Policy Advocacy and Nursing Organizations: A Scoping Review

Abstract

Policy advocacy is a fundamental component of nursing's social mandate. While it has become a core function of nursing organizations across the globe, the discourse around advocacy has focused largely on the responsibilities and accountabilities of individual nurses, with little attention to the policy advocacy work undertaken by nursing organizations. To strengthen this critical function, an understanding of the extant literature is needed to identify areas that require further research. We conducted a scoping review to examine the nature, extent, and range of scholarly work focused on nursing organizations and policy advocacy. A systematic search of six databases produced 4,731 papers and 68 were included for analysis and synthesis. Findings suggest that the literature has been increasing over the years, is largely non-empirical, and covers a broad range of topics ranging from the role and purpose of nursing organizations in policy advocacy, the identity of nursing organizations, the development and process of policy advocacy initiatives, the policy advocacy products of nursing organizations, and the impact and evaluation of organizations’ policy advocacy work. Based on the review, we identify several research gaps and propose areas for further research to strengthen the influence and impact of this critical function undertaken by nursing organizations.

Introduction

As a profession, nursing has a long history of engaging in advocacy to strengthen and advance the profession, patient care and outcomes, health systems, and public policy. Nursing organizations in particular, continue to serve as critical platforms for policy advocacy—the practice of engaging in political processes to initiate, enact, and enforce structural and policy changes to benefit populations (Canadian Nurses Association, 2020; MacDonald et al., 2012a; Matthews, 2012). While a plethora of extant literature focuses on advocacy within nursing, attention is largely placed on examining strategies to strengthen individual nurses’ advocacy skills at the patient level, with limited attention to advocacy at the policy level (Ellenbecker et al., 2017; Reutter & Duncan, 2002; Reutter & Kushner, 2010; Spenceley et al., 2006). Further, despite recognizing policy advocacy as a fundamental component in meeting the profession's social mandate (Bowman, 1973; Catallo et al., 2014; Duncan et al., 2015), policy advocacy enacted by nursing organizations has been subject to less critical examination. This is an important area of inquiry, as advocacy groups are considered one of the most powerful forces in shaping policy agendas, processes, and outcomes (Gardner & Brindis, 2017; Miljan, 2018).

To strengthen this function of nursing organizations, examining their policy spheres of influence and impact, decision-making processes, and advocacy approaches can be particularly meaningful. While much can be learned from the policy advocacy work of organizations in other disciplines, advocacy organizations are not equal in their ability to influence public policy; some have greater political clout than others (Bryant, 2009). The nursing profession's experience in policy advocacy is likely unique given various historical, social, and political factors (e.g., nursing as a gendered profession, the dominance of medicine, society's perceptions of nurses and nursing); and as a result, we chose to situate the review within the nursing context. Although some literature on this topic exists, no comprehensive review has been undertaken to examine the nature, extent, and range of scholarly work focused on nursing organizations and policy advocacy. To our knowledge, two synthesis papers related to this topic exist: MacDonald et al. (2012a) conducted a scoping review to examine the factors that influence nursing organizations’ priority setting when undertaking policy advocacy, and Benton et al. (2017) conducted an integrative review to examine the differences between regulatory bodies, professional associations, and trade unions. Although these reviews provide a useful overview of specific issues related to nursing organizations’ policy advocacy work, without a comprehensive understanding of the scope of literature that exists, identifying knowledge gaps and areas for further research remains difficult.

The purpose of this review was to fill this knowledge gap by assessing the nature, extent, and range of scholarly work focused on examining policy advocacy undertaken by nursing organizations. Specific objectives included mapping the available body of literature in relation to purpose, time, location, and source; identifying the volume of scholarly work; identifying the ways in which policy advocacy by nursing organizations has been studied; identifying gaps within the literature; and informing the development of additional research questions.

Methods

We conducted a scoping review based on Arksey and O’Malley’s (2005) framework with updated guidance by Levac et al. (2010) and Peters et al. (2020). Given the exploratory and descriptive nature of the research question, we identified that a scoping review would be the most appropriate knowledge synthesis method.

Research Question

The research question that guided the scoping review was: what is the nature, extent, and range of scholarly work focused on examining nursing organizations’ advocacy to influence change at the policy level? Levac et al. (2010) suggest that combining broad questions with a clearly articulated scope of inquiry and defining concepts within the question can be useful to establish an effective search strategy. As a result, we understood policy to be “a statement of direction resulting from a decision-making process that applies reason, evidence, and values in public or private settings” (Skelton-Green et al., 2014, p. 88). This included organizational, nursing, health, and public policy at the local (e.g., state or provincial), national, and global levels. Advocacy referred to “the act of supporting or recommending a cause or course of action, undertaken on behalf of persons or issues” (Canadian Nurses Association, 2017). Nursing organizations referred to regulatory bodies, professional associations, nursing labor unions, specialty nursing practice groups, and nursing student groups at the local, national, and international level.

Search Strategy

A search was conducted in July 2020 with the assistance of a professional librarian. We searched six databases, including CINAHL, Medline, Embase, Scopus, HealthSTAR, and ProQuest, given the broad range of literature focused on the review topic as indicated in an initial cursory search. The basic structure of the search was organized under three concepts derived from the research question including nursing organizations, advocacy, and policy. Based on these concepts, search terms and search strings were developed (Table 1). Subject headings were used and “exploded” when possible to increase the number of relevant papers (Table 2).

Table 1.

Search Terms.

Concept	Search Words and Strings
Concept 1: Nursing organizations	Nurs* adj2 (organization* or association* or union* or body or bodies or societ*)
Concept 2: Policy	((Nurs* or public or health* or healthcare or “health care” or social) adj2 (policy or policies or legislation or regulation* or law*))
Concept 3: Advocacy	Advoca*
	Politic*
	Lobbying

Table 2.

Search Strategy Example From Medline Database.

1. (Nurs* adj2 (organization* or association* or union* or body or bodies or societ*)).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms

2. exp Societies, Nursing/

3. ((Nurs* or public or health* or healthcare or “health care” or social) adj2 (policy or policies or legislation or regulation* or law*)).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

4. exp policy/ or exp public policy/ or exp health policy/

5. exp legislation as topic/ or exp legislation, drug/ or exp legislation, food/ or exp legislation, hospital/ or exp legislation, medical/ or exp legislation, nursing/ or exp legislation, pharmacy/ or exp medicare/

6. advoca*.mp.

7. exp consumer advocacy/ or exp patient rights/ or exp reproductive rights/ or exp right to health/ or exp right to work/ or exp social justice/ or exp women's rights/

8. politic*.mp.

9. exp politics/ or exp diplomacy/ or exp lobbying/ or exp political activism/ or exp stakeholder participation/

10. 1 or 2

11. 3 or 4 or 5

12. 6 or 7 or 8 or 9

13. 10 and 11 and 12

14. (editorial* or letter* or news* or interview*).pt.

15. 13 not 14

Inclusion and Exclusion Criteria

The criteria were purposely broad to ensure all relevant scholarly work was captured to meet the objectives of the review. As suggested by Peters et al. (2020), scoping reviews can include both research and non-research sources. We defined scholarly work broadly to include any research or non-research peer reviewed work focused on both nursing organizations and policy advocacy work. Including various types of peer-reviewed work allowed us to fully examine the nature, extent, and range of literature focused on this topic. For the purposes of this review, dissertations and theses were included given their scholarly merit, despite not being commonly accepted as peer reviewed. We understood research papers to be those that investigated a research question focused on policy advocacy and nursing organizations with methods of data collection (primary or secondary), analysis, and interpretation using a methodological approach (Creswell & Creswell, 2018). This included papers of all study designs and methods, as well as dissertations and theses. We understood non-research papers to be those that investigated or discussed a topic, issue, or question related to policy advocacy and nursing organizations without the use of specific methods or methodological approaches. Editorials, commentaries, letters, interviews, and news articles were excluded given the likelihood of limited in-depth exploration and investigation into the topic. Limitations were not placed on publication year or location to meet our objective of mapping the literature in relation to time and location.

Data Management and Article Selection

Papers retrieved from the database search were imported into Covidence (2020), a web-based software used to store, manage, and screen articles for systematic reviews. Two reviewers (PC and TP) participated in all phases of screening and selection. We piloted the inclusion and exclusion criteria using a sample of 100 papers. We resolved conflicts through consensus and further refined the criteria for clarity. Specifically, we clarified the concept of advocacy at the policy level after the pilot given the heterogeneity of papers and the many forms in which it can be taken up. We also further specified what constituted non-research after gaining a sense of the type of papers retrieved for screening. Reviewers independently screened the papers in both the abstract and title, and full-text screening phases. Additional hand searched articles were retrieved through chain searching, and consensus meetings were held to resolve any conflicts (Figure 1).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram template.

Data Extraction

We used a descriptive-analytical narrative method to chart the data. Two separate data extraction forms—one for research and one for non-research papers were developed using Excel spreadsheets. Fields within the extraction forms were based on the objectives of the research question. Common data extracted from both research and non-research papers included the authors, publication year, organizations’ country of origin, jurisdiction of nursing organization discussed (i.e., global, national, provincial/state level), and aims and purpose. While some features were common to both data extraction forms, there were also some differences. Specifically, the extraction form for research papers included additional fields to capture the methods/designs of studies, theoretical or conceptual frameworks, and key findings; while the extraction form for non-research papers included a field to capture key concepts. We piloted the forms using 10% of the included full-text papers, and discrepancies were resolved through consensus. After the pilot, the first author completed the categorization and data extraction for all full-text articles. Papers were first sorted as research versus non-research. Research papers were then further sorted based on their method/design while non-research papers were sorted into further groupings developed by the author. Where ambiguity was noted during this process, the first author consulted additional reviewers.

Data Analysis

Common descriptive data were summarized and analyzed using descriptive statistics. We extracted text related to the aims and purpose of each paper, key findings, and key concepts, and collated and imported the text into Quirkos version 2.3.1 (2020)—a qualitative analysis software to assist with data analysis. We used conventional content analysis to analyze extracted text, which is typically employed when existing theory of a phenomenon is limited (Hsieh & Shannon, 2005). We engaged in basic coding of extracted data as suggested by Peters et al. (2020) and developed several categories and sub-categories through an inductive and iterative process (Hsieh & Shannon, 2005).

Findings

Characteristics of Included Papers

In total, we included 68 papers in the review. We identified 40 (58.8%) as non-research, 28 (41.2%) as research. The literature has been increasing throughout the decades; most papers were published between 2010 and 2020 (n = 26, 38.2%), followed by 2000 and 2009 (n = 21, 30.9%), and 1980 and 1989 (n = 11, 16.2%), respectively. All papers (n = 66, 97%) except two theoretical and conceptual papers discussed a specific nursing organization, with the majority originating from the United States (n = 43, 65.1%) followed by Canada (n = 13, 19.7%) and the United Kingdom (n = 4, 6.1%). Four papers (6.1%) discussed organizations from multiple countries (Table 3).

Table 3.

Included Papers Characterized by Source, Time, and Location (n = 68).

Characteristics	Categories	Included papers n (%)
Source	Research	28 (41.2%)
	Non-Research	40 (58.8%)
Time	2010–2020	26 (38.2%)
	2000–2009	21 (30.9%)
	1980–1989	11 (16.2%)
	1990–1999	9 (13.2%)
	1970–1979	1 (1.5%)
Location (geographic location of organizations discussed in each paper *)	United States only	43 (65.1%)
	Canada only	13 (19.7%)
	United Kingdom only	4 (6.1%)
	Multiple countries	4 (6.1%)
	Korea only	1 (1.5%)
	New Zealand only	1 (1.5%)

Note. *Two conceptual/ theoretical papers did not discuss any specific organization.

Research Papers

A large portion of research papers employed historical methods (n = 12, 42.9%). Others included case studies (n = 3, 10.7%), mixed methods (n = 3, 10.7%), media analysis (n = 3, 10.7%) policy analyses (n = 2, 7.1%), qualitative descriptive studies (n = 2, 7.1%), critical discourse analysis (n = 1, 3.6%), environmental scan method (n = 1, 3.6%), and systematic website review method (n = 1, 3.6%). Out of the 28 research papers, 11 (39.3%) were dissertations and theses. Most research papers were published between 2010 and 2020 (n = 12, 42.9%) followed by 1980 and 1989 (n = 8, 28.5%), 2000 and 2009 (n = 5, 17.9%), and 1990 and 1999 (n = 3, 10.7%). Papers largely focused their inquiry on nursing organizations located in the United States (n = 18, 64.2%) and Canada (n = 7, 25.0%). Sixteen (57.1%) research papers focused on organizations at the national level, seven (25.0%) discussed organizations at the provincial or state level, and five (17.9%) discussed multiple organizations in different jurisdictions. Theories and conceptual frameworks used to guide research papers varied; however, the majority were related to policy process and development, policy and advocacy knowledge and engagement in nursing, and organizational systems (Tables 4 and 5).

Table 4.

Characteristics of Included Research Papers (n = 28).

Characteristics	Categories	Research papers n (%)
Design/method	Historical	12 (42.9%)
	Case Study	3 (10.7%)
	Mixed Methods	3 (10.7%)
	Media Analysis	3 (10.7%)
	Policy Analysis	2 (7.1%)
	Qualitative Descriptive	2 (7.1%)
	Critical Discourse Analysis	1 (3.6%)
	Environmental Scan	1 (3.6%)
	Systematic Website Review	1 (3.6%)
Time (by decade)	2010–2020	12 (42.9%)
	1980–1989	8 (28.5%)
	2000–2009	5 (17.9%)
	1990–1999	3 (10.7%)
Location (geographic location of organizations discussed in each paper)	United States only	18 (64.2%)
	Canada only	7 (25.0%)
	New Zealand only	1 (3.6%)
	United Kingdom only	1 (3.6%)
	Multiple countries	1 (3.6%)
Jurisdiction of Nursing Organizations discussed in each paper	National only	16 (57.1%)
	Provincial/state only	7 (25.0%)
	Multiple jurisdictions (mix of above)	5 (17.9%)

Table 5.

Summary of Included Research Papers (n = 28).

Source	Design/method	Country of organizations	Jurisdiction of organizations	Theoretical/conceptual frameworks that guided study or inquiry	Aim and purpose
Baillie and Gallagher (2010)	Case Study	United Kingdom	National		Details findings from an evaluation of seven sites which where early adopters of the Royal College of Nursing's Dignity Campaign.
Birnbach (1982) *	Historical	United States	Provincial/state		Investigates the earliest unified effort of five American state nurses associations’ campaign for registration status.
Catallo et al. (2014)	Systematic Website Review	Multiple countries	Multiple (national and international)		Examines how international and national professional nursing associations engaged registered nurses in health policy activities, including policy priority setting, policy goals and objectives, policy products, and mechanisms for engaging nurses in policy issues.
Chiu et al. (2020a)	Historical	Canada	National	Bubble Theory and Spheres of Policy Influence Model (Shamian, 2014)	Examines the evolution of the Canadian Nurses Association's policy advocacy agenda over the past century.
Chiu et al. (2020b)	Media Analysis	Canada	Multiple (national and provincial)	Bubble Theory and Spheres of Policy Influence Model (Shamian, 2014)	Examines Canadian nursing organizations’ policy priorities and engagement during a federal election and proposes theoretical frameworks to study policy advocacy in nursing organizations.
Donovan et al. (2012)	Qualitative Descriptive	New Zealand	National	Stages of Nursing's Political Development (Cohen et al., 1996)	Examines the perceptions of policy and political leadership in nursing in New Zealand.
Fondiller (1980) *	Historical	United States	National		Examines the response of the National League for Nursing over two decades to the movement toward higher education in the United States.
Freitas (1986) *	Historical	United States	National	Social Exchange Theory (Blau, 1964)	Investigates the American Nurses Association's evolution relative to the development of power, the structural changes and their effect upon the organization's development of power, the use of power to influence acceptance of controversial issues, and changes that occurred within the organization to promote its power.
Gagnon and Hazlehurst (2020)	Environmental Scan	Canada	Multiple (national and provincial)	Canadian Harm Reduction Policy Project (CHARPP) Framework (Hyshka et al., 2017)	Examines how nursing organizations have undertaken projects related to harm reduction and proposes ways that nursing organizations can strengthen their position on harm reduction.
Hall-Long (1995)	Case Study	United States	National		Examines the Tri-Council for Nursing's political strategies during the 1991 to 1992 reauthorization of the Nurse Education Act.
Hardy (1985) *	Historical	United States	National		Examines the development of the American Nurses Association legislative program from 1896 through 1984, the goals and strategies used to influence federal nurse training funding legislation from 1941 through 1984, and the results of these goals and strategies.
Hardy (1988)	Historical	United States	National		Examines the American Nurses Association legislative policy for federal funding for nursing education between 1952 and 1972 and implications of that policy since that time.
Kelly (2008) *	Policy Analysis	United States	Provincial/state		Examines the policies advocated by New York labor unions and provider advocacy groups, along with state government efforts toward solving the nursing shortage.
Kent and Liaschenko (2004)	Historical	United States	National		Examines how campaign contributions reflect organization values of nursing and medicine by analyzing the contributions made by the American Nursing Association's and the American Medical Association's political action committees (PAC) to candidates for the U.S. House and Senate from 1989 to 2002.
Leurer (2013)	Media Analysis	Canada	Multiple (national and provincial/state)	Policy Cycle	Examines the media advocacy efforts of nursing stakeholders in Saskatchewan, Canada in response to a new government policy that would have impacted educational requirements for licensure as a registered nurse (RN) in that province.
Lewenson (1989) *	Historical	United States	National		Investigates the tension between the politically conservative image of nursing presented in nursing literature and four professional nursing organizations’ actual involvement in the suffrage movement.
MacDonald (2012) *	Case Study (comparative)	Canada	Multiple (National and Provincial)	Whole Systems Socio-Ecological Theory (Gunderson and Holling, 1995; 2002) and Institutional Theory (Scott, 1994; Szyliowicz and Galvin, 2010)	Examines factors that influenced three Canadian nursing associations’ priority setting and policy advocacy for community environmental health (CEH).
Mosley (1996)	Historical	United States	National		Examines the contributions of the National Association of Colored Graduate Nurses and the National Black Nurses Association in advancing the standards of nursing and developing leadership within the ranks of Black nurses.
Rubotzky (2000)	Historical (Post-Modern Feminist Oral History)	United States	National		Examines the success of nursing in overcoming the impediments of tradition, organizing, and acting as an identifiable group; and speaking out with clarity as advocates for the health of American society.
Sampson (2009)	Historical	United States	Provincial/state		Examines the New Hampshire Nurse Practitioner Association's involvement in negotiations over time for independent practice.
Saulnier (2003) *	Policy Analysis (critical)	Canada	Provincial/state		Examines the construction and deconstruction of competing representations of problems that need to be addressed in the policy process, and whether new ideas about ‘problems,’ (i.e., federalism, health, policy, and evidence) can both promote and prevent the uptake of strategies aimed at affecting innovative changes.
Sharp (1994) *	Mixed Methods	United States	Provincial/state	Model of the Political Process of Health—combination of systems theory and equilibrium theory (derived from Bentley, 1949; Easton, 1965, 1966, 1981; Merriam, 1934)	Examines the lobbying strategies used by lobbyists to influence the independent practice of physical therapists and prescriptive authority for licensed nurse practitioners.
Taylor (2016)	Mixed Methods	United States	Provincial/state	Social Cognitive Theory (Bandura, 1986)	Examines the key qualities of advocacy initiatives of two regional nursing associations that motivate nurses to sustain momentum in public policy advocacy beyond a single episode.
Valderama-Wallace (2017)	Critical Discourse Analysis	United States	National		Examines conceptualizations of social justice and connections to broader contexts in the most recent editions of the American Nurses Association's Code of Ethics, Scope of Practice, and Social Policy Statement documents.
Waddell (2019)	Qualitative Descriptive	United States	National	Conceptual Model of Nursing and Health Policy (CMNHP) (Russell and Fawcett, 2005) and Culture of Health Action Framework (CHAF) (Robert Wood Johnson Foundation, 2015)	Examines Facebook and Twitter content associated with three U.S. national nursing organizations during the month preceding the 2016 U.S. presidential election.
Whyte and Duncan (2016)	Media Analysis	Canada	National	Bubble Theory and Spheres of Policy Influence Model (Shamian, 2014)	Examines the methods and messages developed by national nursing organizations to communicate their policy platforms and their strategies for member and public engagement during a federal election.
Woods (1989) *	Historical	United States	National	Model of Organizational Culture (Schein,1986)	Examines the evolution of the position of the American Nurses Association on government health insurance for the aged between 1933 and the enactment of Medicare in 1965, as well as the relationship of that position to the association's organizational culture.
Young (1983) *	Mixed Methods	United States	Provincial/state	Three models of professionalization (attribute, competition, and political model of professionalization)	Examines organized nursing's efforts, during the 1970s and on, to gain autonomy and change legal definitions of nursing practice in 50 states, to provide for expanded services of nurse practitioners and other nurse specialists.

Note. *Indicates papers that are dissertations/theses.

Non-Research Papers

We sorted non-research papers into four key groups. These groups were developed and defined iteratively based on our interpretation of the nature of papers during full-text screening. The four groups developed included (a) analytical papers—those that examined the policy advocacy work of an organization with a presented argument or claim; (b) descriptive papers—those that solely described or summarized the policy advocacy work of an organization with little to no analysis; (c) theoretical and conceptual papers—those that focused on concepts, theories, models, or frameworks used to study nursing organizations, policy, or advocacy; and (d) case examples—those that involved a detailed example or account of advocacy undertaken for a particular policy issue, topic, or event by nursing organizations, without adhering to the methodological principles of an empirical case study approach (Yin, 2018).

We sorted over half of the non-research papers as case examples (n = 21, 52.5%), followed by analytical papers (n = 13, 32.5%), descriptive papers (n = 4, 10.0%), and theoretical or conceptual papers (n = 2, 5.0%). The majority were published in the first two decades of the 2000s (n = 30, 75.0%), while the oldest paper was published in the 1970s. Similar to the research papers, the majority discussed nursing organizations located in the United States (n = 25, 65.8%) followed by Canada (n = 6, 15.8%) (Tables 6 and 7).

Table 6.

Characteristics of Included Non-Research Papers (n = 40).

Characteristics	Categories	Non-research papers n (%)
Type of non-research papers	Case Example	21 (52.5%)
	Analytical	13 (32.5%)
	Descriptive	4 (10.0%)
	Theoretical/conceptual	2 (5.0%)
Time (by decade)	2010–2020	14 (35.0%)
	2000–2009	16 (40.0%)
	1990–1999	6 (15.0%)
	1980–1989	3 (7.5%)
	1970–1979	1 (2.5%)
Location (geographic location of organizations discussed in each paper)*	United States only	25 (65.8%)
	Canada only	6 (15.8%)
	United Kingdom only	3 (7.9%)
	Multiple countries	3 (7.9%)
	Korea only	1 (2.6%)
Jurisdiction of Nursing Organizations discussed in each paper*	National only	26 (68.4%)
	Provincial/state only	10 (26.3%)
	Multiple jurisdictions (mix of above)	2 (5.3%)

Note. *Two theoretical and conceptual papers make no mention of a specific organization.

Table 7.

Summary of Included Non-Research Papers (n = 40).

Source	Type of non-research paper	Country of organizations discussed	Jurisdiction of organization	Aim and purpose
Baumgart (1993)	Case Example	Canada	National	Describes the Canadian Nurses Association's advocacy for quality healthcare.
Bednash (2015)	Analytical	United States	National	Describes the valuable work done through the TriCouncil between 1977 and 2014 for nursing's shared commitment to collaboration.
Bekemeier and Butterfield (2005)	Analytical	United States	National	Critically reviews the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements, Nursing's Social Policy Statement, and Nursing: Scope and Standards of Practice to examine content related to social justice, and to critique them for their support of nursing responsibilities aimed at achieving broad health outcomes attained through social reform.
Betts (1996)	Case Example	United States	National	Describes nursing's participation in healthcare reform debate from 1991 to 1994, with emphasis on the American Nurses Association, TriCouncil of Nursing, and the Nursing Organization Liaison Forum.
Birnbach and Orr (1993)	Case Example	United States	Provincial/state	Describes the strategies that the New York State Nurses Association used to influence the policymakers on issues important to professional nursing, specifically the shortage of nurses.
Blackwell (2008)	Analytical	Multiple	National	Explores the historical perceptions of homosexuality as psychiatric pathology, efficacy of conversion-based therapies in the changing of clients’ homosexual orientations to heterosexual, positions of professional medical and nursing organizations regarding the use of conversion therapies, and ethical considerations these types of therapies pose for psychiatric and mental health nurses.
Bowman (1973)	Theoretical/conceptual	N/A	N/A	Describes how professional nurse organizations may apply political group theory.
Brekken and Evans (2011)	Case Example	United States	Provincial/state	Describes the strategies used to achieve success when opening nurse practice acts.
Cho and Kashka (2004)	Case Example	Korea	National	Reviews the changes to community health nursing in Korea with the aim of describing the evolutionary process that culminated in a community healthcare system that is meeting the needs of Korean citizens who live in rural and isolated areas.
Dick et al. (1986)	Case Example	Canada	National	Chronicles the political activity of the Canadian Nurses Association and its role in lobbying and influencing the guiding legislation for Canada's national health insurance system.
Eaton (2012)	Case Example	United States	Provincial/state	Describes how the Virginia Nurses Association addressed the nursing faculty shortage by introducing legislation to improve faculty salaries and promote nursing education.
Fyffe (2009)	Case Example	Multiple	National	Discusses how nursing as a profession in the United Kingdom is developing its role in shaping and influencing policy using lessons learnt from a policy study tour undertaken in the United States of America.
Green et al. (2004)	Case Example	United States	Provincial/state	Describes a successful collaborative endeavor by organizations within Texas to address the nursing shortage, with emphasis on the strategic planning process for the development and passage of legislation, the content of the legislation, and a 2-year summary of the impact of the legislation on the Texas nursing education infrastructure.
Hansen-Turton et al. (2009)	Case Example	United States	Provincial/state	Describes how advanced practice nurses in the state of Pennsylvania were able to successfully advocate for nursing-related legislative reforms and the years of advocacy conducted by a broad coalition of nurses, which paved the way for the Prescription for Pennsylvania's reforms.
Hundemer and Durando (2014)	Case Example	United States	Provincial/state	Describes how the California School Nurses Association successfully guided a bill to improve the student-to-school nurse ratio, into law.
Jones (2004)	Case Example	United Kingdom	National	Discusses the approach taken by the Royal College of Nursing and its key members in policy formulation and influence related to nurse prescribing.
Keepnews (2011)	Analytical	United States	National	Discusses aspects of the profession's record on issues related to lesbian, gay, bisexual and transgender (LGBT) health and equality in the United States, focusing on civil rights, military discrimination, and human immunodeficiency virus/AIDS.
Kenner (1995)	Case Example	United States	National	Describes the concept of, and need for political action, and the role that professional organizations (with focus on the National Association of Neonatal Nurses) can play in the process by using examples related to healthcare reform.
Kishi and Green (2008)	Case Example	United States	Provincial/state	Describes statewide efforts to address the nursing shortage in Texas including strategies for positively affecting the legislative, regulatory, and health policy processes related to nursing workforce development.
Koehn (2020)	Case Example	United States	Multiple (National and Provincial/state)	Describes and analyzes the policy process through which nurses, individually and organizationally collaborated and advocated to address issues by triggering local, state, and national action by stakeholders.
MacDonald et al. (2012b) *	Theoretical/Conceptual	N/A	N/A	Proposes a conceptual framework to guide research to understand whether and how nursing associations take action for community environmental health.
Madler et al. (2014)	Case Example	United States	Provincial/state	Describes how nurse practitioners in the state of North Dakota used strategic policy actions to obtain independent prescriptive privileges.
Matthews (2012)	Descriptive	United States	National	Reviews the history of professional nursing organizations, and their role in advocating for the nursing profession and for nurses as outlined in the American Nurses Association's Code of Ethics for Nurses with interpretive statements.
Miyamoto and Cook (2019)	Analytical	United States	National	Examines how collaboration at the micro and macro level in nursing can advance the United Nations’ sustainable development goals, with the Nursing Community Coalition as an example.
Nicholas and Breaky (2017)	Analytical	Multiple	National	Discusses social justice issues associated with climate change and human health, and the work of nursing organizations on this topic.
O’Brien (2003)	Case Example	United States	National	Discusses the history of nurse practitioners, their efforts to achieve provider status, and lessons learned from their activism.
Reifsnider (1992)	Analytical	United States	National	Reviews the American Nurses Association and National League for Nursing's Agenda for Health Care Reform, a blueprint for restructuring the healthcare system, within the framework of ethical theory of distributive justice.
Rieger and Moore (2002)	Descriptive	United States	National	Reviews the role of professional organizations in advocacy, specific to cancer related policy and political issues using the Oncology Nursing Society as a paradigm.
Rowell (2003)	Descriptive	United States	National	Describes the documents and activities of the American Nurses Association that promote patient safety.
Sattler (2003)	Case Example	United States	National	Chronicles a 10-year-old movement that has affected policies on both micro and macro levels and nationally and internationally to improve the environmental health status of the healthcare industry.
Silva (1983)	Analytical	United States	National	Analyzes the American Nurses Association's position statement on nursing and social policy.
Thomas et al. (2004)	Case Example	United Kingdom	National	Presents a case history of the process followed by a group of nurses who used their power and influence to improve the provision of continence services within the National Health Service in England.
Villeneuve and Betker (2020)	Descriptive	Canada	National	Describes the history of health system development and reform, considers nursing policy and advocacy in the 21st century, and offer examples of nurse-led solutions from Canadian nurses and the Canadian Nurses Association to build, overhaul, and improve health systems and influence health policy.
Vogelstein (2016)	Analytical	United States	National	Argues that professional healthcare organizations such as the American Medical Association and American Nurses Association ought not to take controversial stances on professional ethics.
Welchman and Griener (2005)	Analytical	Canada	Multiple (national and provincial/state)	Argues that nursing associations’ withdrawal from advocacy for patient care issues is detrimental to nurses and patients.
White (1999)	Analytical	United States	National	Examines the American Nurses Association's published position on assisted suicide and argue that the association's absolute prohibition of assisted suicide is misguided.
White (1983)	Analytical	United Kingdom	National	Examines the pluralist nature of the nursing society and highlights the different and often conflicting objectives of the several interest groups; using the Royal College of Nursing as an example of how these difficulties were dealt with during 1948–1961.
Whyte and Stone (2000)	Case Example	Canada	Provincial/state	Describes the work of one provincial nursing association – the Registered Nurses Association of British Columbia to promote primary healthcare as the foundation of the healthcare system.
Wieck et al. (2004)	Case Example	United States	Provincial/state	Describes how a collaborative model of action was used to influence statewide rules and regulations through a Texas state-based initiative to improve the work environment by incorporating the American Nurses Association staffing principles.
Wilmot (2012)	Analytical	Canada	National	Examines two editions of the Canadian Nurses Association's discussion document on social justice, and particularly its emphasis on the principle of equity. The paper considers whether a coherent justification can be made for the CNA's espousal of equity.

Note. *This paper was a component of MacDonald’s (2012) dissertation, which has also been categorized under research papers.

Key Content of Included Papers

Five key categories were developed to illustrate the nature of scholarly work including (a) the role and purpose of nursing organizations in policy advocacy, (b) the identity of nursing organizations, (c) the development and process of nursing organizations’ policy advocacy initiatives (subcategories: factors influencing policy advocacy initiatives and strategies and tactics), (d) the policy advocacy products of nursing organizations (subcategories: policy positions, and foundational documents and social justice), and (e) the impact and evaluation of nursing organizations’ policy advocacy work.

The Role and Purpose of Nursing Organizations in Policy Advocacy

Seven papers were focused on the role and purpose of nursing organizations within the context of policy advocacy. Some discussed the role of professional nursing organizations in shaping and influencing health and social care policy more broadly (Fyffe, 2009; Kenner, 1995; Matthews, 2012), while others focused on the role of nursing organizations in advancing a specific policy area such as cancer care (Rieger & Moore, 2002) and patient safety (Rowell, 2003). Two papers took a more critical approach: Vogelstein (2016) examined whether professional healthcare associations should take controversial stances on matters related to professional ethics, and the implications of such stances on individual members’ views and positions; while Welchman and Griener (2005) problematized nursing organizations’ withdrawal from advocacy for patient care issues.

The Identity of Nursing Organizations

Five papers were focused on specific characteristics of organizations in relation to their development and identity. Bowman (1973) discussed the application of political group theory to professional nurse organizations and the characteristics that qualify and make nursing organizations successful as political interest and pressure groups. Lewenson (1989) investigated the tension between nursing's politically conservative image as described in the literature and the progressive positions of four American professional nursing associations during the suffrage movement. The other three papers were focused on discussing the American Nurses Association's development and promotion of power (Freitas, 1986), organizational culture and relationship with evolving policy positions (Woods, 1989), and political preference and values based on donations to political parties (Kent & Liaschenko, 2004).

The Development and Process of Nursing Organizations’ Policy Advocacy Initiatives

Thirty-seven papers were focused on the development, process, or evolution of an organization's policy advocacy work. Most papers focused on organizations’ advocacy efforts related to a specific policy issue or topic including: nurse training and education (Fondiller, 1980; Hall-Long, 1995; Hardy, 1985; Hardy, 1988; Leurer, 2013), advanced practice or nurse practitioner practice (Hansen-Turton et al., 2009; Jones, 2004; Madler et al., 2014; O’Brien, 2003; Sampson, 2009; Sharp, 1994; Young, 1983); nursing shortages, salaries, and staffing issues (Birnbach & Orr, 1993; Eaton, 2012; Green et al., 2004; Hundemer & Durando, 2014; Kishi & Green, 2008; Wieck et al., 2004), healthcare reform (Rubotzky, 2000), women’s suffrage (Lewenson, 1989), registration status (Birnbach, 1982), nursing legislation (Brekken & Evans, 2011; Young, 1983), insurance for the aged and enactment of Medicare (Woods, 1989), community health (Cho & Kashka, 2004), primary healthcare (Whyte & Stone, 2000), continence services (Thomas et al., 2004), cancer care (Rieger & Moore, 2002), environmental health (MacDonald, 2012, Sattler, 2003), lesbian, gay, bisexual and transgender health and equality (Keepnews, 2011), and key legislation such as the Canadian Health Act (Dick et al., 1986). Of the 37 papers, six were focused on examining nursing organizations’ policy advocacy agenda in a more evolutionary and holistic manner and described their engagement in multiple policy issues over an extended period of time (Bednash, 2015; Betts, 1996; Chiu et al., 2020a; Freitas, 1986; Mosley, 1996; Villeneuve & Betker, 2020).

Factors Influencing Policy Advocacy Initiatives

Twenty-five papers included some discussion on factors that influence organizations’ policy advocacy work. Common internal factors were related to internal expertise, resources and infrastructure (Baumgart, 1993; Baillie & Gallagher, 2010; Bowman, 1973; Chiu et al., 2020a; Dick et al., 1986; Fyffe, 2009; Hardy, 1985; Hardy, 1988; Kishi & Green, 2008; Rieger & Moore, 2002; Rubotzky, 2000; Woods, 1989; Young, 1983), organizational structures, governance, and leadership (Baillie & Gallagher, 2010; Chiu et al., 2020a; Fondiller, 1980; Freitas, 1986; Fyffe, 2009; Hardy, 1985; Hardy, 1988; Macdonald, 2012; Macdonald et al., 2012b; Rieger & Moore, 2002; White, 1983), and membership size, engagement, and factions (Bowman, 1973; Chiu et al., 2020a; Fondiller, 1980; Hardy, 1985; Hardy, 1988; MacDonald et al., 2012b; Sharp, 1994; White, 1983). Common external factors were related to relationships and coalitions (Birnbach, 1982; Chiu et al., 2020a; Dick et al., 1986; Eaton, 2012; Freitas, 1986; Fyffe, 2009; Hardy, 1988; Kishi & Green, 2008; Koehn, 2020; Rubotzky, 2000; Sampson, 2009), political environments (Birnbach, 1982; Chiu et al., 2020a; Dick et al., 1986; Hardy, 1988; Madler et al., 2014; Mosley, 1996; Sampson, 2009; Sharp, 1994; Woods, 1989; Young, 1983), social changes and trends (Birnbach, 1982; Chiu et al., 2020a; Fondiller, 1980; Freitas, 1986; Hardy, 1985; Hardy, 1988; Mosley, 1996; Sampson, 2009), and healthcare legislation and trends (Chiu et al., 2020a; Fondiller, 1980; Hardy, 1985; Macdonald, 2012; MacDonald et al., 2012b).

Strategies and Tactics

Thirty-seven papers included some discussion on strategies and tactics related to policy advocacy within the organizational context. Some papers were focused on discussing strategies more broadly while others focused on the strategies used by specific organizations. Commonly identified strategies included interorganizational collaboration and coalitions (Baumgart, 1993; Bednash, 2015; Betts, 1996; Birnbach & Orr, 1993; Brekken & Evans, 2011; Chiu et al., 2020b; Cho & Kashka, 2004; Dick et al., 1986; Fyffe, 2009; Green et al., 2004; Hall-Long, 1995; Hardy, 1985; Hansen-Turton et al., 2009; Jones, 2004; Kenner, 1995; Kishi & Green, 2008; MacDonald, 2012; Madler et al., 2014; Miyamoto & Cook, 2019; Mosley, 1996; O’Brien, 2003; Rieger & Moore, 2002; Rubotzky, 2000; Sampson, 2009; Sattler, 2003; Sharp, 1994; Thomas et al., 2004; Wieck et al., 2004; Whyte & Stone, 2000), meeting with policymakers and government (Betts, 1996; Brekken & Evans, 2011; Cho & Kashka, 2004; Green et al., 2004; Hansen-Turton et al., 2009; Hall-Long, 1995; Hardy, 1985; Kishi & Green, 2008; Macdonald, 2012; Madler et al., 2014; Miyamoto & Cook, 2019; O’Brien, 2003; Rieger & Moore, 2002; Sharp, 1994), using media and campaigns to garner public support (Baumgart, 1993; Birnbach, 1982; Birnbach & Orr, 1993; Bowman, 1973; Catallo et al., 2014; Chiu et al., 2020b; Dick et al., 1986; Green et al., 2004; Hall-Long, 1995; Hardy, 1985; Jones, 2004; Kishi & Green, 2008; Leurer, 2013; Macdonald, 2012; Mosley, 1996; Rieger & Moore, 2002; Sattler, 2003; Thomas et al., 2004; Waddell, 2019; Whyte & Duncan, 2016), membership engagement (Baumgart, 1993; Birnbach & Orr, 1993; Catallo et al., 2014; Chiu et al., 2020b; Hall-Long, 1995; Hundemer & Durando, 2014; Jones, 2004; Kenner, 1995; Macdonald, 2012; Madler et al., 2014; Miyamoto & Cook, 2019; O’Brien, 2003; Sampson, 2009; Sharp, 1994; Taylor, 2016; Whyte & Duncan, 2016), strategic planning and seeking experts (Baumgart, 1993; Bednash, 2015; Brekken & Evans, 2011; Birnbach, 1982; Birnbach & Orr, 1993; Fyffe, 2009; Green et al., 2004, Hall-Long, 1995; Jones, 2004; Kenner, 1995; Kishi & Green, 2008; Macdonald, 2012; Madler et al., 2014; Rubotzky, 2000; Sattler, 2003; Sharp, 1994), and providing testimony and writing letters or briefs to decision makers (Baumgart, 1993; Brekken & Evans, 2011; Catallo et al., 2014; Hall-Long, 1995; Hardy, 1985; Hansen-Turton et al., 2009; Hundemer & Durando, 2014; Kenner, 1995; Macdonald, 2012; Miyamoto & Cook, 2019; Rieger & Moore, 2002; Sharp, 1994).

The Policy Advocacy Products of Nursing Organizations

Twenty papers were focused on analyzing or critiquing the policy advocacy products (e.g., position statements, policy briefs, public statements, and discussion papers) of nursing organizations. We further categorized these papers into two sub-categories—those that focused on analyzing or critiquing organizations’ policy positions, and those that focused on organizations’ foundational documents related to social justice.

Policy Positions

Of those 20 papers, 12 were focused on analyzing or critiquing the policy positions of nursing organizations. These papers were focused on examining how organizations constructed their positions in comparison to others (Kelly, 2008; Kent & Liaschenko, 2004; Saulnier, 2003), the evolution of policy positions overtime (Hardy, 1985; Hardy, 1988; Lewenson, 1989; Woods, 1989), and the breadth and depth of policy positions in relation to specific topics such as spheres of influence (Chiu et al., 2020b), harm reduction (Gagnon & Hazlehurst, 2020), and climate change (Nicholas & Breaky, 2017). Two papers were focused on critiquing organizations’ positions on matters that were more controversial such as assisted suicide (White, 1999) and conversion therapy (Blackwell, 2008).

Foundational Documents and Social Justice

Eight papers were focused on the foundational policy documents developed by nursing organizations. Silva (1983), Rowell (2003), and Matthews (2012) examined the American Nurses Association's foundational documents (e.g., Code of Ethics, Social Policy Statement) and its utility in providing a framework for nursing's commitment to society and engagement in professional advocacy. Welchman and Griener (2005) critiqued the American Nurses Association and Canadian Nurses Association's Code of Ethics and argued that the over-reliance on individual nurse responsibility has blinded nursing associations from their responsibility in engaging in advocacy related to patient care issues. The other four papers involved a critique of nursing organizations’ documents in relation to the concept of social justice (Bekemeier & Butterfield, 2005; Reifsnider, 1992; Valderama-Wallace, 2017; Wilmot, 2012).

Policy Advocacy Impact and Evaluation

Thirty papers included some discussion on impact, however, only one paper was a formal evaluation of a nursing organization's policy advocacy campaign (Baillie & Gallagher, 2010). One paper examined the perceptions of policy and political leadership of nursing organizations in New Zealand (Donovan et al., 2012). The other 28 papers included mention of organizations’ policy advocacy impact on specific issues (Bednash, 2015, Betts, 1996; Birnbach, 1982; Birnbach & Orr, 1993; Cho & Kashka, 2004; Dick et al., 1986; Eaton, 2012; Fondiller, 1980; Freitas, 1986; Green et al., 2004; Hansen-Turton et al., 2009; Hardy, 1985; Hardy, 1988; Hundemer & Durando, 2014; Jones, 2004; Kishi & Green, 2008; Koehn, 2020; Leurer, 2013; Madler et al., 2014; Miyamoto & Cook, 2019; Mosley, 1996; O’Brien, 2003; Rubotzky, 2000; Sattler, 2003; Sampson, 2009; Thomas et al., 2004; Wieck et al., 2004, Young, 1983).

Discussion

This review provides an overview of the current state of scholarly work focused on examining the policy advocacy undertaken by nursing organizations. To our knowledge, this is the first scoping review to examine the nature, extent, and range of scholarly work focused on this topic. The broad inclusion criteria enabled the review and analysis of both research and non-research papers, which provided a comprehensive overview of the available literature. The following discussion summarizes the knowledge gaps that have been identified and proposes additional research topics and questions to advance this program of research.

The findings indicate that while the amount of literature has been increasing throughout the decades, policy advocacy within the context of nursing organizations has not been subject to much empirical investigation. Much of the extant literature focuses on national nursing organizations as opposed to those located at the provincial or state level. While we made efforts to categorize the nursing organizations discussed in papers according to their functions based on three common organizational types (regulatory colleges—for public protection; labor unions—for advancing the socioeconomic welfare of nurses; and professional associations—for advancing the profession and influencing public policy) (Benton et al., 2017), the evolving identities, definitions, and functions of organizations created challenges. As a result, accurate categorization was not possible as the clear delineations and conceptualizations between professional associations, unions, and regulatory bodies that exist today were not the case when many of the included papers were written.

The majority of included papers were non-research accounts and descriptions of organizations’ policy advocacy work. Where empirical work exists, there are minimal studies within the contemporary context. While some included in the review were unclear in their reporting of research methodologies and methods, it is clear that many of the studies used a historical method, and other studies were largely qualitative and retrospective. Although these approaches are often employed to describe and understand past events, successes and challenges, and the unique processes involved in policy advocacy; studies focused on policy implementation, outcomes, and evaluation using quantitative and mixed-methods approaches are also required to provide direction for how nursing organizations’ policy advocacy work can be better situated, conducted, and implemented.

Research Gaps and Further Areas of Inquiry

While the findings provide us with some understanding about the policy advocacy work of nursing organizations and how it has been studied; the existing body of work does not provide us with sufficient knowledge to understand how this work can be strengthened to achieve optimal outcomes. We acknowledge that the extant literature focused on policy advocacy of organizations within other disciplines or sectors may inform the work of nursing organizations; however, the unique historical, social, and political contexts in which nursing is situated across jurisdictions require more focused inquiry. Specifically, while generalizations from existing literature can be useful, nursing knowledge requires careful attention to contexts. The areas of inquiry identified in this section provide readers, specifically nurse researchers and policy advocacy practitioners, with considerations for how nursing organizations’ role, influence, and impact can be further investigated to strengthen this critical function.

Linking Decision-Making Processes with Theories of Policy Process and Change

Findings from the review suggest that nursing organizations are engaged in a variety of policy issues and employ several advocacy strategies and tactics to influence and shape policy. Although many papers were focused on discussing the internal and external factors that influenced the development or process of an advocacy initiative, there was little emphasis on the process of decision making that influenced their priority setting and advocacy strategies—two commonly investigated areas within policy studies. Several theories of policy process and change exist, and many influence the approaches taken by policy advocacy groups (Gardner & Brindis, 2017). By examining the decision-making processes of individuals leading the policy advocacy work of nursing organizations and considering them within the context of promising practices and existing theories, the work of nursing organizations can be better evaluated to identify practices that should be leveraged and areas that require improvement.

The Impact of Organizational Factors on Policy Advocacy Process and Outcomes

Despite discussions around the influence of organizational culture and identity on policy advocacy approaches within the included papers, the relationships between internal processes, structures, leadership, and climate on the level of visibility, effectiveness, and influence of organizations has not been widely studied within the nursing context. Institutional theory (Scott, 2013) can be particularly useful in examining how rules, norms, and culture influence organizations’ decision making about their policy advocacy work; and how they positively or negatively impact their outcomes. Cross case comparisons would be meaningful to identify whether trends or patterns exist between organizations’ internal cultures, structures, and processes, and their level of effectiveness in policy advocacy. This is a particularly important area to consider, as it has the potential to inform individuals working within nursing organizations about the internal factors that support or hinder effective policy advocacy processes and outcomes.

From a governance perspective, further investigation into the nuances between joint versus single mandated organizations, stand-alone organizations versus nationally federated models, and unions versus professional associations is needed. While many nursing organizations discussed within the included papers have evolved over time, scholars have focused very little attention on examining the impact of changing governance structures on organizations’ policy advocacy processes, practices, and outcomes. This could involve examining the differences and similarities in policy advocacy engagement, whether the public and decision makers view them differently, and the implications on the success and effectiveness of policy influence. As illustrated by Benton et al. (2017), differences in activities, principal policy focus, political partisanship, source of power, and methods of advocacy have been noted within the literature between regulators, associations, unions. Consequently, by further examining these areas of inquiry, nursing organizations may be better informed as to how they might choose to govern and organize to maximize policy influence and impact.

The Use of External Perspectives to Inform Policy Advocacy Approaches

Another observation noted from the findings is the lack of literature focused on nursing organizations and policy advocacy from an external perspective—that of elected officials or bureaucrats within governments, leaders within other advocacy groups, and members of such organizations. While understanding the internal processes of policy advocacy within organizations is important for identifying ways to improve this work, it is not the only perspective that can inform change. The success of policy advocacy is influenced by several external factors. As suggested in the findings, many nursing organizations seek to influence the decision-making processes of key decision makers. As a result, understanding how they are perceived in the eyes of external stakeholders can inform the advocacy strategies that are taken up. Future research questions may include the following: How do individuals within governments or key decision makers perceive different nursing organizations? What do they make of the policy advocacy work of such organizations and what approaches are they most likely to respond to? How do these perceptions differ from non-nursing organizations?

Advocacy and Policy Change Evaluation

While some of the papers made mention of the impact of organizations’ policy advocacy initiatives (Baillie & Gallagher, 2010; Bednash, 2015, Betts, 1996; Birnbach, 1982; Birnbach & Orr, 1993; Cho & Kashka, 2004; Dick et al., 1986; Donovan et al., 2012; Eaton, 2012; Fondiller, 1980; Freitas, 1986; Green et al., 2004; Hansen-Turton et al., 2009; Hardy, 1985; Hardy, 1988; Hundemer & Durando, 2014; Jones, 2004; Kishi & Green, 2008; Koehn, 2020; Leurer, 2013; Madler et al., 2014; Miyamoto & Cook, 2019; Mosley, 1996; O’Brien, 2003; Rubotzky, 2000; Sattler, 2003; Sampson, 2009; Thomas et al., 2004; Wieck et al., 2004, Young, 1983), greater empirical research is needed to evaluate and examine the relationship between specific advocacy strategies and outcomes such as changes in public awareness and perception, legislation, policy, and practice. Advocacy and policy change evaluation is an important area of inquiry as advocacy organizations are increasingly expected to demonstrate the value of their work to their membership, stakeholders, and funders (Gardner & Brindis, 2017). Although it may be difficult to identify direct causal relationships given the complexity of the policy making process, evaluating the impact and outcomes of organizations’ advocacy work is ultimately required to identify the ways in which organizations can achieve greater influence and impact.

A Critical Lens to Challenge the Status Quo

As indicated in the findings, while some critical analysis of nursing organizations’ engagement on social justice issues exist, scholarship focused on examining nursing organizations’ involvement in significant social movement is limited. Given the civil rights movements within the last few years (Moorley et al., 2020), greater critical analysis is warranted to examine whether the actions of nursing organizations that promote an advocacy role are adequate and effective in addressing the social injustices confronting our time to ensure that these institutions uphold their ethical, moral, and professional obligations. A critical lens may be useful for examining the following questions: How are nursing organizations framing these complex issues? What rhetoric are they engaging in or promoting? How do these issue frames shape nursing organizations’ policy advocacy actions? Is the policy advocacy work of nursing organizations adequate in informing changes at the individual, organizational, and systems levels? These questions provide both researchers and policy advocacy leaders with an opportunity to critically reflect on the unique role and position of nursing organizations in addressing these pressing and complex societal issues.

Approaches to Inquiry

The areas of inquiry identified above can be investigated using a variety of research methods and theoretical frameworks developed in the fields of nursing, social science, policy studies, and organizational studies. Future research related to policy advocacy undertaken by nursing organizations can be examined by focusing on different units of study. For example, researchers may choose to examine organizations’ policy advocacy within the context of a single or on-going event (e.g., a political election, coronavirus pandemic), a process (e.g., decision-making process related to priority setting and advocacy strategies), a relationship (e.g., coalitions within and beyond nursing), or a specific project or policy issue (e.g., mental health, primary healthcare, human resources of health, etc.).

While much of the extant research and non-research literature is focused on examining the policy advocacy work of a single organization, greater attention should also be placed on studying and comparing organizations across jurisdictions at the national and global level. Although some papers did compare nursing organizations with those of other disciplines, most focused internally within the profession. Consequently, there may be much to be gained from future investigations that explicitly compare nursing organizations’ policy advocacy approaches against those of other disciplines. This would not only enhance our understanding of the similarities that exist irrespective of different contexts, but the aspects of policy advocacy that are more sensitive to change based on the various professional, social, political, and economic contexts.

Limitations

Only papers published in English were included given the lack of translation services available. Further, given the unclear reporting of methodologies in some research papers, and the sorting of non-research papers into categories developed by the author, a level of interpretation and judgement was required. Where there was a level of ambiguity, additional reviewers based on expertise were consulted to reach consensus. However, from the body of literature available, there is sufficient breadth and scope to understand the type of questions that nurses have been asking about the advocacy capacity of their organizations and the answers they are providing.

Conclusion

Policy advocacy is often accepted without question as a key function of many nursing organizations. As a result, it has not been subject to much critical examination or empirical investigation. This review has provided an overview of the nature, extent, and range of scholarly work focused on examining policy advocacy undertaken by nursing organizations. The findings lay the groundwork for future areas of inquiry and suggest that a more focused and critically reflective body of knowledge is required to help challenge current approaches, identify areas for improvement, and offer new insights into how these institutions can best meet the needs of nurses, the public, and health systems. To continue to strengthen the policy influence of nursing globally for the betterment of our societies and healthcare systems, our focus must extend beyond the advocacy undertaken by individual nurses to ensure we effectively mobilize the capacity of nursing organizations to have optimal impact on policy, practice, and society.

Author Biographies

Patrick Chiu, RN, MPH is a doctoral candidate at the Faculty of Nursing, University of Alberta.

Greta G. Cummings, RN, PhD, FCAHS, FAAN, FCAN, is a professor at the Faculty of Nursing and Dean of the College of Health Sciences, University of Alberta.

Sally Thorne, RN, PhD, DSc (Hon), FAAN, FCAHS, FCAN, is a professor at the School of Nursing, University of British Columbia.

Kara Schick-Makaroff, RN, PhD is an Associate Professor at the Faculty of Nursing, University of Alberta.