Comparison of Iran’s nursing education with developed and developing countries: a review on descriptive-comparative studies

Nursing education, as a part of higher education system, plays an essential role in the training of nurses, who are known as the backbone of the primary healthcare system all over the world [1]. The nursing education is aimed to train qualified nurses with an appropriate level of knowledge, attitudes, and skills, who can promote the life quality of individuals, families, and community by accepting the roles and responsibilities in line with changing needs of society and developments of healthcare system [2, 3]. Following globalization and developing information and communication technology, nursing education has been developing in quality and quantity, especially in developing countries [4].

As with many other developing countries, nursing education in Iran was introduced by Western missionaries and is mostly influenced by education models in the United States and England [5]. However, in the last decades, especially following the Islamic revolution (1979) and the Iran-Iraq war (1980–88), nursing education in Iran has undergone significant changes and modifications to be more adaptable to the country’s context [6]. These changes were also made to address the growing complexity of the healthcare system, such as increase quality of care, promote nursing authority and competency, improve the social image of nursing profession, and evidence-based nursing care [7‐9]. The modifications include but not limited to the establishment of nursing faculties, transferring of nursing education to the universities, gender equality in nursing education, and developing postgraduate programs [5, 10].

Despite the positive effects of educational changes on developing nursing profession in Iran, like many other developing countries, it has faced undeniable challenges in different aspects and levels. Some of these challenges include increasing rate of student admission to compensate for nursing shortage, inadequate faculty members and clinical instructors, inadequate facilities and clinical training settings, and the gap between knowledge and clinical practice [4, 11, 12].

In Iran, the most important challenge in nursing is the shortage of nurses [13]. The results of a study in 2015 in Iran indicate a shortage of 130,000 nurses and its forecast to 200,000 nurses in 2020 [14]. The number of nurses per hospital bed in different provinces of Iran is 0.6 (less than one nurse) to 1.5 people (more than one nurse). Also, the ratio of nurses per thousand population in Iran is 1.5 people. Iran ranks lower than Egypt, Turkey, Oman, UAE, Kuwait and Qatar [15]. The most important reasons for the challenge of shortage of nurses in Iran are poor social status, early retirement, immigration, willingness to abandon the current job, employment in other jobs, work-related injuries, low employment rates, housekeeping and increase of hospital beds [13]. One strategy considered in Iran to address the challenge of nursing shortage was to increase the number of nursing schools to increase nursing student enrollment. Every year, 11,000 to 15,000 people in Iran graduate from the field of nursing, and 50,000 nursing students are taught at three levels of bachelor, master and doctorate under the supervision of two thousand faculty members in Iranian universities [15]. Increasing the prevalence of chronic diseases is one consequence of life expectancy in Iran [16]. The High prevalence of chronic diseases and advancing age of the Iraniain population in recent years have been considered in the curricula of postgraduate programs and the field of geriatric nursing was launched in 2010 [17].

As a recent challenge, the Covid 19 pandemic has affected various aspects of Iranian life, including education. The results of a qualitative study in Iran showed that although the Covid 19 pandemic created many challenges in the nursing education process, these challenges were associated with opportunities such as emerging technology, innovative educational methods [18].

Considering this reason, and since high-quality education plays a pivotal role in training competent students that have a close relationship with quality of nursing care and patient’s safety, nursing education should move towards ongoing evaluation and promotion [19]. In the other word, it is necessary to modify the nursing education regularly and dynamically based on the ongoing economic, political, and social changes to progress the quality of nursing education and prepare nurses not only for the complexities of the modern health care system but also in meeting the health needs of the country [20].

Today, developing countries are trying to promote and reinforce their nursing education by adopting experiences of other countries, with appropriate and successful education systems [21]. Therefore, using the experiences of these countries in different education levels of nursing, by considering the cultural, political, economic, and social context of Iran, could help to resolve recent challenges in Iran’s nursing education [7]. Recent studies indicated a great interest in comparing the similarities and differences of nursing education in Iran and other countries at different levels to evaluate its status. However, to the best of our knowledge, these studies have not been synthesized to provide a comprehensive understanding of how to promote the nursing education of Iran. Hence, the review is to summarize the studies that evaluate the status of nursing education in Iran by comparing it with other countries, and then present strategies based on the synthesis of included studies. Also, to better describe the development and recent changes of nursing education in Iran, its related evolution was reviewed.

A comprehensive computer-based search was conducted to find full-text and peer-reviewed studies published in English or Persian, up to May 2021. The search was performed on PubMed, Scopus, Web of Science Core Collection, ProQuest, Science Direct, Google Scholar, and also two Iranian databases, including Scientific Information Database (SID, http://​www.​sid.​ir/​) and MagIran (http://​www.​magiran.​com) with no time restriction on the publication. A combination of the following keywords or terms was used: nursing, nurse, education, training, learning, teaching, instruction, coaching, curriculum, evolution, development, history, comparative analysis, Bereday's model, Iran, and Iranian. To find all qualified studies addressing the issue, a manual search was performed through the reference lists of the relevant bibliographies.

We included descriptive-comparative studies if it evaluated the nursing education system, programs, or curriculum in Iran, by comparing it with developing or developed countries using Bereday's model which composes four stages of description, interpretation, juxtaposition, and comparison [22]. We also included qualitative studies and reviews if they addressed history, development, or evolutionary aspects of Iran’s nursing education. But the evidence was excluded if it: 1) was conference proceeding, expert opinion or commentary, 2) only critiqued the Iranian nursing education without comparison with other countries, 3) used other models for comparison of the Iranian nursing education, 4) only reviewed the related challenges or issues in Iranian nursing education, and 5) had low rigor. The rigor of the evidence was evaluated according to methodological quality, authenticity, informational value, and representativeness on a two-point scale (high or low) by two independent investigators [23].

To better address the development process of Iran’s nursing education and understand the concern, organizational documents about Iran’s nursing education programs or curriculum were also included. These documents were obtained via electronic or manual search from the Supreme Council of Planning (SCP) affiliated with the Iranian Ministry of Culture and Higher Education or Supreme Council of Planning in Medical Science (SCPMS) affiliated with the Iranian Ministry of Health and Medical Education (MoHME).

The evidence was identified and selected by three investigators independently from November 11, 2019, to June 14, 2021. In the initial search, 753 studies were identified through the computer-based search. After removing 26 duplicates, 727 records were screened by titles and abstracts and 524 irrelevant records were excluded. Based on a full-text evaluation of the remaining 203 items, 167 records were excluded. We included 25 descriptive-comparative studies [17, 24‐47], four qualitative studies [6, 48‐50], and seven reviews [5, 7, 9, 10, 51‐54] (Table 1). Also, we used 37 organizational documents [55‐91](Fig. 1).

The data of all eligible evidence was summarized using a data extraction form. For all evidence, except organizational documents, details on the author(s) name, publication year, design and objective, evaluated program, and the main findings or conclusion were extracted. If it was necessary, contact was made with the author(s) of the selected evidence to elaborate on the required details. For organizational documents, characteristics of education program, publication year, and the main contents were extracted. With the data extraction, the data synthesis was performed. First, the included evidence was stratified by the evaluated program to organize data into a manageable framework. Second, in each stratify, relevant data of each source was extracted and compiled into a display matrix. Finally, the extracted data in each category were compared, and similar data were grouped and integrated into a comprehensive summation, and it was continually revised to be inclusive much [23]. For accuracy and confirmability of data extraction and synthesis, the process was independently performed by the three investigators, and discussions were held to reach an agreement.

Nurses are the largest group of healthcare providers who play an important role in fulfilling health system mission. Studies have emphasized on the key role of nurses in patients’ lifestyle improvement, diseases prevention, health promotion, and patients’ coping with chronic diseases [93]. In Iran, patients’ level of awareness and expectations about nursing quality care has increased in recent years, which highlight the importance of nurses with more desirable professional competencies [9, 94].

The role of healthcare professionals, including nurses, is expected to change soon. Conventional models of healthcare that mainly focus on providing emergency, acute, and elective services are imperative, but it is not enough, since it cannot provide integrative and collaborative care. Also, sharing information is required for future’s patients, who will become elderly, multiple morbidities, dependent, and often confused [95].

Considering the recent changes and challenges of the healthcare system and educational system, nursing education in Iran requires more attention. Based on the included studies, the Iran’s nursing education does not hold a dissatisfactory position in comparison with other countries. However, Iranian nursing educational system and programs has to be reviewed and revised in selecting its goals and graduate needs, especially in postgraduate levels. We suggest that the concept of “hospitals without walls” to be given more attention in the training of nursing students to provide care at a place and time that will make the patient or client feel more comfortable with emphasis on holistic, integrative, and collaborative care, using a multidisciplinary team approach [95]. Providing care in the community and for elderly and patients involved in multiple chronic diseases should be prioritized, which needs more attention of the Iranian nursing educational system. Even though MSN program in “Geriatric nursing” and also “community health nursing” was developed, there is no certain work position for graduates, and most work in other fields of nursing [44, 81, 84]. In addition, “Telenursing” education should be embedded in the Iranian nursing curriculum because the concept of “Telenursing” will be more emphasis in the upcoming years in Iran and most services are expected to be provided in this way. Nursing students must be trained in a way to provide care in high-tech work environments by providing the required infrastructure and equipment [96]. Generally, the goals of Iran’s nursing education should addressed: 1) advancement in technology; 2) globalization; 3) the era of the educated consumer, alternative therapies, genomics, and palliative care; 4) a shift to population-based care and the increasing complexity of patient care; 5) healthcare costs and challenges posed by managed care; 6) a growing need for interdisciplinary education and collaborative practice; 7) the impact of health policy and regulation; 8) the growing nursing shortage along with the opportunities for lifelong learning and workforce development; and 10) significant advances in nursing science and research [97].

Most Iranian universities or educational nursing programs do not have a clear philosophy, mission, and goals to develop their framework. In addition, Iranian nursing educational programs, especially in graduate level, consist mainly theoretical lessons, which are usually not relate to each other and does not consider the professional interests of students and the community’s needs and demands. Iranian postgraduates’ programs often result in some impracticable thesis/dissertation, while the students do not acquire enough skills and expertise in a specialized nursing field. Hence, Iranian nursing educational system and programs has to be reviewed and revised in different dimensions. In this regards, most included studies have suggested a decentralized method for admitting applicants and a need for more flexible curriculum based on the needs of the community and common diseases while considering cultural, social, historical, and economical background [17, 24‐47]. In addition, these suggestions should be prioritized:

The Iranian nursing education system does not hold a dissatisfactory position. However, to prepare future highly competent nurses to be more versatile for the upcoming changes and advancement, it is expected to Iranian nursing education be reviewed and revised in selecting its goals; admission methods; graduate needs; and research, teaching, and evaluation methodologies, by adopting experiences of other countries, with an appropriate and successful education system.