Reforming Nursing Reimbursement: Direct Payment Models Under Iran’s Nursing Service Act in a Global Context

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In 2007, Iran introduced the Nursing Services Tariff and Adjustment of Nursing Costs Act, a pioneering legislative effort that diverged from traditional payment frameworks by establishing a direct reimbursement model for nursing services. This study evaluates Iran’s Nursing Services Tariff Act as a novel direct reimbursement approach, comparing its structure and impacts with nursing payment systems in the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway. The analysis focuses on professional empowerment and systemic outcomes. Methods Employing a qualitative comparative design, this research integrated semi-structured interviews with six key stakeholders in Iran and a thematic analysis to uncover central insights. A cross-national comparison examined reimbursement mechanisms, legislative contexts, and health system performance across the eight countries. Secondary data were systematically analyzed, complemented by a SWOT framework to assess strengths, weaknesses, opportunities, and challenges. Results Iran’s tariff-based model distinctively compensates nursing services independently, contrasting with bundled payment systems (e.g., United States) or salaried structures (e.g., United Kingdom). Qualitatively, two themes emerged: Professional Development (strengthened identity, satisfaction, justice) and Health System Productivity (cost optimization, patient satisfaction, care quality). However, sustained success demands robust infrastructural support. Conclusion Iran’s Nursing Services Tariff Act presents an innovative model that elevates nursing visibility and optimizes healthcare delivery. Though challenges such as funding allocation persist, the framework offers valuable insights for global healthcare reform. Future studies should explore its scalability and economic viability to inform broader adoption. Direct payment models Health policy Nursing reimbursement Nursing Service Act professional development Contributions to the literature Introduces Iran’s Nursing Service Act, the first direct reimbursement model for nursing, contrasting with global bundled/salaried systems. Shows how direct payments improve nurse recognition, satisfaction, and care quality while optimizing costs. Provides policymakers with evidence to reform nursing reimbursement, stressing the need for funding and infrastructure. Addresses gaps in global literature on nursing compensation and its impact on healthcare outcomes. Highlights solutions for nurse retention and morale, critical challenges in healthcare worldwide. Background The absence of a distinct reimbursement model for direct payment to nurses obscures their critical role in delivering safe, high-quality, and cost-effective healthcare ( 1 ). In many systems, nursing costs are embedded within generalized patient room charges, and care is often billed under physician identifiers, diminishing recognition of nurses’ contributions ( 2 ). This lack of visibility may contribute to demotivation among nursing professionals, impacting retention and morale ( 3 ). Several studies suggest that direct payment pathways for nursing care could expand nurses’ roles in healthcare delivery, thereby enhancing patient access ( 4 – 6 ). Globally, data on nursing compensation are limited, with few countries employing standardized reimbursement models specific to nursing services ( 7 ). Instead, nurse salaries typically reflect local economic conditions, leaving the true value of their care unquantified ( 8 ). Iran’s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act), enacted on June 27, 2007, under Article 123 of the constitution, introduces a pioneering direct reimbursement framework—potentially the first of its kind globally ( 9 ). Its implementation, however, faced significant delays, spanning nearly 15 years until recent efforts by the Deputy of Nursing operationalized the model ( 10 ). This study aimed to compare nursing reimbursement models across different countries and to introduce the Nursing Service Act as a unique direct nursing reimbursement model from Islamic Republic of Iran (IRI). Methods 1. Research Design This study utilized a mixed qualitative-comparative design to examine direct nursing reimbursement models, with Iran’s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act) as the central case study, contextualized within a cross-national comparison. This approach integrates an in-depth exploration of policy implementation with a systematic evaluation of global reimbursement frameworks, enabling the identification of innovative practices and challenges. The research was approved by the Research Ethics Committees of Kermanshah University of Medical Sciences, under ethics code IR.KUMS.REC.1401.379, adhering to ethical standards for participant confidentiality and informed consent. 2. Study Components 2.1. Case Study: Iran’s Nursing Service Act The primary focus was an in-depth qualitative case study of Iran’s Nursing Service Act, a pioneering direct reimbursement model enacted in 2007. This component investigated its legislative origins, implementation trajectory, and outcomes over a 15-year period. 2.2. Comparative Analysis A comparative analysis evaluated nursing reimbursement systems in seven additional countries—the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway—selected for their diverse healthcare financing structures and approaches to nursing compensation. 3. Data Collection Data were collected through a multi-source strategy to ensure depth and breadth of evidence. 3.1. Primary Data Collection 3.1.1. Semi-Structured Interviews : In Iran, 6 semi-structured interviews were conducted with purposively selected policymakers, nursing administrators, and health system experts involved in the Nursing Service Act’s development and rollout. Interviews, lasting 45–60 minutes, explored policy design, barriers, and perceived impacts, using an iteratively refined guide. 3.2. Secondary Data Collection 3.2.1. Policy Documents : Legislative texts, government reports, and implementation guidelines were reviewed, including Iran’s Nursing Service Act (2007) and supplementary directives from the Deputy of Nursing. 3.2.2. Global Literature : A scoping review synthesized peer-reviewed studies, policy briefs, and reports from databases (PubMed, Scopus, WHO Global Health Observatory) and professional bodies (e.g., American Nurses Association, Royal College of Nursing), focusing on reimbursement mechanisms and nursing workforce policies. 4. Sampling 4.1. Countries : Iran was the focal case; comparator countries were chosen based on healthcare system diversity (e.g., single-payer vs. private insurance) and availability of nursing payment data. 4.2. Participants : Interviewees were selected via purposive sampling, targeting individuals with direct expertise in Iran’s reimbursement reform, ensuring rich, context-specific insights. 5. Data Analysis 5.1. Qualitative Case Study Analysis : Interview transcripts and Iranian policy documents were analyzed using reflexive thematic analysis, following Braun and Clarke’s six-phase framework, to identify themes such as policy intent, implementation delays, and stakeholder perspectives ( 11 ). 5.2. Comparative Analysis A bespoke comparative framework assessed three dimensions across all countries: ( 1 ) legislative and policy foundations, ( 2 ) reimbursement mechanisms (direct vs. bundled payments), and ( 3 ) implementation outcomes (e.g., nurse satisfaction, cost-effectiveness). Data were synthesized using matrix-based comparisons. SWOT Analysis: Each country’s model underwent a Strengths, Weaknesses, Opportunities, and Threats analysis to distill best practices and reform opportunities. 6. Rigor and Trustworthiness Triangulation : Converging evidence from interviews, documents, and literature mitigated bias and enriched findings. Reflexivity : The research team documented assumptions and decisions throughout the analysis to enhance transparency. Validation : Findings were validated through member checking with interview participants and peer debriefing with two external experts in health policy and nursing economics ( 12 ). Results 1. Comparative Analysis of Nursing Reimbursement Models The comparative analysis evaluated nursing reimbursement systems across eight countries: Iran, the United States, the United Kingdom, Australia, Canada, Denmark, Japan, and Norway, focusing on legislative foundations, reimbursement mechanisms, and implementation outcomes. A SWOT analysis complemented the framework, highlighting strengths, weaknesses, opportunities, and threats for each model. Iran : Under the Nursing Services Tariff and Adjustment of Nursing Fees Act (2007), Iran introduced a direct reimbursement model, shifting from bundled hospital payments to tariffs for specific nursing services. Implementation, delayed until approximately 2022, increased nurse visibility but faced challenges in funding allocation and administrative capacity ( 9 ). Strengths include enhanced professional recognition; weaknesses include slow rollout and resource constraints; opportunities lie in scalability; threats include economic instability. United States : Nursing costs are predominantly bundled into hospital Diagnosis-Related Group (DRG) payments under Medicare, with no direct reimbursement for nursing services ( 2 ). Private insurers follow suit, obscuring nurses’ financial contributions. Strengths include system simplicity; weaknesses include a lack of nurse-specific valuation; opportunities exist in value-based payment reforms; threats include resistance from hospital lobbies. United Kingdom : The National Health Service (NHS) funds nursing through salaried positions within a single-payer system, with no separate reimbursement for individual services ( 13 ). Strengths include equitable pay; weaknesses include limited recognition of specialized care; opportunities lie in integrating nursing tariffs; threats include budget cuts. Australia : Nurses are compensated via salaried roles under Medicare’s public system, supplemented by fee-for-service payments in the private sectors, though rarely nurse-specific ( 14 ). Strengths include workforce stability; weaknesses include underfunding of public nursing; opportunities exist in expanding private reimbursements; threats include disparities between sectors. Canada : Similar to the UK, Canada’s single-payer system embeds nursing costs in hospital budgets, with no direct payment model ( 15 ). Strengths include universal coverage; weaknesses include the invisibility of nursing contributions; opportunities lie in pilot reimbursement programs; threats include provincial funding variability. Denmark : Nurses receive salaries within a tax-funded healthcare system, with recent experimental direct payment pilots for home care services emerging ( 16 ). Strengths include high nurse satisfaction; weaknesses include slow policy innovation; opportunities lie in scaling pilots; threats include fiscal conservatism. Japan : Nursing costs are bundled into hospital fees under the national insurance system, with some fee-for-service elements for advanced practice nurses ( 17 ). Strengths include structured pay scales; weaknesses include limited direct reimbursement; opportunities exist in expanding nurse-led billing; threats include aging population costs. Norway : A tax-funded system compensates nurses via salaries, with no distinct service reimbursement ( 18 ). Strengths include robust welfare support; weaknesses include a lack of service-specific valuation; opportunities lie in integrating performance-based pay; threats include economic pressures. Synthesis Iran’s model stands out as the only fully implemented direct reimbursement system among the studied countries, contrasting with the predominant bundled or salaried approaches elsewhere. While Iran’s approach enhances nurse visibility, its delayed execution underscores implementation challenges absent in salaried systems like Denmark or Norway, though the latter sacrifice granular recognition of nursing value. 2. Qualitative Case Study Results: Iran’s Nursing Service Act The qualitative case study explored stakeholder perspectives on Iran’s Nursing Service Act through semi-structured interviews with six key informants: two women and four men, aged 45–95 years. Participants included five PhD holders in nursing and one MSc holder, with roles spanning a member of the Islamic Consultative Assembly, the Deputy Director of Education and Technology of the Nursing System Organization, the Director of the Nursing System Organization, the Deputy Director of Support of the Nursing System Organization, and a nursing school director. Their work experience averaged over 20 years, providing deep insights into policy reform. Reflexive thematic analysis identified two overarching themes: Professional Development and Health System Productivity , derived from six subthemes. 2.1. Professional Development Strengthening Professional Identity and Social Status : Interviewees emphasized that direct reimbursement elevated nurses’ recognition as autonomous professionals, shifting perceptions from ancillary staff to essential providers. One policymaker noted, “Tariffs gave nurses a voice in the system.” Increasing Nurses’ Job Satisfaction : Participants reported heightened morale as payments reflected their workload, with a nursing leader stating, “Nurses feel valued for the first time in decades.” Adjusting Perceived Justice : The model addressed pay inequities, aligning compensation with effort and expertise, as a director highlighted: “It’s about fairness—nurses see their worth acknowledged.” 2.2. Health System Productivity Optimizing Health System Costs : Stakeholders observed that tariffing reduced over-reliance on physicians for billable tasks, streamlining resource use. A participant remarked, “We’re cutting inefficiencies by paying for what nurses already do.” Increasing Patient Satisfaction : Direct payments correlated with improved care quality, as nurses prioritized patient needs over administrative burdens, per an administrator: “Patients notice the difference when nurses are empowered.” Improving Quality of Nursing Care : Enhanced funding supported training and staffing, with one interviewee noting, “Better pay means better skills, and that lifts care standards.” The qualitative findings underscore the Nursing Service Act’s dual impact: fostering professional growth among nurses and enhancing systemic efficiency. These themes align with Iran’s comparative uniqueness, reinforcing its potential as a model for direct reimbursement reform. Discussion This study illuminates Iran’s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act) as a pioneering direct reimbursement model, contrasting it with predominantly bundled or salaried nursing payment systems in the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway. The findings reveal dual impacts: professionally, direct payments enhance nurses’ identity, satisfaction, and perceived justice; systemically, they optimize costs, elevate patient satisfaction, and improve care quality. These outcomes position Iran’s model as a potential blueprint for reforming nursing reimbursement globally, addressing a critical gap in recognizing nurses’ economic value. The comparative analysis underscores a global reliance on indirect payment structures, where nursing costs are subsumed within hospital budgets or physician-led billing ( 19 ). In the United States, for instance, Diagnosis-Related Group (DRG) payments obscure nurses’ contributions, a practice linked to understaffing and burnout ( 3 ). Similarly, salaried systems in the UK, Canada, and Norway ensure workforce stability but fail to tie compensation to service-specific outputs, potentially undervaluing specialized care ( 20 ). Iran’s tariff-based approach, despite implementation delays, counters this trend by assigning monetary value to individual nursing acts, aligning with calls for value-based healthcare reforms ( 9 ). However, its challenges, funding constraints, and administrative bottlenecks mirror those in Denmark’s pilot programs, suggesting that direct reimbursement requires robust infrastructure. Qualitatively, the Professional Development and Health System Productivity themes resonate with prior research. Strengthening professional identity through direct payments echoes findings that financial recognition boosts nurses’ autonomy and societal standing ( 1 ). Increased job satisfaction and perceived justice align with studies linking equitable pay to reduced turnover and improved morale ( 21 ). Systemically, optimizing costs via nurse-led billing supports evidence that reallocating resources from physician-centric models enhances efficiency ( 22 ). Enhanced patient satisfaction and care quality corroborate the positive correlation between nurse empowerment and clinical outcomes ( 23 ). Iran’s model thus bridges a theoretical gap: while direct reimbursement is advocated in policy discourse ( 10 ), few countries have operationalized it at scale. These findings have significant implications. For policymakers, Iran’s model suggests that direct reimbursement can elevate nursing’s status and system efficiency, though success hinges on sustained investment and administrative capacity. For nursing leaders globally, it offers a framework to advocate for payment reform, challenging entrenched bundled systems. Future research should explore longitudinal outcomes of Iran’s tariffs on nurse retention and patient health metrics, alongside pilot studies in salaried systems (e.g., UK, Canada) to test direct payment feasibility. Comparative cost-effectiveness analyses could further quantify the model’s economic impact, addressing a gap in current literature. Strengths and Limitations The study’s strengths lie in its multi-method design, triangulating comparative data with stakeholder insights to offer a nuanced view of reimbursement reform. Iran’s case exemplifies how context-specific policies can address universal challenges, such as nurse invisibility, identified across diverse healthcare systems. However, limitations include the qualitative sample’s small size (n = 6), potentially limiting generalizability, and the reliance on secondary data for comparator countries, which may lack granularity. Additionally, the 15-year implementation lag in Iran raises questions about scalability absent economic stability, a threat also noted in the SWOT analysis. Conclusion The Nursing Services Tariff and Adjustment of Nursing Fees Act in Iran is a groundbreaking initiative in direct nursing reimbursement. By establishing a unique model that itemizes nursing services, standardizes tariffs, and incorporates quality and performance metrics, the act has significantly enhanced the recognition and reimbursement of nursing services. The successful implementation of this model provides valuable insights and lessons for other countries seeking to develop similar reimbursement systems. As the global healthcare landscape evolves, the recognition and adequate compensation of nursing services will remain critical for delivering safe, high-quality, and cost-effective care to patients worldwide. Abbreviations IRI Islamic Republic of Iran US United States UK United Kingdom Declarations Data availability The dataset supporting this study is available from the corresponding authors upon reasonable request. Funding No funding Ethics approval and consent to participate The research was approved by the Research Ethics Committees of Kermanshah University of Medical Sciences, under ethics code IR.KUMS.REC.1401.379, adhering to ethical standards for participant confidentiality and informed consent. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author Contribution N.H. Conceptualized the study, conducted semi-structured interviews. M.T.J. Performed thematic analysis and contributed to the cross-national comparison. A.A. Provided expertise on Iran’s Nursing Services Tariff Act and reviewed the manuscript. S.S. Conducted interviews and contributed to the SWOT framework analysis. T.K. Analyzed secondary data and assisted in drafting the manuscript. M.R wrote the main manuscript text and supported data collection and contributed to the qualitative comparative design, and A.E. Supervised the study, provided critical revisions, and finalized the manuscript. All authors reviewed and approved the final manuscript. References McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff. 2011;30(2):202–10. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364(11):1037–45. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. 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Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in Cost Effectiveness and Resource Allocation → Version 1 posted Editorial decision: Revision requested 13 Oct, 2025 Reviewers agreed at journal 30 Sep, 2025 Reviews received at journal 29 Sep, 2025 Reviewers agreed at journal 29 Sep, 2025 Reviews received at journal 05 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers invited by journal 18 Aug, 2025 Editor assigned by journal 06 Aug, 2025 Submission checks completed at journal 06 Aug, 2025 First submitted to journal 04 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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stressing the need for funding and infrastructure.\u003c/li\u003e\n \u003cli\u003eAddresses gaps in global literature on nursing compensation and its impact on healthcare outcomes.\u003c/li\u003e\n \u003cli\u003eHighlights solutions for nurse retention and morale, critical challenges in healthcare worldwide.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eThe absence of a distinct reimbursement model for direct payment to nurses obscures their critical role in delivering safe, high-quality, and cost-effective healthcare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In many systems, nursing costs are embedded within generalized patient room charges, and care is often billed under physician identifiers, diminishing recognition of nurses\u0026rsquo; contributions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This lack of visibility may contribute to demotivation among nursing professionals, impacting retention and morale (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Several studies suggest that direct payment pathways for nursing care could expand nurses\u0026rsquo; roles in healthcare delivery, thereby enhancing patient access (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGlobally, data on nursing compensation are limited, with few countries employing standardized reimbursement models specific to nursing services (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Instead, nurse salaries typically reflect local economic conditions, leaving the true value of their care unquantified (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Iran\u0026rsquo;s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act), enacted on June 27, 2007, under Article 123 of the constitution, introduces a pioneering direct reimbursement framework\u0026mdash;potentially the first of its kind globally (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Its implementation, however, faced significant delays, spanning nearly 15 years until recent efforts by the Deputy of Nursing operationalized the model (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aimed to compare nursing reimbursement models across different countries and to introduce the Nursing Service Act as a unique direct nursing reimbursement model from Islamic Republic of Iran (IRI).\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e1. Research Design\u003c/h3\u003e\n\u003cp\u003eThis study utilized a mixed qualitative-comparative design to examine direct nursing reimbursement models, with Iran\u0026rsquo;s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act) as the central case study, contextualized within a cross-national comparison. This approach integrates an in-depth exploration of policy implementation with a systematic evaluation of global reimbursement frameworks, enabling the identification of innovative practices and challenges. The research was approved by the Research Ethics Committees of Kermanshah University of Medical Sciences, under ethics code IR.KUMS.REC.1401.379, adhering to ethical standards for participant confidentiality and informed consent.\u003c/p\u003e\n\u003ch3\u003e2. Study Components\u003c/h3\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Case Study: Iran\u0026rsquo;s Nursing Service Act\u003c/h2\u003e\u003cp\u003eThe primary focus was an in-depth qualitative case study of Iran\u0026rsquo;s Nursing Service Act, a pioneering direct reimbursement model enacted in 2007. This component investigated its legislative origins, implementation trajectory, and outcomes over a 15-year period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Comparative Analysis\u003c/h2\u003e\u003cp\u003eA comparative analysis evaluated nursing reimbursement systems in seven additional countries\u0026mdash;the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway\u0026mdash;selected for their diverse healthcare financing structures and approaches to nursing compensation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Data Collection\u003c/h3\u003e\n\u003cp\u003eData were collected through a multi-source strategy to ensure depth and breadth of evidence.\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Primary Data Collection\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003e3.1.1. Semi-Structured Interviews\u003c/strong\u003e: In Iran, 6 semi-structured interviews were conducted with purposively selected policymakers, nursing administrators, and health system experts involved in the Nursing Service Act\u0026rsquo;s development and rollout. Interviews, lasting 45\u0026ndash;60 minutes, explored policy design, barriers, and perceived impacts, using an iteratively refined guide.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Secondary Data Collection\u003c/h2\u003e\n \u003cp\u003e\u003cspan\u003e\u003cstrong\u003e3.2.1. Policy Documents\u003c/strong\u003e: Legislative texts, government reports, and implementation guidelines were reviewed, including Iran\u0026rsquo;s Nursing Service Act (2007) and supplementary directives from the Deputy of Nursing.\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e\u003cstrong\u003e3.2.2. Global Literature\u003c/strong\u003e: A scoping review synthesized peer-reviewed studies, policy briefs, and reports from databases (PubMed, Scopus, WHO Global Health Observatory) and professional bodies (e.g., American Nurses Association, Royal College of Nursing), focusing on reimbursement mechanisms and nursing workforce policies.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e4. Sampling\u003c/h3\u003e\n\u003cp\u003e\u003cspan\u003e\u003cstrong\u003e4.1. Countries\u003c/strong\u003e: Iran was the focal case; comparator countries were chosen based on healthcare system diversity (e.g., single-payer vs. private insurance) and availability of nursing payment data.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003cstrong\u003e4.2. Participants\u003c/strong\u003e: Interviewees were selected via purposive sampling, targeting individuals with direct expertise in Iran\u0026rsquo;s reimbursement reform, ensuring rich, context-specific insights.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003e5. Data Analysis\u003c/h3\u003e\n\u003cp\u003e\u003cspan\u003e\u003cstrong\u003e5.1. Qualitative Case Study Analysis\u003c/strong\u003e: Interview transcripts and Iranian policy documents were analyzed using reflexive thematic analysis, following Braun and Clarke\u0026rsquo;s six-phase framework, to identify themes such as policy intent, implementation delays, and stakeholder perspectives (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003cstrong\u003e5.2. Comparative Analysis\u003c/strong\u003e\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eA bespoke comparative framework assessed three dimensions across all countries: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) legislative and policy foundations, (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) reimbursement mechanisms (direct vs. bundled payments), and (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) implementation outcomes (e.g., nurse satisfaction, cost-effectiveness). Data were synthesized using matrix-based comparisons.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSWOT Analysis: Each country\u0026rsquo;s model underwent a Strengths, Weaknesses, Opportunities, and Threats analysis to distill best practices and reform opportunities.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e6. Rigor and Trustworthiness\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eTriangulation\u003c/strong\u003e: Converging evidence from interviews, documents, and literature mitigated bias and enriched findings.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e: The research team documented assumptions and decisions throughout the analysis to enhance transparency.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eValidation\u003c/strong\u003e: Findings were validated through member checking with interview participants and peer debriefing with two external experts in health policy and nursing economics (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Comparative Analysis of Nursing Reimbursement Models\u003c/h3\u003e\n\u003cp\u003eThe comparative analysis evaluated nursing reimbursement systems across eight countries: Iran, the United States, the United Kingdom, Australia, Canada, Denmark, Japan, and Norway, focusing on legislative foundations, reimbursement mechanisms, and implementation outcomes. A SWOT analysis complemented the framework, highlighting strengths, weaknesses, opportunities, and threats for each model.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIran\u003c/b\u003e: Under the \u003cem\u003eNursing Services Tariff and Adjustment of Nursing Fees Act\u003c/em\u003e (2007), Iran introduced a direct reimbursement model, shifting from bundled hospital payments to tariffs for specific nursing services. Implementation, delayed until approximately 2022, increased nurse visibility but faced challenges in funding allocation and administrative capacity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Strengths include enhanced professional recognition; weaknesses include slow rollout and resource constraints; opportunities lie in scalability; threats include economic instability.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eUnited States\u003c/b\u003e: Nursing costs are predominantly bundled into hospital Diagnosis-Related Group (DRG) payments under Medicare, with no direct reimbursement for nursing services (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Private insurers follow suit, obscuring nurses\u0026rsquo; financial contributions. Strengths include system simplicity; weaknesses include a lack of nurse-specific valuation; opportunities exist in value-based payment reforms; threats include resistance from hospital lobbies.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eUnited Kingdom\u003c/b\u003e: The National Health Service (NHS) funds nursing through salaried positions within a single-payer system, with no separate reimbursement for individual services (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Strengths include equitable pay; weaknesses include limited recognition of specialized care; opportunities lie in integrating nursing tariffs; threats include budget cuts.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAustralia\u003c/b\u003e: Nurses are compensated via salaried roles under Medicare\u0026rsquo;s public system, supplemented by fee-for-service payments in the private sectors, though rarely nurse-specific (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Strengths include workforce stability; weaknesses include underfunding of public nursing; opportunities exist in expanding private reimbursements; threats include disparities between sectors.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCanada\u003c/b\u003e: Similar to the UK, Canada\u0026rsquo;s single-payer system embeds nursing costs in hospital budgets, with no direct payment model (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Strengths include universal coverage; weaknesses include the invisibility of nursing contributions; opportunities lie in pilot reimbursement programs; threats include provincial funding variability.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDenmark\u003c/b\u003e: Nurses receive salaries within a tax-funded healthcare system, with recent experimental direct payment pilots for home care services emerging (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Strengths include high nurse satisfaction; weaknesses include slow policy innovation; opportunities lie in scaling pilots; threats include fiscal conservatism.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJapan\u003c/b\u003e: Nursing costs are bundled into hospital fees under the national insurance system, with some fee-for-service elements for advanced practice nurses (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Strengths include structured pay scales; weaknesses include limited direct reimbursement; opportunities exist in expanding nurse-led billing; threats include aging population costs.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eNorway\u003c/b\u003e: A tax-funded system compensates nurses via salaries, with no distinct service reimbursement (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Strengths include robust welfare support; weaknesses include a lack of service-specific valuation; opportunities lie in integrating performance-based pay; threats include economic pressures.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSynthesis\u003c/strong\u003e\u003cp\u003eIran\u0026rsquo;s model stands out as the only fully implemented direct reimbursement system among the studied countries, contrasting with the predominant bundled or salaried approaches elsewhere. While Iran\u0026rsquo;s approach enhances nurse visibility, its delayed execution underscores implementation challenges absent in salaried systems like Denmark or Norway, though the latter sacrifice granular recognition of nursing value.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003e2. Qualitative Case Study Results: Iran’s Nursing Service Act\u003c/h3\u003e\n\u003cp\u003eThe qualitative case study explored stakeholder perspectives on Iran\u0026rsquo;s Nursing Service Act through semi-structured interviews with six key informants: two women and four men, aged 45\u0026ndash;95 years. Participants included five PhD holders in nursing and one MSc holder, with roles spanning a member of the Islamic Consultative Assembly, the Deputy Director of Education and Technology of the Nursing System Organization, the Director of the Nursing System Organization, the Deputy Director of Support of the Nursing System Organization, and a nursing school director. Their work experience averaged over 20 years, providing deep insights into policy reform.\u003c/p\u003e\u003cp\u003eReflexive thematic analysis identified two overarching themes: \u003cb\u003eProfessional Development\u003c/b\u003e and \u003cb\u003eHealth System Productivity\u003c/b\u003e, derived from six subthemes.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.1. Professional Development\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStrengthening Professional Identity and Social Status\u003c/b\u003e: Interviewees emphasized that direct reimbursement elevated nurses\u0026rsquo; recognition as autonomous professionals, shifting perceptions from ancillary staff to essential providers. One policymaker noted, \u003cem\u003e\u0026ldquo;Tariffs gave nurses a voice in the system.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIncreasing Nurses\u0026rsquo; Job Satisfaction\u003c/b\u003e: Participants reported heightened morale as payments reflected their workload, with a nursing leader stating, \u003cem\u003e\u0026ldquo;Nurses feel valued for the first time in decades.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAdjusting Perceived Justice\u003c/b\u003e: The model addressed pay inequities, aligning compensation with effort and expertise, as a director highlighted: \u003cem\u003e\u0026ldquo;It\u0026rsquo;s about fairness\u0026mdash;nurses see their worth acknowledged.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.2. Health System Productivity\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eOptimizing Health System Costs\u003c/b\u003e: Stakeholders observed that tariffing reduced over-reliance on physicians for billable tasks, streamlining resource use. A participant remarked, \u003cem\u003e\u0026ldquo;We\u0026rsquo;re cutting inefficiencies by paying for what nurses already do.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIncreasing Patient Satisfaction\u003c/b\u003e: Direct payments correlated with improved care quality, as nurses prioritized patient needs over administrative burdens, per an administrator: \u003cem\u003e\u0026ldquo;Patients notice the difference when nurses are empowered.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eImproving Quality of Nursing Care\u003c/b\u003e: Enhanced funding supported training and staffing, with one interviewee noting, \u003cem\u003e\u0026ldquo;Better pay means better skills, and that lifts care standards.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe qualitative findings underscore the Nursing Service Act\u0026rsquo;s dual impact: fostering professional growth among nurses and enhancing systemic efficiency. These themes align with Iran\u0026rsquo;s comparative uniqueness, reinforcing its potential as a model for direct reimbursement reform.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study illuminates Iran\u0026rsquo;s Nursing Services Tariff and Adjustment of Nursing Fees Act (Nursing Service Act) as a pioneering direct reimbursement model, contrasting it with predominantly bundled or salaried nursing payment systems in the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway. The findings reveal dual impacts: professionally, direct payments enhance nurses\u0026rsquo; identity, satisfaction, and perceived justice; systemically, they optimize costs, elevate patient satisfaction, and improve care quality. These outcomes position Iran\u0026rsquo;s model as a potential blueprint for reforming nursing reimbursement globally, addressing a critical gap in recognizing nurses\u0026rsquo; economic value.\u003c/p\u003e\u003cp\u003eThe comparative analysis underscores a global reliance on indirect payment structures, where nursing costs are subsumed within hospital budgets or physician-led billing (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the United States, for instance, Diagnosis-Related Group (DRG) payments obscure nurses\u0026rsquo; contributions, a practice linked to understaffing and burnout (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Similarly, salaried systems in the UK, Canada, and Norway ensure workforce stability but fail to tie compensation to service-specific outputs, potentially undervaluing specialized care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Iran\u0026rsquo;s tariff-based approach, despite implementation delays, counters this trend by assigning monetary value to individual nursing acts, aligning with calls for value-based healthcare reforms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, its challenges, funding constraints, and administrative bottlenecks mirror those in Denmark\u0026rsquo;s pilot programs, suggesting that direct reimbursement requires robust infrastructure.\u003c/p\u003e\u003cp\u003eQualitatively, the Professional Development and Health System Productivity themes resonate with prior research. Strengthening professional identity through direct payments echoes findings that financial recognition boosts nurses\u0026rsquo; autonomy and societal standing (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Increased job satisfaction and perceived justice align with studies linking equitable pay to reduced turnover and improved morale (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Systemically, optimizing costs via nurse-led billing supports evidence that reallocating resources from physician-centric models enhances efficiency (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Enhanced patient satisfaction and care quality corroborate the positive correlation between nurse empowerment and clinical outcomes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Iran\u0026rsquo;s model thus bridges a theoretical gap: while direct reimbursement is advocated in policy discourse (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), few countries have operationalized it at scale.\u003c/p\u003e\u003cp\u003eThese findings have significant implications. For policymakers, Iran\u0026rsquo;s model suggests that direct reimbursement can elevate nursing\u0026rsquo;s status and system efficiency, though success hinges on sustained investment and administrative capacity. For nursing leaders globally, it offers a framework to advocate for payment reform, challenging entrenched bundled systems. Future research should explore longitudinal outcomes of Iran\u0026rsquo;s tariffs on nurse retention and patient health metrics, alongside pilot studies in salaried systems (e.g., UK, Canada) to test direct payment feasibility. Comparative cost-effectiveness analyses could further quantify the model\u0026rsquo;s economic impact, addressing a gap in current literature.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study\u0026rsquo;s strengths lie in its multi-method design, triangulating comparative data with stakeholder insights to offer a nuanced view of reimbursement reform. Iran\u0026rsquo;s case exemplifies how context-specific policies can address universal challenges, such as nurse invisibility, identified across diverse healthcare systems. However, limitations include the qualitative sample\u0026rsquo;s small size (n\u0026thinsp;=\u0026thinsp;6), potentially limiting generalizability, and the reliance on secondary data for comparator countries, which may lack granularity. Additionally, the 15-year implementation lag in Iran raises questions about scalability absent economic stability, a threat also noted in the SWOT analysis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Nursing Services Tariff and Adjustment of Nursing Fees Act in Iran is a groundbreaking initiative in direct nursing reimbursement. By establishing a unique model that itemizes nursing services, standardizes tariffs, and incorporates quality and performance metrics, the act has significantly enhanced the recognition and reimbursement of nursing services. The successful implementation of this model provides valuable insights and lessons for other countries seeking to develop similar reimbursement systems. As the global healthcare landscape evolves, the recognition and adequate compensation of nursing services will remain critical for delivering safe, high-quality, and cost-effective care to patients worldwide.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIslamic Republic of Iran\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting this study is available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was approved by the Research Ethics Committees of Kermanshah University of Medical Sciences, under ethics code IR.KUMS.REC.1401.379, adhering to ethical standards for participant confidentiality and informed consent.\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\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.H. Conceptualized the study, conducted semi-structured interviews. M.T.J. Performed thematic analysis and contributed to the cross-national comparison. A.A. Provided expertise on Iran\u0026rsquo;s Nursing Services Tariff Act and reviewed the manuscript. S.S. Conducted interviews and contributed to the SWOT framework analysis. T.K. Analyzed secondary data and assisted in drafting the manuscript. M.R wrote the main manuscript text and supported data collection and contributed to the qualitative comparative design, and A.E. Supervised the study, provided critical revisions, and finalized the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses\u0026rsquo; widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff. 2011;30(2):202\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeedleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364(11):1037\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. lancet. 2014;383(9931):1824\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFink J, Nurse Reimbursement. AJN Am J Nurs. 2023;123(11):17\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWelton JM, Longyear R. Emerging nurse billing and reimbursement models. JONA: J Nurs Adm. 2024:101097.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRambur B, Liebermann E. Fully Support Nurses by Designing Better Payment Models. The Future of Nursing 2020\u0026ndash;2030: Global Applications to Advance Health Equity. Springer; 2023. pp. 99\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDi Nitto M, Napolitano F, Calzolari M, Longobucco Y, Masotta V, Zaghini F, et al. Billing models for measuring nursing care in inpatient and outpatient settings: a scoping review. BMC Health Serv Res. 2025;25(1):95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eM K. Nurses on the move: Migration and the global health care economy. Volume 5. Cornell University Press; 2018 Jul.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAskari MS, Rabeti M, Bayati M. Health economics perspectives of nursing services tariff setting in Islamic Republic of Iran. East Mediterr Health J. 2024;30(9):601\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoshmangir L, Rashidian A, Kouhi F, Gordeev VS. Setting health care services tariffs in Iran: half a century quest for a window of opportunity. Int J Equity Health. 2020;19:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V, Hayfield N, Davey L, Jenkinson E. Doing reflexive thematic analysis. Supporting research in counselling and psychotherapy: Qualitative, quantitative, and mixed methods research. Springer; 2023. pp. 19\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLincoln YS. Naturalistic inquiry: sage; 1985.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchan J, Ball J. Evaluating the impact of a new pay system on nurses in the UK. J Clin Nurs. 2011;20(1\u0026ndash;2):50\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWise S, Hall J, Haywood P, Khana N, Hossain L, van Gool K. Paying for value: options for value-based payment reform in Australia. Aust Health Rev. 2021;46(2):129\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFriend B. Nursing in a single payer health system. Md Nurse. 2010 2010/01//.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChristiansen T. Organization and financing of the Danish health care system. Health Policy. 2002;59(2):107\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTomoya Akiyama Naomi A, Kenshi Hayashida Hiroshi T. Economic Estimation of Nursing Services under the Diagnostic Procedure Combination/Per-Diem Payment System. Journal of Nursing \u0026amp; Care; 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRingard \u0026Aring;, Sagan A, Sperre Saunes I, Lindahl AK. Norway: health system review. Health Syst Transit. 2013;15(8):1\u0026ndash;162.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWelton JM, Harris K. Hospital Billing and Reimbursement: Charging for Inpatient Nursing Care. JONA: J Nurs Adm. 2007;37(4):164\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchan JSI. Nurses work: an analysis of the UK nursing labour market. Routledge; 2018. Dec 20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayes LJ, O\u0026rsquo;Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, et al. Nurse turnover: A literature review \u0026ndash; An update. Int J Nurs Stud. 2012;49(7):887\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChan RJ, Marx W, Bradford N, Gordon L, Bonner A, Douglas C, et al. Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review. Int J Nurs Stud. 2018;81:61\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpence Laschinger HK, Leiter MP. The Impact of Nursing Work Environments on Patient Safety Outcomes: The Mediating Role of Burnout Engagement. JONA: J Nurs Adm. 2006;36(5):259\u0026ndash;67.\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cost-effectiveness-and-resource-allocation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cera","sideBox":"Learn more about [Cost Effectiveness and Resource Allocation](http://resource-allocation.biomedcentral.com)","snPcode":"12962","submissionUrl":"https://submission.nature.com/new-submission/12962/3","title":"Cost Effectiveness and Resource Allocation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Direct payment models, Health policy, Nursing reimbursement, Nursing Service Act, professional development","lastPublishedDoi":"10.21203/rs.3.rs-7293007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7293007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eConventional healthcare payment systems often integrate nursing services within broader physician or institutional billing structures, inadvertently diminishing the recognition and motivation of nurses. In 2007, Iran introduced the Nursing Services Tariff and Adjustment of Nursing Costs Act, a pioneering legislative effort that diverged from traditional payment frameworks by establishing a direct reimbursement model for nursing services. This study evaluates Iran\u0026rsquo;s Nursing Services Tariff Act as a novel direct reimbursement approach, comparing its structure and impacts with nursing payment systems in the United States, United Kingdom, Australia, Canada, Denmark, Japan, and Norway. The analysis focuses on professional empowerment and systemic outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eEmploying a qualitative comparative design, this research integrated semi-structured interviews with six key stakeholders in Iran and a thematic analysis to uncover central insights. A cross-national comparison examined reimbursement mechanisms, legislative contexts, and health system performance across the eight countries. Secondary data were systematically analyzed, complemented by a SWOT framework to assess strengths, weaknesses, opportunities, and challenges.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIran\u0026rsquo;s tariff-based model distinctively compensates nursing services independently, contrasting with bundled payment systems (e.g., United States) or salaried structures (e.g., United Kingdom). Qualitatively, two themes emerged: Professional Development (strengthened identity, satisfaction, justice) and Health System Productivity (cost optimization, patient satisfaction, care quality). However, sustained success demands robust infrastructural support.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIran\u0026rsquo;s Nursing Services Tariff Act presents an innovative model that elevates nursing visibility and optimizes healthcare delivery. Though challenges such as funding allocation persist, the framework offers valuable insights for global healthcare reform. Future studies should explore its scalability and economic viability to inform broader adoption.\u003c/p\u003e","manuscriptTitle":"Reforming Nursing Reimbursement: Direct Payment Models Under Iran’s Nursing Service Act in a Global Context","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-26 10:43:09","doi":"10.21203/rs.3.rs-7293007/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T12:09:21+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"202468228163104246655161467731815305876","date":"2025-09-30T07:32:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T16:33:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233733055896466659647237680090624849897","date":"2025-09-29T13:23:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T03:37:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T20:43:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3512063611698992873624883562457670420","date":"2025-08-26T09:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190620944624262129776695718191288986141","date":"2025-08-26T09:13:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-18T12:47:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-06T15:12:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-06T15:12:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cost Effectiveness and Resource Allocation","date":"2025-08-04T15:54:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cost-effectiveness-and-resource-allocation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cera","sideBox":"Learn more about [Cost Effectiveness and Resource Allocation](http://resource-allocation.biomedcentral.com)","snPcode":"12962","submissionUrl":"https://submission.nature.com/new-submission/12962/3","title":"Cost Effectiveness and Resource Allocation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0fb93eea-5352-4d25-a5a3-6a7e6738f2a9","owner":[],"postedDate":"August 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:00:33+00:00","versionOfRecord":{"articleIdentity":"rs-7293007","link":"https://doi.org/10.1186/s12962-025-00690-0","journal":{"identity":"cost-effectiveness-and-resource-allocation","isVorOnly":false,"title":"Cost Effectiveness and Resource Allocation"},"publishedOn":"2025-12-12 15:57:10","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-08-26 10:43:09","video":"","vorDoi":"10.1186/s12962-025-00690-0","vorDoiUrl":"https://doi.org/10.1186/s12962-025-00690-0","workflowStages":[]},"version":"v1","identity":"rs-7293007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7293007","identity":"rs-7293007","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}