Reimagining community health nursing: a qualitative participatory action research study of nurse-led primary healthcare innovation in rural Saudi Arabia

Rural primary healthcare (PHC) systems face persistent challenges related to access, continuity, and responsiveness, particularly in geographically dispersed communities. Nurses constitute the backbone of rural PHC delivery in Saudi Arabia, yet their leadership role in driving locally grounded innovation remains underexplored. This study aimed to examine how nurses lead and sustain primary healthcare innovation in rural Saudi Arabia using a participatory action research (PAR) approach. A qualitative PAR design was employed with 12 registered nurses working in rural PHC centers. The study unfolded across three iterative cycles of planning, action, observation, and reflection. Data were generated through focus group discussions, in-depth interviews, reflective field notes, and documentation of implemented actions. Reflexive thematic analysis was conducted concurrently with data collection, with participants actively involved in interpretation and refinement of findings. Four interconnected themes were identified: (1) leading from the frontline through locally grounded innovation; (2) co-creating solutions with patients and communities; (3) working within rural constraints through adaptive practices; and (4) organizational enablement as a condition for sustainability. During PAR Cycles 2 and 3, nurses implemented and refined ten practice innovations targeting continuity of care, patient engagement, workflow efficiency, documentation burden, and team learning. Sustainability was strongest when innovations were selective, simple, and embedded into routine workflows and protocols. Nurses in rural Saudi Arabia act as key agents of primary healthcare innovation through incremental, relationship-centered changes grounded in everyday practice. Participatory action research offers a robust framework for strengthening nurse leadership, aligning service improvement with community realities, and supporting sustainable rural PHC transformation. Policy and organizational strategies should explicitly enable nurse-led, participatory innovation to advance equitable community health outcomes.