Exploration of knowledge, attitudes, and perceived benefits towards nurse managers’ participation in the health policy-making process: a qualitative thematic analysis study

Abstract

Background

Participation of nurse managers in policy-making could help policy-makers to propose relevant and effective policies and support other policy actors involved with these processes.

Objective

This study aimed at exploring the attitudes and perceived benefits of nurse managers’ participation in the health policy-making process.

Methods

In this descriptive qualitative research, semi-structured interviews were conducted with 16 nurse managers, government officials, and faculty members. Recruitment was based on purposive sampling from different regions across Iran. A thematic analysis was performed in MAXQDA (version 2012).

Results

After analysis of the qualitative data, four themes and 13 sub-themes emerged. The themes were feelings about nurse managers’ participation, advantages of nurse managers’ participation, problems due to the non-participation of nurse managers, and recommendations for improvement of the policy-making process.

Conclusion

The outcomes provided new insights into the perceived benefits of and attitudes towards nurse managers’ participation in health policy making in the Iranian setting. It is crucial to strengthen the capacity for nurse managers' participation in health policy making to develop effective healthcare policies.

Introduction

In the past decade, economic, policy-related, and social evolutions have led to the adaptation of healthcare management at all levels in organisations and a change in the methods to provide health services (Cathcart and Greenspan, 2012; Kantanen et al., 2017). To deal with these environmental changes, it is necessary for nurses to be part of the core of healthcare (Cummings et al., 2010; García et al., 2020; Thorne, 2019). Nursing is a profession with a high degree of leadership in many healthcare domains due to the nurses’ closeness to patients, families, and society (McHugh et al., 2009; Savage and Kub, 2009). Owing to the influence of nursing in healthcare, the participation of nurses in the governance of healthcare organisations, especially in health policy, is fundamental (National Academies of Sciences and Medicine, 2016; Weber et al., 2015).

The scope and standards from the American Organisation of Nurse Executives for Nurse Administration state that to carry out the responsibilities, the nurse manager should participate in nursing organisational policy making and decision-making in cooperation with nursing personnel and other healthcare providers (Waxman et al., 2017). The International Council of Nurses emphasises that the nurses are closest to the patients and their families, and it is important to enable them to participate in health policy making locally, nationally, and internationally, through support and advocacy (Nurses, 2015). This participation helps improve the quality of the nursing organisation and health systems. Still, in the policy-making process, the role of nurses and their leaders is perceived as that of implementing policies and programmes, rather than participating in and adding the nursing viewpoint, experience, knowledge, and skills to policy decisions and healthcare planning (Benton, 2012; Hajizadeh et al., 2021a). It is, therefore, important for nurse managers to be knowledgeable about the health policy-making process and its wider context, in order for them to influence decisions (Ditlopo et al., 2014; Nurses, 2015).

Health policies are essential to addressing the problems of healthcare services, cost, quality of care, access to healthcare, sustaining positive health outcomes, and promoting the welfare of the public (AbuAlRub and Foudeh, 2017; Mason et al., 2007). It has been suggested that the development of supportive laws, financial aids, and infrastructure can facilitate the participation of stakeholders in policy-making (Khodayari-Zarnaq et al., 2020). It is emphasised that the critical role of nurses in the implementation of improvement plans leads to universal health coverage in the health sector (Ditlopo et al., 2014). Also, the engagement of nurse managers in the policy-making process could help policy-makers to propose more relevant and effective policies and support other policy actors involved with these processes (Green et al., 2011).

Bregar and Savic examined the impact of nurses’ involvement in health policy development on the current healthcare system in Slovenia. Their results indicated that nurses’ involvement in the health policy-making process could have an impact on nursing practice and healthcare provision and could improve the safety and quality of healthcare services and, public health in the long run (Bregar and Savič, 2013). Shariff and Potgieter found that nurse managers’ potential contribution to the policy-making process was not recognised as significant, and they were excluded by policy-makers. Their findings also showed that the benefits of nurse managers' inclusion in the health policy-making process were undermined due to negative publicity about nursing (Shariff and Potgieter, 2012). In another study, Raeda et al. emphasised that nurse leaders and administrators should design appropriate strategies to enhance nurses’ involvement in health policy development (AbuAlRub and Abdulnabi, 2020).

In the Iranian health system, nurses have many problems in clinical care provision, such as a shortage of nurses and other professional issues that cannot be resolved without the active involvement of nurse managers in the policy-making process (Aarabi et al., 2014). During recent years, the participation of Iranian nurse managers in policy-making has increased, but there are still disputes about policy-making for nursing. Therefore, this study explored the attitudes towards and perceived benefits of nurse managers’ participation in the health policy-making process. The nurse managers in this study were those who worked in hospitals and were responsible for supervising the nursing staff in a hospital or clinical setting. They also oversaw patient care, made management and budgetary decisions, set work schedules, coordinated meetings, and made decisions about personnel.

Methods

Study design and research context

This qualitative study, which used a descriptive research design, was conducted from November 2019 to February 2020 at Tabriz University of Medical Sciences, northwest of Iran. This university is affiliated with the Ministry of Health and Medical Education of Iran and has over 15 teaching hospitals to provide medical care for the northwest population of Iran. The hospitals and other medical centres of this university provide health services to about 10 million people living in East Azarbaijan Province and the surrounding provinces. Standards for Reporting Qualitative Research (SRQR) were followed to ensure the study’s trustworthiness.

Participants

The participants were nurse managers working in hospitals, government officials who had key positions in policy-making in the Iranian Ministry of Health and Medical Education, and faculty members who were familiar with nursing and health policy. The nurse managers were chosen from clinical departments within Iranian hospitals. The inclusion criteria for the nurse managers were: having at least a Bachelor’s degree, volunteering for participation, having nursing management experience of at least 3 years, and being able to provide meaningful and rich information about the subject of the study. Government officials and faculty members who had key positions and were well-informed on the topic of nursing and health policy-making were also selected for interviews. The participants who were able to consent and communicate were recruited via a brief telephone introduction. The number of interviews was determined by the research team based on data saturation.

Recruitment and data collection

The participants were recruited via an email invitation and WhatsApp messenger to inform potential participants about the research objectives. If the first author (A.H.) received the agreement of a potential participant, the author would coordinate a date, time, and place for the interview to take place.

An interview guide was developed on the basis of a literature review and pilot interviews (see Table 1). The first author (A.H.) conducted in-depth tape-recorded, face-to-face, or telephone interviews with 16 participants. By using a semi-structured interview approach, all the participants were guided through the same sets of questions. The face-to-face interviews were performed at their workplace. The interview process was recorded digitally. The participants were also asked to provide their age, marital status, education, work experience, years of experience, and managerial and organisational work experiences.

Table 1.

The interview guide.

1- Please tell us about your general experiences about nurse managers participation in health policy making process

2- What are your views and feeling about the nurse managers’ participation in health policy making?

3- What problems may arise due to the lack of nurse managers’ participation in health policy making?

4- What are the advantages of nurse managers’ participation in the health policy making process?

5- What are your recommendations for improvement of the nurse managers' participation in the health policy making process?

6- We have talked about the nurse managers' participation in health policy making. Please feel free to add anything that you think is necessary in order to improve their participation.

Data analysis

The MAXQDA (version 2012) data analysis software was used to manage and organise the data. The transcripts were analysed by using thematic analysis (Braun and Clarke, 2012). All the interviews were audio-recorded and transcribed verbatim into Persian by members of the research team. The researchers continued to listen to the recordings and checked the accuracy of all transcripts. In the next stage, the texts were translated independently into English by two of the researchers (R.K.Z. and A.H.). The transcripts that fitted the research questions were identified as a “meaning unit” and were coded. Finally, the codes were compared based on their differences and similarities and divided into sub-themes and themes.

Trustworthiness

The authors took several measures to conduct a credible and trustworthy study. These measures included data analysis concurrently with data collection, employing constant comparison analysis, active listening, long-term engagement with the participants, and peer checking, which helped with the credibility of the data. Also, the authors recoded all the documents regarding the analytic activities to ensure dependability. To ensure dependability, triangulation was performed in this study which included the following strategies: using different data sources in time (gathering data in different times of the day or at different times in a year), space (collecting data on the same phenomenon in multiples setting), and person (gathering data from different types or level of people, e.g. nurse managers, government officials and faculty members), investigators (used two researchers to make coding, analysis and interpretation decisions), and methods of data collection. To ensure the confirmability of the results, the authors adopted the peer-check method. Furthermore, a maximum-variation sample was recruited to improve the transferability of the findings.

Ethical approval

To observe the ethical codes of research, the approval of the Ethics Committee of Tabriz University of Medical Sciences was obtained under NO IR.TBZMED.REC.1398.1294. All the participants were informed about the purpose of the study and provided informed consent before participation. In this study, all participants contributed voluntarily, received no financial compensation, had the right to withdraw from the study at any stage of the study, made sure that their information was confidential, and that all alleged losses (financial, health and ...) were borne by the research team. The personal identifiers of participants and the raw data, including transcripts, were stored confidentially and were accessible only to the research team.

Results

In total, 16 nurse managers and key informants were interviewed. Six in-depth interviews were conducted face to face, and 10 interviews were conducted over the telephone. Due to the restrictions caused by the COVID-19 pandemic, not all the interviews could be conducted face to face. The demographic data of the participants are shown in Table 2. Most of the participants were over 45 years old and worked in leadership capacities for more than 20 years.

Table 2.

Demographic data of the study participants (n = 16).

Characteristics	Number
Gender
Female	9
Male	7
Age
<40	2
40–49	11
>50	3
Marital status
Married	16
Single	0
Educational level
Bachelor	4
Master	5
PhD	7
Year of work experience
1–10	1
11–20	3
21–30	11
>30	1
Organisational position
Nurse managers	9
Government officials	3
Scientific faculty member	4

Four themes and the associated sub-themes emerged from the analysis: (1) Feelings about nurse managers’ participation; (2) Advantages of nurse managers’ participation; (3) Problems due to the non-participation of nurse managers; (4) Recommendations for improvement of the policy-making process (Table 3).

Table 3.

Themes and sub-themes developed from analysis.

Themes	Sub-themes
Feeling about nurse managers’ participation	Policy making as a networking
	Negative attitude towards the current policy making
	Existence of a policy-making process for physicians
Advantages of nurse managers’ participation	Advantages of the individual level
	Improving hospital performance
	Progress in the policy making process
	Help with professional nursing excellence
	Improve the function of the health system
Problems due to non-participation of nurse managers	Problems for nurse managers
	Problems in the policy making process
	Expected problems for the nursing professional
Recommendations for improvement of the policy process	Need for policy making based on the principle of participation
	Evidence-based policy making

Feelings about nurse managers’ participation

Policy-making as networking

The participants stated that policy-making is networking and to shape policy, it is necessary to focus on the cooperation between policy-makers and nurses. One nurse manager reported:

“In policy-making, everyone has to work like a team. In fact, policy-making is a network process. We work as a team on clinical issues, and the same should happen here.”

Negative attitude towards current policy-making

Many nurse managers mentioned that because health policy-making is not in the interests of all healthcare providers, they have negative attitudes towards policy development. Another nurse manager mentioned:

“Without the nurses’ participation, they will suffer from policy-making. That’s why I don’t feel good about it. Policies are for some people, but not for nurses.”

Existence of a policy-making process for physicians

Traditionally, physicians in the Iranian health systems have dictated the formation of health policies. Indeed, nurses believe that physicians have hindered their activities in managerial and policy positions, and that policies and programmes are designed for physicians. One of the nurse managers stated:

“In my opinion, our health system is entirely in the hands of doctors. For example, the head and director of our hospital are both doctors, and all policies and programmes are developed by doctors for themselves.”

Advantages of nurse managers’ participation

Advantages of the individual level

There is considerable understanding regarding the reasons or benefits of nurse managers’ involvement, such as skills acquisition, increasing the motivation of nurses, and financial support. Another nurse manager expressed:

“Our participation definitely has benefits for us. If I participate, I will learn things better. I will also be financially secure.”

Improving hospital performance

Nurse managers play an integral role in healthcare. Our participants thought that if nurse managers actively participate in health policy-making, they can use proper management to reduce costs and improve the quality of hospital services. One participant stated:

“Nurse managers should strengthen communication with hospitals and policy-makers to understand their attitudes toward participation in policy-making. Overall, their participation can help control costs and provide better services.”

Progress in the policy-making process

The nurse managers’ active participation in policy-making can lead to progress in the policy-making process. It is necessary to strengthen the role of nurses and nurse managers in healthcare policy-making to better implement this process. Another participant reported:

“Nurse managers need to be active in this process. They can help with the process, especially since they can perform better in the performance stage.”

Help with professional nursing excellence

Nursing professionals know that health policy is valued and can help advance the nursing discipline. The nurse managers in our study reported that if they participated in policy-making, their participation would improve the quality of nursing skills. One of the nurse managers stated:

“If I was part of the team that was advising the government on the transformation of health, I could also learn more about policy. I would pass this knowledge on to nurses and lead to better nursing.”

Improve the function of the health system

Nurses historically respond to changes in the needs of healthcare and health service delivery with professional responsibility. Most of the participants emphasised that because of the nurses' ability, their participation in policy-making leads to better functioning of the health system. One participant commented:

“As you know, nurses are the largest group in hospitals, and if they are satisfied with the policy, the hospital and the health system will perform better. This leads the health system to achieve its goals.”

Problems due to the non-participation of nurse managers

Problems for nurse managers

The findings revealed that if nurse managers cannot participate in policy-making, they will not be empowered and will not perform the management function well in hospitals. One of the nurse managers stated:

“Management is a broad task. If I am isolated, I will not progress and I will not learn anything new. I don’t have to perform only clinical duties, and can also do managerial tasks.”

Problems in the policy-making process

Most of the participants stated that nurse managers’ non-activity in policy-making leads to problems in the policy making process. There are a number of professional forums and professional organisations seeking to influence and shape policy and address particular specialist areas of practice and patient care. The health policy-making process must be accomplished with the participation of all stakeholders, including nurses. One nurse manager mentioned:

“I have not been involved in the policy-making process. How do they expect me to implement the announced policy and programme? I don’t believe in their plans and I won’t help implement them.”

Expected problems for the nursing professional

Nurses work at the front line in all healthcare settings, providing hands-on care for patients. Their efforts to clarify and promote nursing are compromised because they have limited participation in the policy-making process. Another participant stated:

“That’s why nursing hasn’t progressed and won’t progress. Since nursing is not involved in policy-making, policies will not work in its favour, and nurses become isolated and frustrated every day.”

Recommendations for improvement of the policy-making process

Need for policy-making based on the principle of participation

Participatory policy-making is an approach whereby consultative or participatory means are used to achieve accountability, transparency, and active citizenship. Also, some participants explained that nurse managers have no understanding of how policy-makers shape policies, and this is necessary to be done in partnership. One nurse manager reported:

“I have not been involved in policy making. I need to be involved in this process. Policy-makers need to take a participatory approach. That’s how everyone is satisfied.”

Evidence-based policy making

Participants expressed that policy decisions should be based on, or informed by, rigorously established objective evidence. Another participant said:

...“ Another important issue is that decisions and policies must be based on new evidence. Unfortunately, policy-makers act emotionally. The use of evidence in this process is very beneficial.”

Discussion

This qualitative study investigated the attitudes towards and perceived benefits of nurse managers’ participation in the policy-making process. Moreover, it examined the benefits and problems of nurse managers’ participation attached to different levels of policy making in the health system. The findings are novel, and to the best of our knowledge, this is the first study to explore nurse managers’ participation in policy making in Iran.

The participants felt that policy making is networking, and it is necessary to involve all the stakeholders. Consistent with our findings, Walt et al. showed that networking brings together many different groups and individuals for a common purpose or cause, who may have little similarity in standards or contribution. Network analysis reflects the phenomenon of shared decision-making and the exchange of resources to achieve specific goals (Walt et al., 2008). The appropriate approach is to network with peers in order to share ideas and concerns, to create an opportunity for learning the issues, and participate as a group or a coalition (Sheehan, 2010). Most nurse managers noted that negative attitudes towards and a lack of interest in current policy making limited their participation. A study was conducted on the involvement of nurses in HIV policy development in Nyanza Province, Kenya, and the findings showed that the participants still lacked the trust and interest to be involved in the policy-making process, although they associated participation with nursing care (Akunja et al., 2012). Most of the participants stated that a significant proportion of physicians were part of the policy development process. In fact, physicians were given the majority of policy-making positions, and nursing issues were represented by other health professionals at health policy-making forums (Ditlopo et al., 2014; Shariff and Potgieter, 2012). Generally, nurses are crucial members of the healthcare systems and their inputs in policy development would improve health delivery (Acheampong et al., 2021).

There is also a lack of understanding regarding the reasons or benefits of nurse managers’ involvement, but our findings indicated that this involvement can lead to improvement in nurse managers and hospital performance, advance the policy-making process, help with professional nursing excellence, and, in the long run, promote the function of the health system. A previous study showed that the major benefit of being involved in policy development was forming connections and partnerships (Akunja et al., 2012). Also, a previous study conducted in Iran indicated that a weakness in the characteristics of nurse managers, inefficient organisational structure, and environmental factors are the barriers to participation, while improved cooperation and communication, governmental and non-governmental organisation activities, and reforms in the health policy-making process are facilitators of nurse managers’ participation. Furthermore, identifying these factors can benefit the participation of nurse managers in the health policy-making process (Hajizadeh et al., 2021b). Nurses should become more interested as they gain confidence in their abilities, and are able to identify the many benefits associated with participation in health policy activities (Hall-Long, 2009). Such results are consistent with previous studies, such as the study by AbuAlRub and Foudeh which reported that participation improves the health of the public, the opportunity to develop new skills, personal professional advancement, improvement of the quality of care, safety, risk prevention, and the power of the nursing profession (AbuAlRub and Foudeh, 2017).

The participants reflected on the basic problems due to the non-participation of nurse managers in policy making. The literature suggests that nurses make up the majority of the health workforce globally and, therefore, the health system cannot function without their participation (Asuquo et al., 2016; Ditlopo et al., 2014). One of the important challenges addressed by the interviewees was problems related to the implementation of the policy-making process. Findings of Marquis and Huston showed that managers who are uninformed about the legal, political, economic, and social factors affecting healthcare may make strategic planning errors that have disastrous implications for their professional development and the financial viability of the organisation (Marquis and Huston, 2009). The necessity for nurses to participate in health policy development has been widely emphasised, but this call for increasing nurses’ involvement in policy making has not been very successful thus far (Edwards et al., 2009). To improve the policy-making process, nurses and their managers need to specialise in health policy research and analysis and actively participate in all stages of policy making (AbuAlRub and Abdulnabi, 2020). Similar to the prior research, the present study concluded that evidence-based policy making is necessary. The previous studies also suggested that by gathering evidence-based knowledge, nurses and their leaders could shape health policy by identifying and developing evidence to potentially improve healthcare (Hall-Long, 2009; Nursing, 2011).

Conclusion

This research has offered new insights into the attitudes towards and benefits of nurse managers’ participation in policy-making in Iran. It is suggested that providing nurse managers with a platform from which the perceived benefits can be discussed can have a real impact upon policy and practice changes, to better involve them in the policy-making process. These results are considered as baseline data and information for upstream managers to increase nurses’ and their managers’ involvement in health policy making. It is important to strengthen the capacity and participation of nurse managers in health policy development to create effective policies as they are the main implementers of these policies. This would help improve health outcomes and lead to effective health service delivery. By increasing involvement in health policy activities and focusing more on the perceived benefits, the nursing profession and its political position might be strengthened, and consequently, the function of the health systems might be improved.

Recommendations for future research

Future studies can design a conceptual framework to facilitate nurse managers’ participation in the policy-making process. Moreover, future research should also investigate the attitudes of policy-makers and upstream managers, which help identify benefits and overcome barriers to the involvement of nurse managers in the policy-making process. The reasons for the negative attitude of the nursing profession to the policy-making process are also worth considering. Also, the challenges and problems of nurse managers' participation in the health policy-making process from the perspective of various stakeholders should be examined. Finally, a study to investigate the platforms required for nurse managers’ participation in the policy-making process is warranted.

Limitations

Due to purposive sampling, most participants were older than 45 years and their knowledge was of the past. Although we purposively sampled participants to ensure a diversity of opinions and experiences, we were only able to include participants who were interested in being interviewed. Also, the participants were recruited from governmental settings, so the generalisability of findings to other settings, such as private settings, may be limited. Due to the spread of COVID-19, the researchers were forced to conduct 10 interviews over the telephone, and thus the participants' behaviour and body language could not be observed, and this compromised the analysis and interpretation of responses. Finally, the COVID-19 pandemic and heavy workload in emergency conditions may have affected the participants' opinions and responses.

Key points for policy, practice, and/or research

• • Understanding the perceived benefits and attitudes towards nurse managers’ participation in the health policy-making process can support better participation for nurse managers.

• • Nurse managers were rarely involved in the health policy-making process in Iran. Attention needs to be given to increasing nurse managers’ involvement in policy-making.

• • Participation in the health policy-making process in Iran can lead to supporting nursing, patients, and their family.

Biography

Alireza Hajizadeh PhD student in the School of Public Health in Tehran University of Medical Sciences.

Vahid Zamanzadeh Professor at the Department of Medical Surgery in the Faculty of Nursing in Tabriz University of Medical Sciences.

Rahim Khodayari-Zarnaq Associate Professor at the Department of Health Policy and Management in the School of Management and Medical Informatics in Tabriz University of Medical Sciences.

ORCID iD

Rahim Khodayari-Zarnaq https://orcid.org/0000-0003-1626-4505