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# Role of nurses in the management of noncommunicable diseases in Middle Eastern countries: A scoping review

Joy Hanoun, Pascale Beloni, Jean Toniolo

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## To cite this version:

Joy Hanoun, Pascale Beloni, Jean Toniolo. Role of nurses in the management of noncommunicable diseases in Middle Eastern countries: A scoping review. Nursing Outlook, 2025, 73 (4), pp.102479. 10.1016/j.outlook.2025.102479. hal-05313483

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# Role of nurses in the management of noncommunicable diseases in Middle Eastern countries: A scoping review

<figure><img src="image_4.png" /></figure>

Joy Hanoun, RN, MPH, PhD(c) a, c, *, Pascale Beloni, RN, PhD a, b, Jean Toniolo, RN, MPH, PhD a, b

## ARTICLE INFO

**Article history:**

Received 17 March 2025

Received in revised form 25 May 2025

Accepted 5 June 2025

Available online 2 July 2025

**Keywords:**

Nurses

Nurse-led management

Chronic diseases

Nurses' knowledge

Middle East

Health policy

## ABSTRACT

**Background:** Chronic diseases affect over 20 million people in the Middle East, posing major public health challenges. Task shifting—particularly nurse-led care—is a promising strategy to address care gaps; however, yet its scope and effectiveness in this region remain poorly documented.

**Purpose:** This scoping review aimed to describe nurses' roles in chronic disease management across the Middle East, assess their knowledge levels, and identify existing challenges.

**Methods:** Following Cochrane guidelines, we searched six databases (January–February 2024), screened studies in duplicate, and conducted a descriptive analysis. Study quality was appraised using the Downs and Black checklist (quantitative) and the CASP checklist (qualitative).

**Discussion:** Sixty-seven studies were included. Nurses were involved in various domains such as palliative care, diabetes management, patient education, and pandemic response. Key barriers included limited training, emotional burden, and cultural taboos.

**Conclusion:** Nurses play a critical yet under-recognized role. Strengthening education, policy support, and advanced roles is vital to improving chronic disease care in the region.

**Reporting Method:** PRISMA.

© 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

## Introduction

The Middle East is a geographical area that stretches from the eastern Mediterranean to Western Asia and includes parts of North Africa. While there is no universally agreed-upon definition, the region generally encompasses countries such as Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey, the United Arab Emirates, and Yemen. Some classifications also include Afghanistan and Libya, particularly in analyses of regional health trends. The Middle East is renowned for its significant geopolitical, historical, and cultural importance and is the birthplace of several ancient civilizations and major world religions (Encyclopaedia Britannica, 2024).

The Middle East is undergoing a significant epidemiological transition marked by a rising burden of chronic diseases, even as infectious diseases remain a persistent challenge (Al-Mandhari et al., 2021; Memish et al., 2014). This shift is driven by rapid economic

development, urbanization, and lifestyle changes, including increased tobacco use, physical inactivity, and unhealthy diets (Afshin et al., 2019; WHO EMRO, 2023). Chronic diseases, or non-communicable diseases (NCDs), are defined as long-term health conditions that are not transmissible and often progress slowly, including cardiovascular diseases (CVDs), cancer, diabetes, chronic respiratory diseases, and mental health disorders (World Health Organisation, 2021). Globally, NCDs account for 74% of all deaths (World Health Organisation, 2022), with low- and middle-income countries, including those in the Middle East, bearing a disproportionate burden (GBD 2019 NCD Collaborators, 2023).

In the Middle East, NCDs contribute significantly to mortality and morbidity. For instance, Saudi Arabia reports that NCDs are responsible for 73% of deaths (Saudi Ministry of Health, 2021), while Iran faces an NCD-related mortality rate of 82% (Djalalinia et al., 2022). Similarly, Egypt has seen a steady rise in NCD prevalence, with CVDs and diabetes emerging as leading causes of disability (El-Saadani et al., 2021). Despite these alarming trends, health care systems in the region face critical challenges, including workforce shortages, uneven resource distribution, and fragmented care delivery (Alharbi et al., 2024; World Bank, 2022). For example, Egypt

<footnote>ª Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France</footnote>

<footnote>ᵇ Département Universitaire de Sciences Infirmières, Facultés de Médecine et Pharmacie, Université de Limoges, Limoges, France</footnote>

<footnote>ᶜ Département des Sciences Infirmières, Faculté de Santé Publique, Université Antonine, Hadat-Baabda, Lebanon</footnote>

<footnote>* Corresponding author: Joy Hanoun, Institute of Epidemiology and Tropical Neurology, 2 rue du Dr Marcland, 87025 Limoges cedex, France.
E-mail address: joy.hanoun@unilim.fr (J. Hanoun).</footnote>
has 0.9 physicians and 1.8 nurses per 1,000 population, whereas Saudi Arabia reports 3.1 physicians and 4.2 nurses per 1,000 (WHO Global Health Observatory, 2023).

Nurses play a pivotal role in mitigating the NCD burden, particularly as frontline providers in primary care and chronic disease management. The World Health Organization (WHO) emphasizes nurse-led interventions as a key strategy for achieving universal health coverage by 2030 (World Health Organisation, 2023). Expanding nurses' scope of practice—through advanced roles such as nurse practitioners (NPs) and clinical specialists—has proven effective in improving NCD outcomes, especially in underserved regions (Al-Ruzzieh et al., 2022; Maier et al., 2021). Task shifting, where nurses assume responsibilities traditionally held by physicians, has also demonstrated success in chronic disease management (Kara et al., 2023; Toniolo et al., 2024). Nurses contribute through patient education, lifestyle counseling, chronic disease clinics, and telehealth services (Alharbi et al., 2024; Bauer et al., 2020).

Despite their critical role, there remains a gap in understanding the specific competencies, knowledge, and challenges faced by nurses across different Middle Eastern countries in managing NCDs (Toniolo et al., 2024). A comprehensive review of their roles is essential to identify strengths, gaps, and opportunities for policy reform, education, and resource allocation. By defining nurses' contributions across this diverse region, health care leaders can optimize workforce strategies, enhance training programs, and build resilient health systems capable of addressing both infectious diseases and the growing NCD crisis (WHO EMRO, 2023).

What are the roles and knowledge of nurses in managing NCDs in the Middle East?

This study provides a comprehensive analysis of nurses' current roles in NCD management across Middle Eastern countries. It assesses their knowledge levels, identifies challenges, and highlights practice gaps. The findings will inform targeted interventions to strengthen nursing capacity, promote policy coherence, and improve chronic disease outcomes throughout the Middle East.

## Methods

We conducted a scoping review (Munn et al., 2018) following the key points outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al., 2019) and adhered to the PRISMA Extension for Scoping Reviews guidelines (Tricco et al., 2018). The review was conducted from January 01, 2024 to February 20, 2024. This study and its protocol were registered in the PROSPERO database (CRD42024510225).

## Justification for Scoping Review

A scoping review was chosen as the most appropriate methodology for this study because it allows for comprehensive mapping of the existing literature on the roles and knowledge of nurses in managing NCDs in the Middle East. Given the broad and exploratory nature of the research question, a scoping review is well-suited for identifying key concepts, summarizing the current evidence, and highlighting gaps in the literature. This approach is particularly valuable for informing future research, policy development, and practice improvements in nurse-led NCD management in this diverse and under-researched area.

## Search Strategy

To identify relevant articles, six sources were searched as follows: MEDLINE, CINAHL, Web of Science, Google Scholar, Embase, and PsycINFO (Bramer et al., 2017). The search strategy used a combination of subject headings and keywords related to the main topics of the review: nursing, NCDs, and the Middle East. Additionally, a

"title and abstract" search was performed in MEDLINE. The search strategy was adapted based on the specificity of each database. The search strategy used for each database is presented in Table S1.

## Inclusion and Exclusion Criteria

For the "population" segment, the review included all studies that assessed nurse-led care for NCDs, nurses' understanding of NCDs, or adult patients receiving nursing interventions for NCD management in the Middle East. The "intervention" section included any nurse-led interventions related to the care of chronic diseases, whether delivered in inpatient, outpatient, or community-based settings. This encompasses tasks typically performed by physicians (Maier & Aiken, 2016), as well as studies assessing nurses' knowledge of chronic disease management. The "outcomes" considered were the effectiveness of nursing interventions, the level of nurses' knowledge about NCDs, and the challenges and gaps identified in their management. Regarding "study design," the review was open to different research methodologies relevant to the topic. Studies were excluded if they did not provide clear results for nurses, were incomplete or ongoing, contained editorial content, were conference proceedings, or were published in non-peer-reviewed journals. There were no restrictions on language or publication dates.

## Selection and Data Collection Processes

Rayyan QCRI was used to manage all identified articles and remove duplicates (Ouzzani et al., 2016).

The study selection process was conducted independently by two researchers who were blinded to each other's decisions at each stage. Initially, studies were identified by reading the titles and abstracts, and eligible articles were read in full. In the case of disagreement, a third researcher was consulted.

## Data Extraction and Data Synthesis

Data extraction was performed systematically using an Excel spreadsheet that included information such as the first author's name, year of publication, journal, country in which the study was conducted, main objective, study design, disease, intervention/care of interest, sample characteristics, intervention/care outcomes, facilitators, barriers, and study limitations identified by the authors. A descriptive synthesis was used, and no meta-analysis was performed. Subgroup analyses were performed according to disease type and location.

## Quality Assessment

A descriptive analysis of the included studies was conducted, and their quality was assessed using the Downs and Black Scale (1998) for quantitative studies. Although the original authors did not define specific cutoff points for quality categories, subsequent studies have proposed classifications. For instance, a systematic review by Silverman et al. (2012) categorized scores as follows: excellent (26–28), good (20–25), fair (15–19), and poor (≤14). Similarly, Kosik et al. (2019) applied comparable thresholds in their assessment of randomized controlled trials. The quality of qualitative studies was assessed using the CASP checklist for qualitative research, along with the COREQ checklist from the EQUATOR Network to ensure comprehensive reporting standards (Tong et al., 2007).

This study did not require ethical approval.

## Results

A total of 651 records were identified in six electronic databases: MEDLINE (n = 131), CINAHL (n = 112), Web of Science (n = 300),
Embase (n = 24), and PsycINFO (n = 60). After the removal of 25 duplicate records, 626 unique records remained and were screened based on their title and abstract. During the screening phase, 432 records were excluded for not meeting the predefined inclusion criteria. These exclusions were primarily due to the absence of relevance to chronic disease management, lack of a nursing focus, or the records being unrelated to editorials, commentaries, or clinical studies.

This left 194 articles for full-text review. Among these, 97 full-text articles were assessed for eligibility. The remaining full texts were either inaccessible or duplicated from previously included studies. Of the 97 full-text articles reviewed, 30 were excluded for various reasons. In 26 cases, the population studied was not specific to nursing. Two studies did not clearly define or describe nursing roles. One study did not involve any nursing intervention related to

NCDs, and one article was based solely on the author's experience or was a nonsystematic literature review.

Ultimately, 67 studies met the inclusion criteria and were included in the qualitative synthesis of this scoping review (Figure 1).

## Description of the Selected Studies

Table S2 presents the characteristics of each study. Of the 626 studies identified between 1969 and February 2024, 67 were included. The main study designs were as follows: 20 cross-sectional studies, 24 interventional studies (including eight randomized controlled trials, eight quasi-experimental studies, and eight non-randomized studies), and 23 qualitative studies. These studies included 2,962 nurses and 8,249 patients in total.

<figure><img src="image_5.png" /><figcaption>**Figure 1.** PRISMA flowchart.
Source: http://www.prismastatement.org/ (Toniolo et al., 2024).</figcaption></figure>
Turkey was the country with the highest number of studies related to our review (n = 25) (Akin et al., 2008; Admi et al., 2017; Admi et al., 2013; Akin et al., 2010; Bayram et al., 2014; Ben-Arye et al., 2017; Borimnejad et al., 2018; Granek et al., 2019; Güner et al., 2018; Kadmon et al., 2015; Kamisli et al., 2017; Khorami Markani et al., 2013; Kuzeyli Yildirim, 2008; Kuzeyli Yildirim et al., 2009; Monas et al., 2012; Oran, 2001; Oskay et al., 2014; Oz et al., 2012; Ozaras and Abaan, 2018; Secginli & Nahcivan, 2011; Seven et al., 2017; Shahriary et al., 2015; Tirgari et al., 2012; Tokkaya & Karayurt, 2010; Usta Yeşilbalkan et al., 2009), followed by Iran (n = 17) (Abu Kishk et al., 2019; Al-Saadi et al., 2024; Bagheri et al., 2012; Blaer et al., 2003; Bashkin et al., 2023; Dayan et al., 2021; Eilat-Tsanani et al., 2016; Kara et al., 2023; Mohammadpour et al., 2015; Moosavi et al., 2020; Nir et al., 2009; Nouhi et al., 2021; Obaid et al., 2023; Saouma Nehmé et al., 2020; Şengün İlan et al., 2023; Uslu & Arslan, 2023), and Israel (n = 11) (Admi et al., 2013; Admi et al., 2017; Bashkin et al., 2023; Ben-Arye et al., 2017; Blaer et al., 2003; Delabr, 1999; Eilat-Tsanani et al., 2016; Granek et al., 2019; Kadmon et al., 2015; Monas et al., 2012; Nir et al., 2009).

Lebanon (n = 2) (Doumit et al., 2007; Saouma Nehmé et al., 2020) and Palestine (n = 2) (Abu Kishk et al., 2019; Abu-Odah et al., 2023) each contributed two studies, while Jordan (n = 4) (Al-Jauissy et al., 2009; Ansbro et al., 2021; Obaid et al., 2023; Obeidat et al., 2017) and Saudi Arabia (n = 4) (Alilyyani et al., 2023; Bashkin et al., 2023; Shahabi et al., 2022; Senitan et al., 2018) each contributed four. The United Arab Emirates contributed one study (n = 1) (Brownie et al., 2015).

Although the inclusion criteria did not restrict language, only articles published in English and French were identified and included in this review's analysis.

## Quality Assessment and Limitations of the Included Studies

Overall, the quantitative studies included in this review demonstrated what can be considered good methodological quality, as assessed using the Downs and Black checklist (Downs & Black, 1998). The median score was 21 (interquartile range [IQR]: 21–25), with scores ranging from 19 to 26 out of a maximum of 28. Most studies scored lower on the internal validity subscale, primarily due to the lack of power calculations or sample size estimations. Detailed scoring for each study is provided in Table S3.

Regarding qualitative studies, most fulfilled the methodological criteria outlined by relevant EQUATOR guidelines (e.g., COREQ, SRQR). However, several critical elements were frequently underreported, including the researcher-participant relationship, reflexivity, and justification for data saturation. Results of the CASP checklist evaluation are presented in Table S4.

## Results of the Included Studies

The distribution of the studies included in our review was as follows: cancer was the focus of 42 studies (n = 42), representing 62.6% of the total; CVDs (n = 10), representing 14.9%; endocrinological diseases (n = 7), representing 10.4%; pulmonary diseases (n = 2), representing 2.9%; neurological diseases (n = 3), representing 4.4%; renal diseases (n = 2), representing 2.9%; and mental health (n = 1), representing 1.5%. The results of the individual studies are presented in Table S2.

## Role and Knowledge of Nursing Among Chronic Diseases

Among the 42 cancer studies included in the review, 20 focused on general cancer topics, nine specifically addressed breast cancer, and seven focused on general cancer pain management. Nurses play a central and multifaceted role in chronic disease management. In cancer care, nurses have integrated cultural differences into their practice, as illustrated by Oran (2001) in Turkey, which highlights

the critical role that nurses play in patient education, perioperative care, and postoperative pain management for cancer patients. Moreover, Doumit et al. (2007) in Lebanon emphasized the importance of nurses in understanding and addressing the emotional and physical needs of oncology patients receiving palliative care. Akin et al. (2008) demonstrated the active involvement of nurses in delivering psychosocial interventions to breast cancer patients undergoing chemotherapy in Turkey. The study detailed how nurses provided individualized emotional support, facilitated communication about treatment-related anxieties, and guided patients through coping strategies aimed at strengthening their self-efficacy. These nursing actions contributed significantly to improving patients' psychological well-being and overall quality of life during chemotherapy. Rather than proposing what nurses should do, this study highlighted concrete interventions that have already been integrated into nursing practice within the oncology care setting. Taken together, these studies demonstrate that nurses are integral to providing holistic care, ensuring patient education, managing pain, and supporting the emotional well-being of patients with chronic conditions.

Of the 10 cardiovascular studies included in our review, two were on coronary heart disease, one on heart failure, one on cardiovascular care for refugees, and one on the role of nurses in cardiovascular care. Nurses play a crucial role in managing CVDs by providing specialized care, patient education, and ongoing support. In Israel, Blaer et al. (2003) described how nurses played a central role in managing patients with cardiovascular conditions in intensive-care settings. Their responsibilities include monitoring the hemodynamic status, administering medications, providing patient education, and supporting families during critical illnesses. The study also highlighted the parallel development of cardiovascular nursing education programs aimed at enhancing nurses' technical and clinical decision-making skills in cardiac care nursing. Nir et al. (2009) further emphasized the support that nurses provide to caregivers of stroke survivors, offering emotional support and guidance on care management. Bagheri et al. (2012) in Iran underscored the importance of nurses maintaining patient dignity through respectful communication, providing sufficient information, and ensuring the privacy of patients with heart failure. Mohammadpour et al. (2015) demonstrated the effectiveness of nurse-led educational interventions in improving the self-care skills of patients with myocardial infarction. Another noteworthy study by Mohammadi et al. (2023) illustrated the beneficial impact of telenursing on the quality of life of caregivers of older stroke patients.

We included seven endocrinology studies on diabetes, diabetic foot ulcers, and telenursing. Nurses are vital in the management of endocrine disorders, particularly diabetes, by providing continuous education and care plans. For example, Yeter and Emiroğlu (2006) demonstrated that frequent home visits by public health nurses in Turkey resulted in significant improvements in diabetes management. Pishdad et al. (2007) showed enhanced adherence to diabetes management guidelines in nurse-managed programs in Iran. Ahmadi et al. (2018) highlighted the role of peer-led education in empowering patients with diabetes. These studies reinforce the importance of nurses' patient education, self-care capacity building, and continuous support in improving outcomes for endocrine disorders.

Our review included two pulmonology studies that focused on COPD. One study examined a home-care model (Bal Özkaptan & Kapucu, 2016), and the other evaluated a nurse-led pulmonary rehabilitation program (Akinci, 2005, 2007). The nurses in these studies provided education, monitoring, and tailored interventions to patients. A separate study by Moosavi et al. (2020) on spiritual care guidelines, although centered on cancer, also highlighted how nurses can address holistic patient needs, including those of lung cancer patients.
Regarding mental health, oncology nurses in Israel have effec-
tively addressed emotional distress and suicidality (Granek et al.,
2019). The study identified barriers such as a lack of training and
stigma, highlighting the need for specialized support. Another study
by Al Saadi (2024) in Qatar detailed the ethical dilemmas nurses face
in cases of undisclosed diagnoses.

Of the two nephrology studies, one examined perceived social support and quality of life in patients undergoing hemodialysis (Rambod & Rafii, 2010), and the other studied multidisciplinary rehabilitation (Toulabi et al., 2016). The findings highlight the importance of psychosocial and spiritual support, with nurses being the key facilitators. However, the limited number of protocols addressing these holistic needs remains challenging.

For neurology, one study explored caregiving for patients with Alzheimer's disease (Navab et al., 2012), one assessed nurses' knowledge of epilepsy (Alilyyani et al., 2023), and one examined progressive muscle relaxation in patients with epilepsy (Talo & Turan, 2023). These studies reinforce the critical role of nurses in educating patients and caregivers and delivering therapeutic interventions.

In the field of mental health, several studies have highlighted the challenges that nurses face. In Israel, oncology nurses have effectively addressed emotional distress and suicidality among patients despite significant barriers, such as a lack of training and persistent stigma (Granek et al., 2019). Similarly, a study in Qatar revealed the ethical dilemmas nurses encounter, particularly in cases involving the nondisclosure of diagnoses (Al Saadi et al., 2024). Regarding perinatal mental health, Saleh et al. (2020) emphasized the urgent need for structured screening tools and clear guidelines for post-partum depression, noting that inadequate training and the absence of well-defined policies remain major obstacles. Together, these findings highlight the critical need for enhanced training and clearer frameworks to support nurses in effectively managing mental health issues.

Challenges and Gaps to Nurse-Led Chronic Disease Management

S2 Table details the challenges and gaps identified in this study. One of the main issues highlighted was the significant gap in nurses' knowledge of chronic disease management. For example, in a study on epilepsy care, nurses' correct response rates varied widely from 52.8% to 88.9%, indicating a lack of consistent knowledge and training (Alilyyani, 2023). This gap underscores the need for ongoing education and training programs to ensure that nurses are well-prepared to manage chronic conditions effectively.

Another significant challenge is the emotional and physical strain on nurses and caregivers. This is particularly evident in the care of individuals with Alzheimer's disease, where caregivers often experience high levels of stress and anxiety about the progressive deterioration of their loved ones (Navab, 2012). Although nurses play a crucial role in supporting caregivers by providing information and emotional support, they are at risk of burnout and emotional exhaustion due to the demanding nature of their work environments.

Structural barriers within health care systems further complicate nurse-led management of chronic conditions. For instance, in the context of hemodialysis care, a review identified a lack of structured protocols to routinely address patients' psychosocial and spiritual needs, representing a substantial gap in comprehensive care (Rambod, 2010). Moreover, the limited availability of resources and support systems for managing conditions such as COPD and heart failure further exacerbates the challenges faced by both caregivers and patients (Bal Özkaptan, 2016; Mohammadpour et al., 2015).

This review also highlights the potential benefits of integrating multidisciplinary approaches into chronic disease management, as demonstrated in studies on cardiovascular and nephrology care. However, such integration requires improved coordination and communication among health care providers to ensure effective care

delivery (Mohammadi et al., 2023). Finally, the lack of uniformity in training and challenges in adapting standardized protocols across different care settings remain significant barriers to effective management of chronic diseases.

Discussion

Our systematic review underscores the important and multi-
faceted roles that nurses play in managing chronic diseases, in-
cluding cancer, CVDs, endocrinological disorders, neurological
diseases, pulmonary diseases, renal diseases, and mental health
across the Middle East. These findings align with the
WHO's emphasis on the importance of task shifting and advanced
nursing practice in addressing the growing burden of NCDs.
Comprehensive search strategies applied across multiple databases,
including PubMed, PsycINFO, CINAHL, Web of Science, and Embase,
ensured the robustness of our data by capturing diverse nursing
roles and their applications across chronic conditions (World Health
Organization, 2018).

Cancer care emerged as the dominant focus area, representing 55.9% of the reviewed studies. Nurses demonstrated their indispensable role in patient education, perioperative care, and postoperative monitoring. In Turkey, oncology nurses play a pivotal role in managing cancer pain during specialized procedures such as percutaneous chordotomy by ensuring meticulous perioperative planning and targeted patient education (Oran, 2001). Similarly, in Lebanon, palliative care nurses addressed both the physical and emotional needs of oncology patients through patient-centered communication, fostering trust and understanding between patients and caregivers (Doumit et al., 2007; Saouma Nehmé et al., 2020). Nurse-led psychosocial interventions in Turkey have been shown to significantly improve the quality of life and self-efficacy of patients with breast cancer undergoing chemotherapy, underscoring the need for specialized training and educational programs for oncology nurses (Akin et al., 2008; Bayram et al., 2014). These findings are consistent with the global evidence from North America and Europe, where nurse-led interventions have consistently enhanced clinical and psychosocial outcomes in cancer care (Bauer & Bodenheimer, 2017; Macmillan Cancer Support, 2019).

Notable comparisons can be drawn between cancer care and CVD management, which accounted for 16.2% of the studies reviewed. Cardiovascular nursing emphasizes patient education, lifestyle modifications, and the prevention of complications such as heart failure. For instance, nurse-led educational programs in Iran have significantly improved self-care practices among myocardial infarction patients (Mohammadpour et al., 2015). In Israel, advanced cardiovascular nursing education programs have enhanced nurses' competencies in intensive cardiac care settings (Blaer et al., 2003). Evidence from Africa highlights how nurses navigate resource-limited environments to implement evidence-based interventions effectively, often overcoming systemic constraints (Toniolo et al., 2024). While cancer care frequently addresses emotional and psychosocial needs, cardiovascular nursing tends to focus on physiological monitoring and management of comorbidities. These findings collectively illustrate the adaptability and critical nature of nursing roles across diverse contexts, as supported by WHO guidelines advocating enhanced nursing education to improve patient outcomes (World Health Organization, 2017).

Diabetes management is another example of nurse-led care ef-
fectiveness. In Turkey and Iran, nurses have implemented con-
tinuous education programs and personalized care plans, resulting
in significant improvements in glycemic control and adherence to
management protocols (Ahmadi et al., 2018; Kıtış & Emiroğlu, 2006).
These findings align with international studies, particularly in North
America and Europe, where nurse-managed diabetes programs have
demonstrated similar success in improving clinical outcomes and
patient adherence (Pishdad et al., 2007). The consistent impact of nursing interventions across regions underscores the universal applicability of these strategies for managing chronic metabolic conditions.

Nurses also play crucial roles in managing neurological, pulmonary, and renal diseases as well as mental health. Studies from Turkey and Saudi Arabia have demonstrated that nurses provide essential support to caregivers of patients with Alzheimer's disease and manage epilepsy, thereby improving patient outcomes and reducing the caregiver burden (Alilyyani et al., 2023; Navab et al., 2012). Globally, these findings are consistent with evidence from the United States, where nurse-led interventions have been shown to significantly reduce caregiver stress and improve care quality in patients with Alzheimer's disease (National Institute of Aging, 2020).

In pulmonary care, home-based rehabilitation programs for patients with COPD in Turkey significantly improved pulmonary function and quality of life, mirroring similar successes in Canadian settings (Akinci & Olgun, 2011; Bal Özkaptan & Kapucu, 2016). In renal care, nurse-led multidisciplinary approaches in Iran enhanced the quality of life of hemodialysis patients, whereas comparable models in Australia demonstrated reduced hospitalizations and better care coordination for patients with chronic kidney disease (Kidney Health Australia, 2020; Toulabi et al., 2016).

In the domain of mental health, oncology nurses in Israel have effectively addressed emotional distress and suicidality among patients with cancer, findings that resonate with studies from the United Kingdom, demonstrating the importance of integrating mental health support into chronic disease management (Granek et al., 2019; Macmillan Cancer Support, 2019). This holistic approach underscores the necessity of addressing both physical and psychological needs to ensure comprehensive care, a priority that is increasingly recognized in global nursing practice.

Despite these positive outcomes, significant challenges persist in the nurse-led management of chronic diseases. The variability in training, emotional and physical burdens, and structural barriers within the health care systems remain major obstacles. Comprehensive strategies, including enhancing nursing education and training, fostering multidisciplinary collaboration, and developing context-specific guidelines, are required to address these gaps. The implementation of advanced practice nursing roles, such as those of NPs, offers a promising solution. In Oman, the successful integration of NPs has demonstrated the potential of these roles in enhancing health care access, improving chronic disease management, and reducing costs, highlighting a scalable model for other Middle Eastern countries (Al Ismaili et al., 2024).

The inclusion of spiritual care in chronic disease management, although underexplored in the Middle East and Africa, is a critical developmental area. Evidence from the United States and United Kingdom suggests that addressing patients' spiritual needs can significantly improve emotional well-being and quality of life (Koenig, 2012; Puchalski et al., 2009). Integrating spiritual care into nursing practice in these regions could fill a vital gap, align with global trends, and improve patient satisfaction (Puchalski et al., 2014).

This review highlights the essential role of nurses in managing chronic diseases and underscores the need for continued investment in their education, professional development, and integration into care models. By adapting global best practices to local contexts, health care systems—particularly in resource-constrained settings—can optimize nurse-led interventions to improve patient outcomes and promote equitable, high-quality care.

To enrich the interpretation of these findings, the review applied Abbott's system of professions, a sociological framework that examines how professions negotiate their jurisdiction, defined as authority over specific tasks, knowledge domains, and client problems (Abbott, 1988). In the Middle East, nurses are increasingly asserting workplace jurisdiction over core functions such as patient education,

psychosocial support, clinical surveillance, and care co-ordination—roles traditionally dominated by physicians.

However, as Abbott emphasizes, workplace jurisdiction often lacks formal legal or institutional recognition. This misalignment between what nurses do in practice and what they are officially authorized to do creates structural vulnerabilities. It risks marginalizing their contributions, limiting the scalability of interventions, and undermining the long-term integration of advanced nursing roles in chronic disease management.

Viewing nurse-led interventions through this lens shifts the analysis from mere role description to understanding them as acts of professional boundary negotiation, emerging in response to system deficiencies and workforce gaps. To secure and amplify these gains, health reforms must extend beyond capacity building to include policy and legal frameworks that institutionalize expanded nursing roles. Aligning workplace, legal, and public jurisdictions will be essential to unlocking the full potential of the nursing workforce in the region.

## Strengths

This review is the first of its kind to synthesize empirical evidence on nurse-led chronic disease management in the Middle East, a region where such research remains scarce. By integrating findings across diverse settings, it provides valuable insights into nursing practices within a unique sociocultural and socioeconomic context, enhancing the regional relevance and applicability of its conclusions.

## Limitations

Several limitations should be acknowledged. First, the methodological quality of some included studies was moderate, particularly regarding external validity and study heterogeneity. Although all eligible studies were included to ensure a comprehensive evidence map—consistent with the scoping review approach—methodological appraisal using the Downs and Black checklist (1998) was conducted to enhance transparency.

Second, the geographic concentration of studies in a few countries limits the generalizability of findings across the Middle East. Additionally, small sample sizes and culturally specific results may restrict broader applicability. Finally, structural challenges such as limited nursing training and inadequate institutional support were commonly reported and may have influenced the reported effectiveness of nurse-led interventions.

## Conclusion

This review provides a comprehensive overview of nurses' knowledge, roles, and contributions to the management of NCDs in the Middle East. Despite nurses' critical involvement in patient education, clinical monitoring, perioperative care, and palliative support, their impact remains constrained by multiple barriers.

These include methodological weaknesses in existing studies, insufficient clinical training, lack of formal recognition for expanded roles, and limited institutional support. Addressing these challenges requires systemic reforms, including strengthening nursing education, developing supportive policy frameworks, and integrating nurse-led models into national strategies for chronic disease management.

Future research should employ more rigorous and comparative designs to assess the effectiveness and scalability of these interventions. Expanding advanced nursing roles in the region may help mitigate workforce shortages and meet the rising demand for high-quality, person-centered care. Ultimately, institutionalizing these roles could significantly enhance the resilience and performance of health care systems across the Middle East.
# Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

# CRediT Statement

**Beloni Pascale:** Writing- Review and Editing, Validation, Supervision, Methodology, Conceptualization. **Toniolo Jean:** Writing- Review and Editing, Validation, Supervision, Methodology, Conceptualization. **Hanoun Joy:** Writing- Review and Editing, Writing- Original draft, Resources, Methodology, Formal Analysis, Data curation, Conceptualization.

# Declaration of Competing Interest

The authors declare that they have no known competing financial or personal interests that could have appeared to influence the work reported in this article. There are no financial relationships, personal relationships, or organizational affiliations that might raise questions of bias in connection with this paper.

All authors have reviewed and approved the final version of the paper. We affirm that the article presents our genuine findings and that no conflict of interest exists in any aspect of the research or publication process.

# Declaration of Generative AI and AI-Assisted Technologies in the Writing Process

During the preparation of this work, the authors used Rayyan QCRI to manage study selection, screen references, and remove duplicates during the scoping review process. After using this tool, the authors reviewed and edited the content as needed and took full responsibility for the content of the publication.

# Acknowledgments

None.

# Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.outlook.2025.102479.

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