How information technology influences organizational communication: the mediating role of organizational structure. PSU Res Rev. 2024;8(3):633–47. Alizadeh Sani M, Hosseini A, Tabassomi A. Impact of welfare facilities on positive psychological capital. Manage Stud Dev Evol. 2018;27(87):29–44. Bok C, Ng CH, Koh JWH, Ong ZH, Ghazali HZB, Tan LHE, et al. Interprofessional communication (IPC) for medical students: a scoping review. BMC Med Educ. 2020;20:1–17. Doustmohammadian A. Dimensions and Components of Food Security from Quran Perspectives: a Review Study. Quran Med. 2022;7(4):26–33. Buchelt B, Frączkiewicz-Wronka A, Dobrowolska M. The organizational aspect of human resource management as a determinant of the potential of polish hospitals to manage medical professionals in healthcare 4.0. Sustainability. 2020;12(12):5118. Jokiniemi K, Korhonen K, Kärkkäinen A, Pekkarinen T, Pietilä AM. Clinical nurse specialist role implementation structures, processes and outcomes: participatory action research. J Clin Nurs. 2021;30(15–16):2222–33. Kilpatrick K, Tchouaket E, Carter N, Bryant-Lukosius D, DiCenso A. Structural and process factors that influence clinical nurse specialist role implementation. Clin Nurse Specialist. 2016;30(2):89–100. Carter N. Clinical nurse specialists and nurse practitioners: title confusion and lack of role clarity. Nurs Leadersh. 2010;189. Bryant-Lukosius D, Carter N, Kilpatrick K, Martin-Misener R, Donald F, Kaasalainen S et al. The clinical nurse specialist role in Canada. Nursing leadership (Toronto, Ont). 2010;23:140–66. Sadati AK, Siahi M. Absence of nursing position in the new health policies in Iran: a dialogue with nursing scholars and nursing managers. Int J Community Based Nurs Midwifery. 2016;4(4):397. Sievers B, Wolf S. Achieving clinical nurse specialist competencies and outcomes through interdisciplinary education. Clin Nurse Specialist. 2006;20(2):75–80. Donabedian A. The role of outcomes in quality assessment and assurance. QRB-Quality Rev Bull. 1992;18(11):356–60. Negarandeh R, Kamran A, Heydari H. Iran’s health system performance in achieving goals based on the World Health Organization’s framework: a scoping review. ournal Res Health. 2023. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6602437","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501410615,"identity":"2a0c018c-0450-496e-9b6e-889b0c32fd97","order_by":0,"name":"Amir vahedian azimi","email":"","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"vahedian","lastName":"azimi","suffix":""},{"id":501410616,"identity":"31feda53-18e4-470c-a3fd-3644b8c15522","order_by":1,"name":"Jamileh mokhtari nouri","email":"","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jamileh","middleName":"mokhtari","lastName":"nouri","suffix":""},{"id":501410617,"identity":"31b241c2-2e03-4b71-b034-4211dc6badb1","order_by":2,"name":"leila karimi","email":"","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"leila","middleName":"","lastName":"karimi","suffix":""},{"id":501410618,"identity":"7c9252b5-6d59-4b57-8bb7-13752efb91ab","order_by":3,"name":"Seyed Tayeb Moradian","email":"","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Tayeb","lastName":"Moradian","suffix":""},{"id":501410619,"identity":"13d2016a-8e15-4710-b8d0-01bb0771ea5d","order_by":4,"name":"Abbas Ebadi","email":"","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Abbas","middleName":"","lastName":"Ebadi","suffix":""},{"id":501410620,"identity":"5b73941f-82bb-4464-a3d3-a8d8e9701113","order_by":5,"name":"Saeed hashemi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACAwYGNiAlAeZIfPxjA2MTqUVyZkMa0VogQJqz4TBhLebsx589+JhjYc/f3nzwNuOO84n9s5sPPmCosYnGpcWyJ8fccOY2icQZZ44lWxeeuZ04486xZAOGY2m5DbgcdiCHTZp3m0QCw40cM+kZbLcTG4AMCcaGw7i1nH/+TPrvNgl7+fvvv0nzsJ1LnE9Qy40EM2nGbRKMG27wAK1rO5C4gbCWN2aSvUC/bDyTZmw540yy8cYbackGCfj8cj79mcTPbXX2cscPP7zxocJOdt6N5IMPPtTY4NSCARzBKhOIVQ4C9qQoHgWjYBSMgpEBALQHYoiHkDRkAAAAAElFTkSuQmCC","orcid":"","institution":"Baqiyatallah University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Saeed","middleName":"","lastName":"hashemi","suffix":""}],"badges":[],"createdAt":"2025-05-06 11:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6602437/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6602437/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89394071,"identity":"8dab7838-8117-475d-b48c-b7de42f1a68d","added_by":"auto","created_at":"2025-08-19 13:29:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":857619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6602437/v1/7b0d3579-2d70-41c2-9901-cb42e750f882.pdf"},{"id":89392289,"identity":"24749613-a44a-4a81-8fb0-567a19ee086f","added_by":"auto","created_at":"2025-08-19 13:13:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27598,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-6602437/v1/531345d1c9ed6dd28e117cab.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Opportunities in the Implementation of Clinical Nurse Specialist Roles in Iran's Healthcare System: A Qualitative Exploration","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, global healthcare systems have experienced substantial transformations due to various factors, including aging populations, remarkable advancements in medical technologies, increased disease complexity, and rising public expectations for higher-quality healthcare services. Amidst these evolving dynamics, nurses, as the largest segment of the healthcare workforce, play an indispensable role in ensuring, maintaining, and improving public health. Among them, Clinical Nurse Specialists (CNSs) hold a pivotal position, contributing to advanced patient care, education, research, and quality improvement initiatives within healthcare systems(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The Iranian healthcare system, however, faces significant challenges that hinder the delivery of high-quality nursing services. These challenges include shortages of human resources, excessive workloads, resource limitations, and structural inefficiencies in healthcare delivery(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Within this context, the need for leveraging the expertise of CNSs to provide advanced care and elevate the quality of healthcare services has become increasingly evident. International evidence has demonstrated the effective integration of CNS roles in reducing healthcare costs, improving patient outcomes, and enhancing patient satisfaction. For instance, countries such as Canada, and Australia have successfully incorporated CNS roles into their healthcare systems, yielding substantial benefits (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).In contrast, the Iranian healthcare system has yet to fully utilize the potential of highly trained nursing professionals with master\u0026rsquo;s and doctoral degrees. Although these professionals possess the knowledge and expertise required for advanced clinical practice, their roles remain underdeveloped and under recognized. Research within Iran highlights multiple barriers to the implementation of CNS roles, such as limited awareness and acceptance of the CNS role among healthcare managers, inadequate resources, and insufficient specialized training for nurses(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Moreover, a lack of coordination and collaboration among healthcare team members has been identified as a critical obstacle, further limiting the effective deployment of CNSs in Iran's healthcare system(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile international studies underscore the contributions of CNSs to cost-effective, high-quality care, research in Iran has predominantly focused on quantitative approaches, such as surveys, to identify structural barriers to CNS role implementation. Although these studies have provided valuable insights into external and systemic factors, they often fail to capture the deeper, more complex cultural, social, and organizational dynamics that influence the integration of CNSs. Consequently, there is a significant gap in the literature regarding the qualitative exploration of these multifaceted barriers(\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).Given the socio-cultural and organizational complexities of the Iranian healthcare system, a qualitative research approach is essential to understand the nuanced and often hidden factors affecting CNS role implementation. Qualitative methods are uniquely equipped to explore the experiences, attitudes, and perceptions of key stakeholders, including CNSs, healthcare managers, and other members of the healthcare team(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).Such insights are critical for identifying both personal and structural barriers that hinder the effective integration of CNS roles.\u003c/p\u003e\u003cp\u003eThis study aims to address this gap by employing a qualitative approach to explore the barriers and challenges associated with the implementation of CNS roles in Iran\u0026rsquo;s healthcare system. By drawing on the perspectives of CNSs, healthcare managers, and other stakeholders, the research seeks to provide a comprehensive understanding of the factors that influence the integration of this role. The findings will offer evidence-based insights to inform policy-making and the development of strategies to optimize the utilization of highly qualified nursing professionals in Iran.\u003c/p\u003e\u003cp\u003eGiven the pressing challenges facing the Iranian healthcare system and the proven potential of CNSs to enhance healthcare outcomes, this study is both timely and critical. By identifying the specific barriers and opportunities for the effective integration of CNS roles, the research will contribute to advancing nursing practice and improving the overall quality of healthcare services in Iran.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1. Study design\u003c/h2\u003e\u003cp\u003eThis study utilized a qualitative content analysis approach, grounded in the naturalistic paradigm, which posits that reality is subjective and constructed through individual experiences and interactions(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The philosophical foundation aligns with the interpretivist perspective, emphasizing the exploration of participants\u0026rsquo; experiences to derive contextually rich insights(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eData collection and analysis followed the Donabedian model, which served as the theoretical framework. According to this model, structure pertains to the context in which services are offered, process relates to the way services are delivered, and outcome reflects the effects of services on patients' health status(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The study was conducted from February 2020 to September 2021 at Baqiyatallah University of Medical Sciences in Tehran. A purposive sampling method was employed to select participants from various professional roles, such as nursing volunteers, head nurses, hospital managers, physicians, nursing faculty members, policymakers, and nursing board members. The inclusion criteria for nurse participants included agreeing to participate in the study, holding a minimum of a master's degree, and having at least five years of work experience in intensive care units or general practice clinics. The research adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist (Supplementary File 1) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) to ensure rigorous methodology and comprehensive reporting.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e2–2. Participants\u003c/h3\u003e\n\u003cp\u003e Maximum variation sampling was utilized to ensure that participants from diverse backgrounds (e.g., age, sex, work experience, executive experience, clinical experience in ICU or general wards, and employment in public or private hospitals) were included. Sampling continued until data saturation was reached, following Francis's suggestion, which states that three consecutive interviews revealing no new information indicate data saturation(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Exclusion criteria involved a lack of interest in further participation in the interview, although no participants met this criterion.\u003c/p\u003e\n\u003ch3\u003e2–3. Data collection\u003c/h3\u003e\n\u003cp\u003e Nineteen in-depth, semi-structured face-to-face interviews were conducted outside of participants' working hours. The interviews followed a flexible format, starting with an open-ended question to establish trust and explore participants' experiences regarding the differences between the roles of master\u0026rsquo;s-level and general nurses. Additional questions were customized based on the Donabedian model, focusing on the structure, process, and outcome aspects of clinical nurse specialist roles. Probing questions, such as \"Can you elaborate on that?\" and \"When you say..., what do you mean?\" were used to clarify and deepen responses (Supplementary File 2). Interviews were audio-recorded with participants' written and verbal consent. After transcription, the interviews were re-read multiple times to gain a comprehensive understanding of the data. Each interview served as a unit of analysis. Meaning units (e.g., words, sentences, or paragraphs with related aspects) were identified, condensed, and categorized. Codes and categories were finalized through consensus among the research team, with clear definitions and labels assigned to each category.\u003c/p\u003e\n\u003ch3\u003e2–4. Data analysis\u003c/h3\u003e\n\u003cp\u003eThe analysis process was conducted concurrently with data collection, utilizing constant comparison as the methodological approach. The data was analyzed using guided content analysis, a method suitable for validating or developing a theory or framework (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).The MAXQDA software version 10 was employed for data analysis (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Both authors, S.H and L.K, coded the data, and the final analysis was confirmed through discussion.\u003c/p\u003e\n\u003ch3\u003e2–5. Rigor\u003c/h3\u003e\n\u003cp\u003eThe COREQ checklist was used to guide the study(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) (Supplementary File 1). We implemented Lincoln and Guba's recommendations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) to enhance trustworthiness in our study. For credibility, we engaged in prolonged engagement and member checking. To promote transferability, we utilized rich descriptions and detailed description of the research processes and an audit trail were maintained. For dependability, Interviews were conducted by the same interviewer, using consistent questions, locations, and timing to ensure reliability. Confirmability was ensured through reflexivity and methodological transparency. These measures bolstered the trustworthiness and rigor of our research.\u003c/p\u003e"},{"header":"Findings","content":"\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;1. Participants characteristics\u003c/h2\u003e\u003cp\u003eThe study included 19 participants, all of whom held master's or doctoral degrees in nursing and had previous clinical experience. The majority of the participants were male, and their ages ranged from 36 to 56 years. The participants had diverse backgrounds, serving as nursing faculty members, board members, and department heads. In terms of clinical experience, they had been involved in clinical activities for varying durations, ranging from 9 to 30 years ( Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003echaracteristics of the study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003cp\u003e(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducational\u003c/p\u003e\u003cp\u003eLevel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWork\u003c/p\u003e\u003cp\u003eExperience\u003c/p\u003e\u003cp\u003e(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInterview duration (minutes)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUniversity faculty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eICU nurse\u0026thinsp;+\u0026thinsp;Cardiac perfusionist\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eICU nurse\u0026thinsp;+\u0026thinsp;General nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUniversity faculty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eICU nurse\u0026thinsp;+\u0026thinsp;Supervisor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDean of the School of Nursing\u0026thinsp;+\u0026thinsp;Board of Nursing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDirector of Intensive Care Unit\u0026thinsp;+\u0026thinsp;Board\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHospital nursing director\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eGeneral nurse\u0026thinsp;+\u0026thinsp;Wound Expert\u0026thinsp;+\u0026thinsp;Researcher\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUniversity faculty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUniversity faculty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eBoard of Nursing\u0026thinsp;+\u0026thinsp;Palliative Care Policymaker\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUniversity faculty\u0026thinsp;+\u0026thinsp;Doctor\u003c/p\u003e\u003cp\u003eHead of the hospital's intensive care unit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDirector General of the Office of Health Promotion and Clinical Nursing Services, Deputy Director of Nursing, Ministry of Health\u0026thinsp;+\u0026thinsp;Board of Nursing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHead of the Nursing Science Development Working Group\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHead of the Hospital Intensive Care Unit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDeputy Director of Nursing, Ministry of Health and Treatment\u0026thinsp;+\u0026thinsp;Board of Nursing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eGeneral nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhd Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDean of the Faculty\u0026thinsp;+\u0026thinsp;ICU nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData analysis was conducted using Donabedian\u0026rsquo;s directed content analysis method, which provides a robust framework for identifying the challenges faced by specialist nurses across three dimensions: structure, process, and outcome.\u003c/p\u003e\u003cp\u003eThe analysis revealed three main categories in the structural dimension, two main categories in the process dimension, and one main category in the outcome dimension. In the structural dimension, the main categories identified were human resources, organizational structure, and facilities. In the process dimension, the main categories included the interactive processes involved in the implementation of care and treatment, as well as diagnosis and treatment. In the outcome dimension, the primary category was health status (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Further details of each main category, along with their corresponding subcategories, are elaborated in the subsequent sections of the manuscript.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSub-categories and categories of the study\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub-categories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategories Structural dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Nurse Specialist's Demotivation\u003c/p\u003e\u003cp\u003ePoor culture building\u003c/p\u003e\u003cp\u003eInefficient management in attracting human capital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHuman Resources Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeakness in the policy-making system\u003c/p\u003e\u003cp\u003eIncomplete implementation of legal regulations\u003c/p\u003e\u003cp\u003eIneffective organization\u003c/p\u003e\u003cp\u003eIneffective specialized curriculum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOrganizational structure Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInappropriate allocation of financial resources\u003c/p\u003e\u003cp\u003eInappropriate educational facilities\u003c/p\u003e\u003cp\u003eLack of specialization in the clinical environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFacility/Amenity Barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub-categories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCategories\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcess dimension\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeakness of the professional evaluation system\u003c/p\u003e\u003cp\u003eIneffective inter-professional and intra-professional interactions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInteractive process during care and treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor participation in treatment decisions\u003c/p\u003e\u003cp\u003eClinical exploitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eDiagnosis/Treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub-categories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCategories\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcom dimension\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInefficiency of the results monitoring system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth status (morbidity/mortality)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e1. structural Barriers\u003c/p\u003e\u003cp\u003eBased on the Donabedian model and informed by the experiences and statements of the participants, the implementation of the specialist nurse role is contingent upon the establishment of necessary infrastructures. Without these foundational elements, the effective adoption of this role remains unattainable. Accordingly, three main categories\u0026mdash;human resources, organizational structure, and facilities and amenities\u0026mdash;were identified and extracted as structural barriers.\u003c/p\u003e\u003cp\u003e1\u0026ndash;1. Human Resources as Structural Barriers\u003c/p\u003e\u003cp\u003eIn organizations, including healthcare systems, all employees\u0026mdash;such as managers, supervisors, experts, and staff at various levels\u0026mdash;are collectively referred to as human resources(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Human resources represent the most critical asset of any organization. According to the participants, the low motivation of specialist nurses, poor culture building, and inefficiencies in the management system for attracting human capital were identified as key obstacles in this domain.\u003c/p\u003e\u003cp\u003e1-1-1. Clinical Nurse Specialist's Demotivation\u003c/p\u003e\u003cp\u003eApathy was highlighted by most participants as a significant barrier preventing nurses from pursuing higher levels of knowledge and professional development. (P.9), with 26 years of work experience as a Wound Care Expert, stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"If you have a capable senior nurse manager, it's better than a nurse manager with 30 years of experience who does routine work, because that doesn't create any motivation for promoting her nurses... Motivation is created when you, a group of senior managers, are seen by these people (high academic degrees).\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-1-2. Poor Culture Building\u003c/p\u003e\u003cp\u003eParticipants emphasized that effectively implementing and utilizing the role of clinical nurse specialists requires significant efforts in building a culture. They noted that cyberspace and media platforms should raise societal awareness of the importance of this role. Public education and awareness campaigns should highlight the contributions of clinical nurse specialists in advancing the health system, such as delivering cost-effective services within the framework of comprehensive and universal health coverage, prioritizing health promotion and prevention over treatment, and adhering to primary healthcare principles.\u003c/p\u003e\u003cp\u003eIn this context, (P.10), a faculty member with 27 years of experience, remarked:\u003c/p\u003e\u003cp\u003e\"Whenever something is going to happen, the first thing that needs to be anticipated is to create a culture; that is, we must first make our friends, respected colleagues in nursing, and the public aware that nursing includes various areas, such as its preventive role, which can be useful.\"\u003c/p\u003e\u003cp\u003e1-1-3. Inefficient Management in Attracting Human Capital\u003c/p\u003e\u003cp\u003eInefficient management in attracting and retaining human capital was identified as a structural weakness within the health system. Participants pointed to ongoing challenges, including inadequate staffing levels, which place excessive workloads on available nurses. (P.3), who has 15 years of experience in the ICU, commented:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The number of nurses is so low that whatever staff they give me is not enough to provide services, and each nurse has to care for a large number of patients.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1\u0026ndash;2. Organizational Structure Barriers\u003c/p\u003e\u003cp\u003eOrganizational structure refers to the set of rules and regulations that define the division of tasks among individuals and employees to achieve common goals(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Four subcategories were identified as structural barriers: weaknesses in the policy-making system, incomplete implementation of legal regulations, inefficient organization, and ineffectiveness of specialized curricula.\u003c/p\u003e\u003cp\u003e1-2-1. Weaknesses in the Policy-Making System\u003c/p\u003e\u003cp\u003eCollaboration and coordination among decision-making bodies were recognized by participants as crucial for the successful establishment and utilization of clinical nurse specialists. (P.7), with 26 years of work experience and an executive position,highlighted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We currently have a disconnect between the Health Department of the Ministry of Health and the Nursing Department. The relationship between the Deputy Health and the Deputy Nursing in the Ministry of Health has been severed. The relationship between the Deputy Education and the Deputy Nursing has been severed. Well, it is natural that we cannot have clinical nurse specialists due to the lack of coordination between the components of the health system.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-2-2. Incomplete Implementation of Legal Regulations\u003c/p\u003e\u003cp\u003e Participants emphasized the necessity of fully implementing the approvals and guidelines required for clinical nurse specialists to effectively function in the Iranian health system. However, many noted a lack of comprehensive planning in this regard. (P.11), a faculty member with 18 years of experience, stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We do everything in the intensive care unit now, but we had people who had no problem removing the endotracheal tube 20 times. But when the patient had trouble removing the endotracheal tube, they ask you and say: Who said to remove it? In that case, there is no executive or legal guarantee to protect us, and we are easily convicted.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-2-3. Ineffective Organization\u003c/p\u003e\u003cp\u003eProper organization, including clear job descriptions, well-structured organizational charts, and the recruitment of specialist nurses, was identified as essential for the effective provision of care by clinical nurse specialists. Despite the presence of nurses with advanced degrees, participants reported a lack of defined roles within clinical settings. (P.15), with 28 years of experience and head of the Nursing Science Development Working Group, noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"When you look at hospital charts, they have a position called nurse. In this position, you can get an associate's degree, bachelor's degree, master's degree, or doctorate in nursing; it doesn't matter.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-2-4. Ineffectiveness of Specialized Curricula\u003c/p\u003e\u003cp\u003eParticipants criticized current nursing education for failing to address the needs of specialist nurses and the future demands of community health. They stressed the importance of designing specialized educational programs based on systematic needs assessments. (P.17), with 29 years of experience and serving as Deputy Director of Nursing at the Ministry of Health, explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Our education system, the Education Office of the Ministry of Health, designs its courses, which, of course, could be based on a general needs assessment. Unfortunately, they did not work on this issue because education is a process that starts with a needs assessment and continues until individuals graduate.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1\u0026ndash;3. Facility and Amenity Barriers\u003c/p\u003e\u003cp\u003eWelfare facilities and amenities significantly influence employees\u0026rsquo; working conditions, address their challenges, and ensure their mental and physical well-being(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Three subcategories were identified as barriers: inappropriate allocation of financial resources, inadequate educational facilities, and lack of specialization in the clinical environment.\u003c/p\u003e\u003cp\u003e1-3-1. Inappropriate Allocation of Financial Resources\u003c/p\u003e\u003cp\u003eParticipants emphasized the need for adequate resource allocation to support the employment of clinical nurse specialists. (P.5), with 10 years of work experience and an executive position, observed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Although it is good to employ nurses with master's and doctoral degrees in specialized departments, it is not at all the case that these people are different from undergraduate nurses in terms of salary and services they receive.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-3-2. Inadequate Educational Facilities\u003c/p\u003e\u003cp\u003eDespite being integral members of healthcare teams, nurses often lack access to up-to-date knowledge due to their demanding workloads. This gap hampers their professional development. (P.3), with 15 years of ICU experience, remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It is enough for a graduate nurse to only work in the hospital and not be active in congressional discussions and educational issues. After a while, this person is no different from ordinary nurses. That is, if we have a graduate nurse who has only worked in the clinic, due to being busy working consecutive shifts, they are separated from education and access to knowledge and are reduced to the level of a specialist. This is a danger that actually threatens our specialized nursing.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e1-3-3. Lack of Specialization in the Clinical Environment\u003c/p\u003e\u003cp\u003eAn appropriate clinical environment was identified as critical for providing specialized training to nurses. Participants expressed concerns over the lack of environments tailored to specific nursing specializations. (P.1), with 20 years of experience as a faculty member, explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"You can't say I won't change my resources and clinical environments to specialize as a nurse. Suppose you study at a university with a military approach but have no clinical environment for military practice. That's unacceptable.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e2. Process Barriers\u003c/p\u003e\u003cp\u003eProcess barriers in clinical settings arise due to the employment of nurses without professional qualifications, lack of task segregation, and inadequate communication among treatment team members. These challenges significantly affect the effective provision of care. Two main categories were identified: the interactive process during care delivery and the process of diagnosis and treatment.\u003c/p\u003e\u003cp\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1. Interactive Process During Care Delivery\u003c/p\u003e\u003cp\u003eThe interactive process refers to the coordination and interaction between treatment team members to provide comprehensive care for patients(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Effective communication, as a core concept in nursing, is essential for high-quality care. Barriers identified in this category included weaknesses in the professional evaluation system and ineffective interprofessional and intraprofessional interactions.\u003c/p\u003e\u003cp\u003e2-1-1. Weaknesses in the Professional Evaluation System\u003c/p\u003e\u003cp\u003eParticipants highlighted the importance of implementing a system to assess the professional qualifications of clinical nurse specialists upon employment and to evaluate their caring behaviors regularly. (P.14), with 24 years of experience and serving as Director General of the Office of Health Promotion and Clinical Nursing Services, Deputy Director of Nursing at the Ministry of Health, stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"In the specialized field, we should not repeat the mistake we made in general nursing. That is, we should not think that everyone with a master's degree in nursing can be a specialist. In addition to a master's degree, one must have a certificate of professional competence, and this certificate needs to be reviewed and renewed every 3\u0026ndash;4 years.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e2-1-2. Ineffective Inter professional and Intra professional Interactions\u003c/p\u003e\u003cp\u003e Participants emphasized that quality patient care requires effective communication among all treatment team members, including physicians, general nurses, and clinical nurse specialists. However, barriers such as resistance to the specialist nurse role were identified. (P.15), with 28 years of experience and Head of the Nursing Science Development Working Group, remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"There is no doubt that the biggest challenge that specialist nursing roles face is that they have a problem with the term 'specialist nurse' to the point where they fear that specialist nurses will replace doctors in the hospital. What is more interesting is that we also have a problem among nurses themselves. When a graduate comes to work on the ward, the other nurses say, 'So what did they teach you in your postgraduate studies?'\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e2\u0026ndash;2. Diagnosis and Treatment\u003c/p\u003e\u003cp\u003eParticipants reported significant weaknesses in utilizing the diagnostic and therapeutic roles of clinical nurse specialists to enhance patient care. Two subcategories were identified: poor participation in therapeutic decision-making and clinical exploitation.\u003c/p\u003e\u003cp\u003e2-2-1. Poor Participation in Therapeutic Decision-Making\u003c/p\u003e\u003cp\u003eThe Iranian health system does not involve clinical nurse specialists in treatment planning. Participants noted that leveraging the expertise of specialist nurses could enhance patient care quality. (P.1), with 20 years of experience and serving as a university faculty member, explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Specialist nurses in the intensive care unit do not interfere in the diagnosis and treatment process, and in practice, their duties are limited to the area of care and do not include medical interventions. Nurses are defined everywhere in the world as planners, especially in specialized areas.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e2-2-2. Clinical Exploitation\u003c/p\u003e\u003cp\u003eIn clinical settings, participants reported that clinical nurse specialists are often subservient to physicians, performing tasks beyond their defined responsibilities without proper recognition or compensation. (P.13), with 30 years of experience and serving as Head of the hospital's intensive care unit, stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"In the clinical setting, nurses do things they have no responsibility for simply because doctors, without even giving orders, say that nurses have to do it. Nurses comply because they fear punishment if they don't, despite not being paid for these services.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e3. Consequence Barriers\u003c/p\u003e\u003cp\u003eHealth is defined as a state of complete physical, mental, and social well-being(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The absence of adequate planning and infrastructure for deploying clinical nurse specialists has resulted in a lack of recognition and an incomplete evaluation of their activities and contributions. Within this category, the subcategory of an ineffective monitoring system was identified as a key consequence barrier, affecting health outcomes such as morbidity and mortality rates.\u003c/p\u003e\u003cp\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;1. Inefficiency of the Results Monitoring System\u003c/p\u003e\u003cp\u003eParticipants noted that master's and doctoral-level nurses, serving as clinical nurse specialists within the Iranian healthcare system, contribute to expediting patient recovery and discharge. Their efforts positively impact patient and family satisfaction while reducing hospital complications. However, the absence of a structured results monitoring system prevents the assessment of their true impact.\u003c/p\u003e\u003cp\u003e(P.12), with 20 years of experience and serving as a Palliative Care Policymaker, emphasized:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We need to constantly measure the outcomes of clinical nurse specialists. If my efficiency and outcome, for example, quality improvement, improves, then it is clear that the creation of the clinical nurse specialist role has been successful.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study reveal significant barriers and challenges to the implementation of Clinical Nurse Specialist (CNS) roles in Iran\u0026rsquo;s healthcare system. By employing the Donabedian model, the structural, process, and outcome dimensions of these challenges were explored. The results provide valuable insights into the socio-cultural, organizational, and professional dynamics that hinder the effective utilization of CNSs in healthcare settings. In this discussion, we compare the findings with previous research, highlight the implications for practice and policy, and suggest strategies for overcoming the identified barriers.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStructural Barriers\u003c/h2\u003e\u003cp\u003eThe structural barriers identified in this study, including human resource issues, organizational inefficiencies, and facility-related shortcomings, align with the findings of previous studies(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).For instance, Jokiniemi et al (2021) highlighted that organizational structure and resource allocation play pivotal roles in the successful integration of CNS roles(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, Kilpatrick, Carter and Bryant-Lukosius emphasized that supportive infrastructure are essential for CNS implementation(\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the Iranian context, participants reported demotivation among CNSs, poor culture-building efforts, and inefficient management in attracting qualified personnel. This is consistent with Sadati, who identified a lack of awareness and acceptance of the CNS role among healthcare managers as a significant obstacle(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).To address these issues, targeted strategies such as increasing public and professional awareness through media campaigns and educational initiatives are essential. Additionally, organizational reforms that prioritize the recruitment, retention, and professional development of CNSs should be implemented. Providing competitive salaries and clear career progression pathways can help mitigate the demotivation and attrition of highly qualified nurses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eProcess Barriers\u003c/h2\u003e\u003cp\u003eProcess-related barriers, particularly those involving interprofessional and intraprofessional interactions, were prominent in this study. Weaknesses in communication and collaboration among healthcare team members were frequently cited by participants. Sievers et al. (2006) emphasized that interprofessional communication is critical for delivering high-quality care and optimizing the roles of specialized professionals like CNSs(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, in the Iranian healthcare system, the lack of professional evaluation systems and poor participation of CNSs in treatment decision-making processes limit their effectiveness. Participants also noted that CNSs are often excluded from critical care planning and are subjected to clinical exploitation, reflecting systemic undervaluation of their expertise.\u003c/p\u003e\u003cp\u003eAddressing these barriers requires the establishment of robust frameworks for interprofessional collaboration. Regular training programs focusing on team-based care and communication skills can enhance the integration of CNSs into healthcare teams. Moreover, formal recognition of CNSs as key contributors to patient care planning should be institutionalized through policy changes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eOutcome Barriers\u003c/h2\u003e\u003cp\u003eThe study also highlighted inefficiencies in monitoring the outcomes of CNS roles. Participants reported that the lack of a results monitoring system prevents the accurate assessment of CNS contributions to patient outcomes, such as reduced morbidity and mortality rates. This finding aligns with Donabedian\u0026rsquo;s (1992) assertion that outcome evaluation is a critical component of healthcare quality assessment(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).Similar challenges were reported by Negarandeh et al (2023), who noted the absence of systematic outcome measurement in Iranian healthcare settings(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). To overcome this barrier, it is essential to develop and implement standardized metrics for evaluating the impact of CNSs on patient outcomes. Integrating these metrics into existing healthcare information systems can facilitate ongoing monitoring and quality improvement. Furthermore, regular audits and feedback mechanisms should be established to ensure the accountability and continuous professional development of CNSs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e\u003cp\u003eThe findings of this study underscore the urgent need for evidence-based policy interventions to support the integration of CNS roles in Iran. Policymakers should prioritize the development of clear regulations and guidelines that define the scope of practice, responsibilities, and competencies of CNSs. Additionally, investing in the professional development of CNSs through specialized training programs and international collaborations can enhance their capacity to meet the growing demands of the healthcare system.\u003c/p\u003e\u003cp\u003eFrom a practical perspective, healthcare managers should foster a culture of collaboration and mutual respect among team members. Creating opportunities for CNSs to participate in decision-making processes and providing them with the necessary resources and support can enhance their contributions to patient care. Finally, addressing structural issues such as inadequate resource allocation and organizational inefficiencies will require a coordinated effort involving all stakeholders in the healthcare system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eOne limitation of the study was the lack of access to contact clinical nursing professionals working in other countries. Another limitation of the study is the gender imbalance among the participants, with the majority being male. This gender disparity may have implications for the generalizability of the study's findings, as the experiences and perspectives of female participants may differ from those of male participants. Future studies should strive for a more balanced gender representation to ensure a comprehensive understanding of the topic. It is worth noting that despite these limitations, the study still provides valuable insights into the barriers to CNS role implementation in Iran.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile this study offers valuable insights into the barriers to CNS role implementation, it is not without limitations. The qualitative design, though suitable for exploring complex phenomena, limits the generalizability of the findings. Future research should consider using mixed-methods approaches to validate and build upon these findings. Additionally, longitudinal studies that track the implementation of CNS roles over time can provide deeper insights into the effectiveness of proposed interventions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePhD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDoctor of Philosophy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCNS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eClinical nurse Specialist\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCOREQ\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated Criteria for Reporting Qualitative Studies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMAXQDA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSoftware for Qualitative Data Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was assessed and approved by the ethics committee belonging to Baqiyatallah University of Medical Sciences (BUMS) with the ethical ID: IR.BMSU.REC.1399.288. All procedures involving human participants were conducted in full accordance with the ethical guidelines and regulations outlined in the Declaration of Helsinki. Informed consent to participate was obtained from all participants after providing them with detailed information about the study's objectives, methods, and confidentiality measures. Participation was voluntary, and participants could withdraw from the study at any time without facing any consequences. To maintain confidentiality, participants' identities were protected, and they were referred to using codes (e.g., P1, P2, P3, etc.) instead of their actual names.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The data will be available to anyone upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding source\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept, design and supervision:\u0026nbsp;Seyed Tayeb Moradian,\u0026nbsp;Amir vahedian azimi, Jamileh mokhtari nouri, Abbas Ebadi; acquisition of data:\u0026nbsp;Saeed Hashemi, analysis and interpretation of data:\u0026nbsp;Saeed Hashemi,\u0026nbsp;leila karimi; drafting of the manuscript;\u0026nbsp;Saeed Hashemi,\u0026nbsp;leila karimi\u0026nbsp;and\u0026nbsp;Amir vahedian azimi; critical revision of the manuscript for important intellectual content, statistical analysis and administrative, technical and material support:\u0026nbsp;Seyed Tayeb Moradian,\u0026nbsp;Amir vahedian azimi, Jamileh mokhtari nouri, Abbas Ebadi\u0026nbsp;,\u0026nbsp;leila karimi and\u0026nbsp;Saeed Hashemi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors would like to express their gratitude to all the participants who generously shared their valuable experiences in this study.\u0026nbsp;Further, we would like to express our gratitude for the guidance and advice provided by the Clinical Research Development Unit of Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Tehran, Iran.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChan GK, Holly VW. Global view of the clinical nurse specialist role. Clinical Nurse Specialist Role and Practice: Springer; 2021. pp. 3\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmadi Chenari H, Zakerimoghadam M, Baumann SL. Nursing in Iran: Issues and challenges. Nurs Sci Q. 2020;33(3):264\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoussel J, Commentary. Taking the Pulse on the Integration of the Clinical Nurse Specialist Role in Canada. Nurs Leadersh (Toronto Ont). 2016;29(3):18\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRamis M-A, Pearson A, Wu C-JJ. The experience of being an advanced practice nurse in Australian acute care settings: A systematic review of qualitative evidence. JBI Evid Synthesis. 2012;10(58):3960\u0026ndash;4018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSanjari M, Baradaran HR, Aalaa M, Mehrdad N. 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Clin Nurse Specialist. 2019;33(3):117\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang X, Meng K, Chen S. Competency framework for specialist critical care nurses: a modified Delphi study. Nurs Crit Care. 2020;25(1):45\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFallon N, Cassidy I, Doody O. Irish respiratory clinical nurse specialists\u0026rsquo; experiences of their role: A qualitative exploration. Clin Nurse Specialist. 2018;32(5):240\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRenjith V, Yesodharan R, Noronha JA, Ladd E, George A. Qualitative methods in health care research. Int J Prev Med. 2021;12(1):20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuba EG. Naturalistic inquiry. Improving Hum Perform Q. 1979;8(4):268\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePolit D, Beck C. Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams \u0026amp; Wilkins; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonabedian A. Advantages and limitations of explicit criteria for assessing the quality of health care. Milbank Meml Fund Q Health Soc. 1981;59(1):99\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhaffari Sardasht F, Jafarnejad F, Jahani N. Applying donabedian quality-of-care framework in assessing the structure of preconception care in urban health centers, Mashhad, 2012. J Mazandaran Univ Med Sci. 2014;24(116):149\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrancis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, Grimshaw JM. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol health. 2010;25(10):1229\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuckartz U, R\u0026auml;diker S. Analyzing qualitative data with MAXQDA: Springer; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElo S, K\u0026auml;\u0026auml;ri\u0026auml;inen M, Kanste O, P\u0026ouml;lkki T, Utriainen K, Kyng\u0026auml;s H. Qualitative content analysis: A focus on trustworthiness. SAGE open. 2014;4(1):2158244014522633.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwanson RA. Foundations of human resource development. Berrett-Koehler; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChew X, Alharbi R, Khaw KW, Alnoor A. How information technology influences organizational communication: the mediating role of organizational structure. PSU Res Rev. 2024;8(3):633\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlizadeh Sani M, Hosseini A, Tabassomi A. Impact of welfare facilities on positive psychological capital. Manage Stud Dev Evol. 2018;27(87):29\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBok C, Ng CH, Koh JWH, Ong ZH, Ghazali HZB, Tan LHE, et al. Interprofessional communication (IPC) for medical students: a scoping review. BMC Med Educ. 2020;20:1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoustmohammadian A. Dimensions and Components of Food Security from Quran Perspectives: a Review Study. Quran Med. 2022;7(4):26\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchelt B, Frączkiewicz-Wronka A, Dobrowolska M. The organizational aspect of human resource management as a determinant of the potential of polish hospitals to manage medical professionals in healthcare 4.0. Sustainability. 2020;12(12):5118.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJokiniemi K, Korhonen K, K\u0026auml;rkk\u0026auml;inen A, Pekkarinen T, Pietil\u0026auml; AM. Clinical nurse specialist role implementation structures, processes and outcomes: participatory action research. J Clin Nurs. 2021;30(15\u0026ndash;16):2222\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKilpatrick K, Tchouaket E, Carter N, Bryant-Lukosius D, DiCenso A. Structural and process factors that influence clinical nurse specialist role implementation. Clin Nurse Specialist. 2016;30(2):89\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarter N. Clinical nurse specialists and nurse practitioners: title confusion and lack of role clarity. Nurs Leadersh. 2010;189.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBryant-Lukosius D, Carter N, Kilpatrick K, Martin-Misener R, Donald F, Kaasalainen S et al. The clinical nurse specialist role in Canada. Nursing leadership (Toronto, Ont). 2010;23:140\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSadati AK, Siahi M. Absence of nursing position in the new health policies in Iran: a dialogue with nursing scholars and nursing managers. Int J Community Based Nurs Midwifery. 2016;4(4):397.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSievers B, Wolf S. Achieving clinical nurse specialist competencies and outcomes through interdisciplinary education. Clin Nurse Specialist. 2006;20(2):75\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonabedian A. The role of outcomes in quality assessment and assurance. QRB-Quality Rev Bull. 1992;18(11):356\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNegarandeh R, Kamran A, Heydari H. Iran\u0026rsquo;s health system performance in achieving goals based on the World Health Organization\u0026rsquo;s framework: a scoping review. ournal Res Health. 2023.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Barriers, Opportunities, Clinical Nurse Specialist, Iran","lastPublishedDoi":"10.21203/rs.3.rs-6602437/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6602437/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe Iranian healthcare system will encounter significant challenges in the future, such as evolving disease patterns and rising healthcare expenses. Although clinical nurse specialists play a crucial role in decreasing hospital readmissions, enhancing quality of life, and alleviating the financial strain on the healthcare system, integrating their role into the Iranian healthcare system presents both a challenge and an opportunity. The aim of this study, using a qualitative approach, was to explore the barriers and challenges associated with implementing Clinical Nurse Specialist (CNS) roles in the Iranian healthcare system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study was conducted using the directed content analysis approach. A purposeful sampling method with maximum variation was performed among the nurses holding a master's degree or higher. Data were collected using 19 in-depth semi-structured interviews and analysis process was conducted using the Graneheim and Lundman method, utilizing MAXQDA software version 10.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe analysis revealed three main categories in the structural dimension, two main categories in the process dimension, and one main category in the outcome dimension. In the structural dimension, the main categories identified were human resources, organizational structure, and facilities. In the process dimension, the main categories included the interactive processes involved in the implementation of care and treatment, as well as diagnosis and treatment. In the outcome dimension, the primary category was health status\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe successful integration of CNS roles into Iran\u0026rsquo;s healthcare system requires addressing the multifaceted barriers identified in this study. By drawing on international experiences and tailoring strategies to the unique socio-cultural and organizational context of Iran, policymakers and healthcare leaders can unlock the potential of CNSs to improve healthcare quality, reduce costs, and enhance patient satisfaction. The findings of this study serve as a foundation for developing evidence-based policies and practices that support the optimal utilization of highly qualified nursing professionals in Iran.\u003c/p\u003e","manuscriptTitle":"Barriers and Opportunities in the Implementation of Clinical Nurse Specialist Roles in Iran's Healthcare System: A Qualitative Exploration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 13:12:55","doi":"10.21203/rs.3.rs-6602437/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-31T19:34:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170176315074700100705960540290819869526","date":"2025-08-21T11:48:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-16T07:42:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82783604800782236793552615955015069698","date":"2025-08-12T03:24:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T09:36:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-21T10:48:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-21T10:43:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T12:59:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-20T12:58:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7c03062c-fefa-4305-aed8-725b81d0e3d4","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-19T13:12:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 13:12:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6602437","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6602437","identity":"rs-6602437","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}