Experiences of nurses and midwives in policy development in low- and middle-income countries: Qualitative systematic review

3.1. Inclusion and exclusion criteria

3.2. Search strategy

A three-step search strategy was utilized in this review. An initial limited search of CINAHL and MEDLINE was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search using all identified keywords and index terms was then undertaken across all included databases, from database inception to the date of the search. Thirdly, the reference lists of all identified reports and articles were searched for additional studies. The search was conducted in December of 2019 and updated in April of 2021. Databases searched were: Medline (Ovid), Embase (Elsevier), CINAHL (EBSCO), APA PsycInfo (EBSCO), Sociological Abstracts (ProQuest), Social Services Abstracts (ProQuest), Anthrosource (American Anthropological Association), Cochrane Central Register of Controlled Trials (Cochrane Library), and Web of Science (Clarivate Analytics). The complete search strategies are included as Appendix 1.

3.3. Selection and quality assessment

The articles that met the inclusion criteria were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research tool (Lockwood et al., 2015) by two independent reviewers. The authors worked in pairs and any disagreements were resolved with open dialogue and with the assistance of a third reviewer when needed. All articles were included regardless of quality assessment. The quality appraisal checklist of selected articles is provided in Appendix 2 - Table S1.

3.4. Data extraction

Qualitative data from papers included in the review were extracted by two independent reviewers and by using the standardized data extraction tool from JBI-QARI. No textual data was included so use of the JBI-NOTARI tool was not necessary. The data extracted included specific details about the phenomena of interest, populations, study methods, and outcomes of significance to the review question and specific objectives.

3.5. Data synthesis

4.1. Characteristics

In terms of critical appraisal, studies were generally appraised to be of high quality, ranging from 70% to 100% in terms of quality. The areas that tended to score the lowest were around whether the researcher(s) situated themselves culturally or theoretically and whether the influence of the researcher on the research, and vice- versa, were addressed.

Data extraction, synthesis and meta- aggregation of these articles resulted in four major themes and their subthemes: 1) Marginal representation; 2) Determinants of Involvement; 3) Leadership as a pathway; and 4) Promoting Nurses’ Involvement. These four themes and their sub themes are used as the organizing framework of the findings section of this manuscript.

4.2. Theme 1: Marginal representation of nurses in policy development

This major theme refers to the limited level of involvement of nurses in policy development including the perception of excluding nurses and midwives in policy formulation work at multiple levels: individual, institutional, and systemic level. For example, they are often perceived to be absent at the national level and often were more engaged as policy implementers and not policy makers especially at the frontlines of healthcare. This theme was identified in five reports.

In a study in Kenya, nurses acknowledged that they were inadequately involved in national policy development due to the top-down approach where nurses had fewer opportunities and were mostly excluded and marginalized at a national level (Juma et al., 2014). This also aligned with the reality that nurses were employed at lower levels of the Kenyan health care system but not at higher levels (Juma et al., 2014). Further, Kenyan nurses also felt that they required comprehension and abilities to be involved in the policy-making process; this was primarily because of the nursing curriculum failing to include advocacy and political skills that are essential to impact policies within the healthcare system (Juma et al., 2014). This is also reflected in the culture of nursing in Kenya which reinforces the minimal role of nurses engagement in policy development due the established hierarchical system (Juma et al., 2014). Some participants commented that nurses are “allergic to change” and mostly rely on higher positions to make decisions due to “self-imposed mind block” (Juma et al., 2014, p. 5).

Similarly, Asuquo (2019) conducted a study in Nigeria looking at nurses’ leadership in the development of policy and found that nurses’ leadership in health system policy is perceived to be a falsehood primarily due to nurses always being the implementers rather than the policy makers. The nurse leaders in this study indicated that nurses’ leadership in policy is a “no go area” where their participation is not demanded and their absence not noticed unlike their physician counterparts (Asuquo, 2019). Nigerian nurses also expressed marginal representation in knowledge creation via research in either independent or collaborative studies (Asuquo, 2019). Although involved in state level research projects, nurses expressed participation was limited to being data collectors and not research designers and investigators (Asuquo, 2019).

The marginal representation of nurses in policy development has impact on their work morale especially those in managerial roles. In Buys and Muller's (2000) study of nursing service managers’ experiences of the transformation of provincial health services, nurse managers expressed feelings of “anger, fear, uncertainty, powerlessness, and low morale” as a result of their lack of participation in policy development and the new changes in provincial health services management policies (Buys and Muller, 2000, p. 52). The new changes were often accompanied with lack of communication, higher workload, poor monetary compensation, inadequate recognition and resources, and lack of involvement of nurse managers in the decision making, which further intensified their unhappiness and dissatisfaction. Nurses also expressed fears of receiving unwanted reactions from upstream managers when they expressed their desire to participate in the policy making process (Hajizadeh et al., 2021). Nurses and midwives also felt overlooked and unacknowledged (Acheampong et al., 2021). This lack of voice at the policy making tables can further lead to lack of interest, limited participation, and marginal representation of nurses and midwives in policy making (Asuquo, 2019).

4.3. Theme 2: Determinants of nurses’ involvement in policy development

This main theme refers to factors that influence the perceived ability of nurses and midwives to be engaged in policy formulation activities and has two sub-themes related to (a) individual factors and (b) organizational and systemic factors. At the individual level, nurses feel that they do not receive sufficient training in policy development and are often perceived and blamed for being complacent and disinterested. At the organization and systematic level, the existing hierarchy in healthcare, with nurses often on the bottom, result in perceived barriers to involvement in policy development. This theme was identified in four studies.

4.4. Sub-theme 2.1 Individual factors

Individual nurses and midwives often felt blamed for not being involved in the policy development without considerations of institutional and systemic level issues that may have impacted on their ability to participate in policy development work. This leads to nurses and midwives being erroneously viewed as being resistant to change and content with their subservient role of taking orders from other professionals above them in the hierarchical ladder of the health system (e.g. physicians) rather than being able to contribute knowledge that could facilitate collaboration (Acheampong et al., 2021; Asuquo, 2019; Juma et al., 2014). They also pointed to the need for multi-level mentorship of existing nurse leaders as an imperative to create the needed changes in nurses and midwives’ equitable involvement in health and healthcare research.

4.5. Sub-theme 2.2 Organizational and systemic factors

Organizational and systemic level issues are another set of factors that influence nurses’ involvement in policy development. Hajizadeh et al. (2021) conducted a study in Iran and found that nurse-managers’ lower academic training, fear of losing jobs from higher level managers, and lack of leadership competencies are some of the organizational factors that create hesitancy in policy development involvement. Other organizational structure factors include nurse leaders’ minimal authority, inability of nursing organizations to adopt reforms and changes due to its conservative approach, and exclusion of nurses due to top-down policy decision-making (Hajizadeh et al., 2021). Further, institutions also create barriers for nurse managers to be engaged in policy making through heavy workload assignment, sustaining societal negative images of nurses’ involvement in policy making, and lack of transparency on the process of policy making (Hajizadeh et al., 2021).

A major systemic barrier for nurses’ participation in policy making was physician dominated health system (Acheampong et al., 2021; Asuquo, 2019; Hajizadeh et al., 2021; Juma et al., 2014) where nurses’ in policy making is not expected, unlike it is for physicians (Asuquo, 2019). The Iranian health system has a strong influence of physicians due to traditional power relations within the national policy development platform (Hajizadeh et al., 2021). Nurses are mostly represented within nursing practice settings such as frontline care whereas physicians are represented beyond their area of practice such as head of department, administrative directors, managers of programs, and head of provincial and district health offices (Asuquo, 2019; Juma et al., 2014). Asuquo (2019) claims that institutional research grants are often discussed in the higher arenas of decision making areas where physicians are present but nurses are often absent, and the translation is systematic exclusion of nurses in the policy making enterprise. This systematic domination of nurses by other disciplines such as medicine is a major factor in nurses and midwives’ marginal representation and invisibility in organizational and systemic policy making arenas.

4.6. Theme 3: Leadership as a pathway to involvement in policy development

This theme refers to the role of leadership in nurses’ and midwives’ engagement in policy development. Having nurses and midwives in leadership roles fosters their involvement in policy development was prevalent in five studies.

Leadership as a pathway to involvement in policy development can be achieved through strategic mentoring by those already in leadership roles. Asuquo (2019) states that nursing leadership is necessary for:

“…translating research evidence into practice as well as using research evidence to inform policy. The inclusion of nursing input in strategic decision making is fundamental to attaining and achieving health outcome as nurses are not just health stakeholders but qualified and experienced professionals that could assume a pivotal role in the health care system.” Asuquo (2019), p.1121

Asuquo (2019) further notes that research mentorship can be a way to bridge the individual and institutional gap where nurses learn the skills needed to become researchers, policy developers, and leaders of self and others. Similarly, Hajizadeh et al. (2021) asserts that access, communication, and collaboration of nurse leaders with key government officials and upstream managers can be advantageous for their participation in policy-making. In addition, upstream managers should also make an effort in implementing strategies to enhance nurse leaders’ participation in government and political affairs (Hajizadeh et al., 2021). This could be in the form of policymakers creating opportunities where nurse leaders can participate in policy making from the very beginning of the process (Hajizadeh et al., 2021; Kemp et al., 2018). This highlights a bi-directional approach whereby nurses reach out to other disciplines for mentorship support and others also become allies and advocates for nurses’ active participation in policy making arenas.

Organizations should also support nurses and provide clear frameworks to supervise or mentor nurses to encourage them to participate in policy discussions (Arries, 2006; Assegaai and Schneider, 2019; Hajizadeh et al., 2021). Assegaai and Schneider (2019) affirm that ward-based outreach team nurse leaders often have informal support processes in place but not a clear framework of the support needed. Supportive supervision from the organization for monitoring and supervision of the policy process is key in not only involving health professionals (including nurses) in policy decision-making but it is vital to maintain transparency as well (Hajizadeh et al., 2021). Other facilitators of policy involvement include promoting the culture of participatory management where employees including nurses take an active role in the decision-making process of the institution and the establishment of trust between policy makers and nurses/midwives and this can be achieved with a supportive and ambience organizational culture (Hajizadeh et al., 2021).

4.7. Theme 4: Promoting nurses and midwives’ involvement in policy development

The final theme refers to ways of fostering nurses and midwives’ involvement in policy development, and this was identified in seven studies. Nurses can be encouraged to meaningfully engage in policy development through several ways. These include research, creation of policy making opportunities, targeted professional development initiatives and guidelines, authentic engagement of frontline nurses and midwives in policy development work, better communication system (e.g., bottom-up approach, multidirectional), community of practice, equitable allocation of resources, nursing curricula content, closing the academic-practice divide and increasing interdisciplinary teamwork within the nursing process.

Nurses’ and midwives’ participation in the development of the policies that impact on health care delivery is a motivating factor. This can be achieved through creating opportunities for nurse and midwife involvement, empowering them with skills and engaging in a bottom-up approach in policy making. According to Juma et al. (2014), generating nursing evidence has the capacity to influence policy at local, national and international levels with nurses and midwives more involved in policy making. Nursing and midwifery leaders need to be promoted and motivated by creating opportunities where they can have hands-on experience in policy-making processes; this could offer nurses the knowledge and skills necessary to compete in policy leadership positions and to be more proactive in policy-making activities (Juma et al., 2014). Additionally, Makhuvha et al. (2007) asserts guidelines aimed to recognize and remunerate nurse educators along with empowering them with skills of problem solving and assertiveness; this can assist in enhancing the image of nursing and retain nursing professionals for policy formulation work. Apart from this, frontline nurses should also be consulted when developing policies to promote a bottom-up approach to policy making (Buys and Muller, 2000; Juma et al., 2014; Richter et al., 2013). Buys and Muller (2000) discuss the importance of two-way communication and professional development between nurse managers and the higher system of health services asserting that this can lead to greater power for both parties. Richter et al. (2013)’s research to strengthen nurses’ engagement in Acquired Immunodeficiency Syndrome (AIDS) policy development offered a bottom-up approach as a facilitator. The authors further elaborated that frontline nurses and managers were involved in a policy development process via workshops where they provided feedback, challenges, and gaps in the service delivery, and they were generating information which was then circulated to the national level decision makers (Richter et al., 2013). Kemp et al. (2018) also mentioned the importance of workshops where the Ugandan midwives had an opportunity to share space for exploration of ideas, reflection, and planning, and a safe community of practice area with levelling of the hierarchies. One of the midwives in the role of quality assurance manager expressed that the participant workshops with midwives were significant in the revision of national standards due to the feedback and revisions suggested (Kemp et al., 2018).

Impartiality in the distribution or allocation of resources is another way nurse managers can be involved in policy development (Hajizadeh et al., 2021). The inequitable distribution of resources such as human, monetary, and information to the various disciplines within the health workforce creates an environment of overrepresentation of some disciplines (e.g., physicians) and underrepresentation of others (e.g., nurses and midwives). This makes it challenging for nurses and midwives to be actively involved in policy development work. Thus, a fair and just resource allocation is vital to nurses and midwives’ participation in policy making.

Closing the academic-practice divide and increasing interdisciplinary teamwork within the nursing process is another way to foster nurses’ and midwives’ involvement in policy development. Nursing curricula need to integrate courses that offer skills and knowledge on working with health policy and politics (Hajizadeh et al., 2021; Juma et al., 2014). This can be in the form of either changes in content of curricular courses or in the form of in-service training but should include the processes and politics of policy making (Hajizadeh et al., 2021). Apart from this, a collaborative and cooperative relationship between nursing education institutions and hospital nurses is another facilitator that can strengthen policy in universities by including service nurses’ needs and engagement in policy making (Hajizadeh et al., 2021). This is important to close the academic-practice divide. In terms of the nursing process, an increment in team activity such as believing in each other for a shared goal can assist nurses to realize the importance of and the need for involvement in policy formulation (Hajizadeh et al., 2021).

5.1. Research and policy literacy

The first issue that is associated with nurses and midwives’ underrepresentation in policy development is research and policy literature, which refers to the ability to identify and understand research, political, and policy knowledge (Etowa et al., 2020). Evidence-based policy development is anchored in relevant systematically investigated information and knowledge. Critical understanding of research and policy is required to enable nurses and midwives in various roles within healthcare to understand, critique and participate in policy making. Nurses and midwives have a need for both the technical research knowledge and practical skills of navigating the politics and policy making terrains within their practice contexts. While nurses and midwives are well-positioned to play a leading role in improving healthcare in LMICs, their potential contribution and meaningful engagement in health policy development processes are constrained by several factors, including but not limited to, a lack of research training and mentoring, limited prior experience with knowledge translation or with dialogue engagement with policy makers. As a result, nurses have not historically been involved in the development of health system policies, despite the impact that such policies have on their practice and care provision.

A key attribute of policy influence is knowledge (Bianco, 2001) and knowledge is power (Etowa et al., 2020) and power is the ability to achieve goals and influence others (Arabi et al., 2014). Knowledge is an essential component of nurses and midwives’ abilities to actively analyse organizational and systemic processes necessary for effective healthcare service delivery (Arabi et al., 2014). Nurses are knowledgeable about nursing issues and can play an instrumental role in development, implementation, and evaluation of governmental healthcare policies (Hewison, 2008). This knowledge prepares them for policy competence, which is the level of policy influence when “they can direct their organizations in response to the challenges and opportunities related to political situations and also make policies which have desirable effects on their organizations” (Arabi et al., 2014, p. 318). These authors further assert that:

“nurses’ policy influence is nurses’ ability in influencing decisions and affairs related to health through political knowledge, effective communication, and collaboration with other members of the health team, which results in the improvement of nurses’ job environment and increases patient outcomes. Nurses’ influence in health polices protects patient safety, increases quality of care, and facilitates their access to the required resources and promotes quality health care (Arabi et al., 2014, p. 319).

Being knowledgeable also equips nurses with the tools to advocate for changes. Arabi et al. (2014) identified the advocacy role of nurses as an integral part of policy development processes. Without nurse and midwife involvement in political and policy processes, the advocating role of nurses and midwives will be ineffective (Boswell et al., 2005). These activities can empower nurses and midwives with the knowledge that can influence decision makers, they need to understand the “open system” they work in and the many factors that influence the system (Arabi et al., 2014). As advocates, nurses need to ensure that all influencers of decision makers are well understood and considered.

5.2. Subordination of nurses and midwives within hierarchical healthcare institutions and systems

Findings demonstrating a ‘top-down approach’ is typical in LMICs with nurses being employed at ‘lower levels’, demonstrating the hierarchy of nurses in the health care system. The subordination of nurses and midwives is a healthcare cultural issue, where nurses and midwives are seen as powerless and without influence (Varghese et al., 2018). Many nurses and nurse midwives themselves acknowledged that they did not have the required knowledge or skills to be involved in policy development. Across individual, organization, and systematic levels, nurses and midwives are seen in a subservient role, which is compounded by traditional gender roles and patriarchal expectations (Anders, 2021; Jivraj Shariff, 2015). These systemic relations of power were perpetuated by the practices and expectations of nurses and physicians. Nurses were expected to be frontline and to follow orders, usually only invited to join policy development teams after major decisions were made (Asuquo, 2019; Juma et al., 2014). Medical involvement in policy-making tends to focus on enhancing the medical professional status of those in high-level positions or demonstrating power at the expense of other professions and colleagues.

A major systematic barrier for nurses’ participation in policy making was the physician dominated health system (Asuquo, 2019; Hajizadeh et al., 2021; Juma et al., 2014) and lack of expectation of nurses and midwives to be involved in policy development (Asuquo, 2019). When nurses were invited to participate in policy development, their roles continued to be more menial tasks and implementers, rather than involved in the initial discussions. It will be important for systematic changes to be implemented to help facilitate nurses’ involvement in policy development, such as the provision of resources, budgets, and time. As identified by others, the image of nurses and midwives as followers rather than leaders is perpetuated by the current system as well as the media (Arabi et al., 2014), which needs to be modified.

Nurses and midwives being involved in policy development can enhance patient safety and quality of care. As nurses and midwives are the front line workers, they have a major impact on the patient experience and the quality of care they recieve as well as being knowledgeable in needs at the bedside. It is essential to have a team approach to ensure high quality of care for patients. Nurse and midwife involvement in policy development can not only benefit themselves (Macdonald et al., 2015) but also other health professionals (Green and Johnson., 2015) through enhanced collaboration and teamwork, bringing together multiple perspectives to enact positive policy changes.

5.3. Lack of nurses in leadership

Nurses and nurse midwives need to be included in policy development by including them from the beginning of policy development initiatives (Hajizadeh et al., 2021; Juma et al., 2014). While mentoring and supervising nurses individually or connecting with the government to build more trusting relationships is important, for significant change to occur, more needs to be done. For example, nurses and health care professionals need to attend to the obvious social and institutional stereotypes of nurses that construct hierarchies that falsely perpetuate nurses as having less knowledge and skills. This perception creates a gap of nurses in leadership positions as they are often passed over for such positions, despite making up the majority of frontline workers (Anders, 2021).

On the other hand, having nurses and midwives in leadership roles fosters their involvement in policy development. It will be important to create opportunities and have others who have more privilege to support and create room for nurses and midwives who have been trying to be involved for decades. As mentioned by Hajizadeh et al. (2021) upstream managers could play a role through implementing strategies to enhance nurse leaders’ participation in government and political affairs, thus creating a bi-directional approach whereby nurses reach out to other disciplines for mentorship support and those in higher positions act as allies and advocates for nurses’ active participation in policy development. Creating a healthy work environment where nurses and midwives feel empowered to be involved in policy development is critical to their involvement, meaning leaders and administrators play an important role in ensuring such an environment exists (Jivraj Shariff, 2015).

Nurses and midwives make ideal policy advocates given their engagement with patients and other healthcare professionals, making them experts in their clinical area of practice (Anders, 2021). Including policy development skills in nursing education and consulting with nurses at the beginning of policy development may help; however, to make significant changes, nurses need to be shown more respect and be included as equal members in the health care system. It is essential to remove barriers to nurses and midwives in places of leadership, including the understaffing and overburdening of frontline workers (Varghese et al., 2018).

5.4. Implications

These findings have implications for changes in various dimensions of health and nursing practice including education, research, and policy and practice.

5.5. Education implementations

To enhance the involvement of nurses and midwives in policy development, there needs to be systematic changes and opportunities to create leadership development. Specifically, there needs to be a strong emphasis on training for nurses and midwives that support transformation of nurses’ learning and professional development to engage in policy development in LMICs (Anders, 2021; Boswell et al., 2005). Education can take the form of revising curricula content during the education of upcoming nurses and midwives but also through professional development workshops for nurses who are already in the field to ensure that nurses and midwives understand their potential role in policy development and the general process (AbuAlRub and Foudeh, 2017). Beyond education in policy development, continual training in leadership skills, critical thinking, and conflict management is important to ensure that nurses have the leadership skills necessary to actively engage as necessary (AbuAlRub and Foudeh, 2017). Additionally, there needs to be training for upper level management and physicians about the inclusion of nurses in policy development in order to work on changing the systematic barriers that limit nurses and midwives’ involvement in policy development.

5.6. Research implication

Considering the lack of research on midwives’ involvement in policy making, with only one study focusing on midwives, one research implication is to further explore the experience of midwives in regard to their contribution and involvement in policy. Additionally, it will be important to continue to investigate nurses’ and midwives’ experiences of involvement in policy development to monitor changes as nurses and midwives become more involved in policy development in LMICS.

5.7. Policy and practice implications

At the individual level, awareness around stereotypes of nurses and midwives needs to be acknowledged by all healthcare providers and policy makers. Those with privilege and therefore more power need to support and create room for nurses and nurse midwives to be involved in policy development. At the system level, significant changes are needed to restructure how decisions are made. Systemic relations of power need to be negotiated and challenged to prevent the perpetuation of stereotypical expectations of nurses and physicians.

5.8. Limitations

Limitations of this review include a focus that is more on nurses than midwives, as only one study included midwives. Therefore, the findings of this qualitative systematic review may not be as representative for midwives as much as it is for nurses. The review had some deviations from the published protocol; however, these deviations did not change the focus of the review and is argued to have strengthened the qualitative synthesis approach. All deviations are noted in the methods section. Finally, due to the low number of studies, no comparison across LMICs was possible, which limits the ability for comparison of successful involvement of nurses and midwives in policy development in certain LMICs compared to others which could act as a guide for other countries.