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The objectives reported in this paper were those aimed to: build consensus on factors that act as facilitators and barriers to nurse leaders' participation in health policy development in Kenya, Uganda and Tanzania.
A Delphi survey was applied which included: expert panelists, iterative rounds, statistical analysis, and consensus building. The expert panelists were purposively selected and included national nurse leaders in leadership positions in East Africa.
Data collection was done, in three iterative rounds, and utilized a questionnaire with open and closed ended questions. Data analysis was done by examining the data for the most commonly occurring categories for the open ended questions and descriptive statistics for structured questions. The findings of the study indicate that both facilitators and barriers exist. The former include: being involved in health policy development, having knowledge and skills, enhancing the image of nursing and enabling structures and processes.
The latter include: lack of involvement, negative image of nursing and structures and processes which exclude them. There is a window of opportunity to enhance national nurse leaders' participation in health policy development. Nurse leaders have a key role in mentoring, supporting and developing future nurse policy makers.
Nurses constitute the largest health care workforce in most countries. An estimated 35 million nurses make up the greater part of the global health workforce [ 1 ]. Nurses interact closely with patients and their families and often accompany patients around the clock in all sectors of health care. This gives nurses a broad appreciation of health needs, of how factors in the environment affect the health situation for clients, their families and communities and of how people respond to different strategies and services.
Nurses command expert knowledge based on their education and experience that could contribute positively towards improving all spheres of health care. ICN [ 2 ] reiterates that nurses can make a major contribution in promoting and shaping effective health policy because they closely interact with clients, gaining an appreciation of the health needs of the population and factors that influence these health needs.
Policy in the context of this paper refers to the principles that govern a chosen course of action or inaction towards attainment of goals which influence the interest of the public [ 3 ]. Health policies are guidelines, directives or principles pertaining to the health sector that govern the action or inaction that influence the health of the population [ 4 ].
National health policies impact on nursing profession and health care. Studies reviewed from USA, Australia, New Zealand, and Canada, revealed that national health policy reforms were often related to budget cuts. These reforms resulted in downsizing nurse staffing, and, in turn, created ripple effects on nurses and patient care. The impact largely took the form of negative consequences for nurses and patients in terms of: decreased staffing, increased workload, decreased job satisfaction, job insecurity and decreased quality and quantity of patient care, growth in numbers of unlicensed personnel, and ethical dilemmas [ 5 - 8 ].
Some positive effects, such as nurses becoming more assertive and gaining autonomy, ensued [ 9 ]. Nurses demonstrate some degree of political participation, although their level of political participation is restricted.
Politics in this context is defined as striving to share power or to influence the distribution of power among groups within the state [ 10 ]. Political activity refers to being part of groups and participating in activity to influence health policy.
In studies undertaken in the USA [ 9 - 12 ], results indicated that most nurses participated in political activities and thought that people like them could influence government activities. Furthermore, a more recent study conducted by Kunaviktikul et al.
Reported findings indicated that the majority of the former were not involved in national health policy development. These findings suggest that whilst nurses are not apolitical, they appear to be at various levels of political engagement in different countries.
Historically, nursing has suffered from a poor public image that it has found difficult to cast off [ 16 - 18 ]. Nursing, however, has not since been able to sustain this influence at policy level, and the image of nursing has remained low compared to other professions such as medicine. This has resulted in significant withdrawal of nursing from social and political activism and in the lessening of the reputation of nurses as a social change agent; as a result, there has been a loss in nursing power as regards policy making [ 19 ].
Although the need for political action and policy influence has been recognized, nursing education has been slow to respond to this call [ 20 ]. The preparation imparted by nursing education, does not adequately equip nurses with the knowledge and skills necessary for involvement in policy development [ 21 - 23 ].
Studies reviewed reveal that it is possible for contemporary nurses to influence health policy. Factors include: being involved and gaining experience in policy development, having role models, being educated and knowledgeable about health systems and policy development process, political activism, conducting research to expand knowledge, being supported by professional organizations and developing leadership skills [ 13 , 24 - 27 ]. When nurses are involved and successfully influence health policy development, there are clear benefits to the patient, the profession and the nurse.
Nurses have made progress in political participation and they exert influence in health policy development in some industrialized countries such as the United States of America USA and the United Kingdom UK. These studies indicated that when nurses participated in policy development they were able to make valuable contributions and positively influence areas that include: access to health services; suicide prevention in adolescents; development of guidelines for the care of pregnant women and their children; child abuse policy; authorizing nurses to prescribe medication within the framework of the Nurse Prescribers Formulary NPF ; and improving continence services.
Confounding these circumstances is the traditional patriarchal system in which the decision-makers are men in the household. These factors and others contribute to the comparatively lower status of women in East Africa. The patriarchal social order also is reflected in the overall health care system [ 32 ]; Health care is not gender neutral. Patriarchal forces extensively affect the nursing workforce, which is constituted mostly of women [ 34 ]. Gendered social ideals have significant implications for the roles, responsibilities, and capabilities of individuals [ 34 ].
Nurses and nursing image are inherently linked to the dynamics that affect women. The majority of the nurses in the East African Region are educated at the diploma level as an entry point into the profession; this level of education renders them less educated than other health care professionals [ 35 , 36 ]. Nursing education mainly focuses on clinical skills and theory related to patient care and management, not on leadership development or policy issues [ 35 , 36 ]. Access to higher education at the tertiary level is limited and expensive.
Organizational structures within which the majority of nurses are positioned and have functioned, particularly in the East African context, are bureaucratic. Policies, power and decisions are vested in the top level managers of the organization, whereas, the lower levels are mainly involved in implementation of those decisions [ 26 , 37 , 38 ]. There are few nurses, despite their being the largest workforce in health care, represented in senior management; nurses in these positions often adopt the ethos of senior management and represent management values rather than nursing issues or values [ 39 ].
Interestingly, there also is a higher proportion of male nurses in senior management positions compared to the proportion of males in the profession [ 40 ]. Workplace conditions for nurses commonly discourage participation in policy development.
A small minority, however, were involved in the policy development process, mainly in the policy adoption, implementation and evaluation stages. Nurses face challenges in being involved in health policy development at the grassroots level, as well as at the government level. Nurses believe that they are excluded and are not part of the health policy development process and that they are not present in large enough numbers to make a difference.
Other major factors acting as barriers to participation include inadequate political and policy development skills, lack of status of women that also shapers the image of nursing, lack of education and lack of supportive organizational structures. However, research studies reveal that when nurses are involved and successfully influence health policy development, there are benefits to health care delivery.
A Delphi survey was applied and included the following: expert panelists, iterative rounds, statistical analysis, and consensus building [ 43 ]. The target population for this study comprised of nurse leaders who occupied national or provincial leadership positions in East Africa. The sample was derived from the target population and consisted of nurse leaders working in national or provincial leadership positions from the Ministry of Health or equivalent , Nursing Councils, National Nurses Associations and Universities.
Purposive sampling was used because the intention was to include participants who were knowledgeable about the subject being studied. Subjective expertise included possessing knowledge derived from experience in health policy implementation, from having been affected by health policy, or from having participated in the health policy development process.
Mandated expertise entailed knowledge and experience in terms of the job requirement related to participation in the health policy development process. Objective expertise entailed knowledge gained through academic position, education and research with regards to the policy development process. Of the 37 expert panelists invited to participate in the second round, 24 The data collection tool was developed by the researchers.
The tool was a questionnaire and was developed with reference to research literature. The Round 1 questionnaire aimed to collect qualitative data and included two sections. Section 1 covered demographic data on the panelists with reference to country represented, organization represented, number of years of experience in nursing, and number of years in current position.
The demographic data helped to confirm that the sample was representative of nurse leaders as proposed in the sampling framework and that participants possessed the critical characteristics relevant to achieving the aim of the study. Round 2 and 3 questionnaires were a reflection of the data collected in Round 1 and were developed into quantitative questionnaires.
Pre-testing of the questionnaires was conducted, in all rounds. The participants who were selected to pretest the tool comprised a purposive sample of nurse leaders senior management level positions whose role included participation in the policy development process. These individuals were excluded from the main study. The participants indicated that they found: the questions clear; language acceptable; topic relevant to nursing and related to health policy development; and the instrument user friendly.
Delphi surveys mainly are concerned with face validity and content validity. Face validity was achieved by pre-testing the tool for exhibiting: clarity of content, being reflective of the topic studied, clarity of language, being unambiguous and readable [ 45 ]. Content validity was enhanced in three respects.
Second, all three questionnaires were pre-tested with a representative sample of nurse leaders, to ensure that the concepts included in the study were actually related to health policy development process. Third, the purposive study sample was comprised of a panel of experts who participate in the health policy development process.
The qualitative data from the open ended questions in the Round 1 questionnaire were transcribed verbatim into Word documents; the documents were read for relationships and patterns.
Similarities and differences were identified; words and phrases were grouped by cutting and pasting the Word document into clusters of similar ideas and concepts and by highlighting in different colours.
This procedure aided in grouping similar ideas together and identifying the most commonly occurring attributes and concepts. The analysis of this phase was undertaken independently by the researcher and an assistant; individual notes were compared to validate the concepts that occurred. The concepts that most commonly occurred were then developed by the researcher into questions for questionnaire. The areas that deferred were noted and reevaluated by the researcher and assistant.
These questionnaires utilized a Likert scale with numerical values attached to the scale range: one 1 indicated strongly agree and five 5 indicated strongly disagree. Data were analyzed utilizing descriptive statistics. Data reported in this paper are mainly frequency distributions that include summaries of categories, percentage agreement, mean and standard deviation.
In this study, consensus was built over three rounds. The first round generated unstructured data that are presented in the first column as labeled in the tables. Categories that did not achieve convergence in the second round were omitted from the third round; these have been left blank and highlighted in the tables. Approvals were secured from the National Councils concerned with research clearance in Kenya, Uganda and Tanzania.
Qualitative themes from the FGDs. Tables index. Full Size. Discussions This study investigated application of or deviation from policy at the point of care by the nursing staff in an empirical health setting in NSW, Australia. Limitations A limitation of this research was a focus on only two hospital sites in Sydney, Australia, with a relatively small participation rate.
Conclusion Deviation from policy by health professionals has severe implications for staff and patients, deserving greater attention towards its management. References [1] Westbrook JI, R. American Review of Public Administration, Quality Management in Healthcare, Social policy and society: a journal of the Social Policy Association, Condon, Street-level bureaucracy and policy implementation in community public health nursing: a qualitative study of the experiences of student and novice health visitors.
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