A framework for nursing participation in health policy making: a systematic review

Background : Nurses as the majority of the health care workforce help in the health systems strengthening. Nurses' involvement in health policy making is clear; however, still few are involved in policy-making processes, even in the clinical context. The aim of the present systematic review was to designing a framework for nursing participation in health policy making. Methods: The present systematic review was designed on studies conducted between 2000 and 2019. Four online databases including PubMed, EMBASE, SCOPUS and Science Direct were searched using comprehensive terms. Study selection, quality assessment, data extraction, and data analysis were independently done by two reviewers. Inclusion criteria included published studies in English language and between 2000 to 2019, participants such as nurses and the healthcare managers, mentioned influential factors, types of participants were included nurses and the healthcare managers, study designs and methods clearly defined. The methodological quality of included article was appraised using the checklists of CASP and MMAT. Finally, the data were analyzed using content analysis. Results: After quality assessment, 11 studies, according to inclusion criteria, were retrieved. Nine studies had a good, two a medium, and non-articles was poor methodological quality. Three main identified themes were: nursing-related factors (4 sub- themes), management and organizational factors (8 sub-themes) and creating a positive work environment (3 sub-themes). Conclusion: The designed framework in the present review can act as a facilitator of developing more participation on behalf of nursing staff in the processes of policy making about health systems. Nurses can utilize this finding to develop empowering programs to play efficient roles and increase their participation in health policy making. Further studies are required to survey the relation between these factors and nursing participation in health policy making.


Abstract
Background : Nurses as the majority of the health care workforce help in the health systems strengthening. Nurses' involvement in health policy making is clear; however, still few are involved in policy-making processes, even in the clinical context. The aim of the present systematic review was to designing a framework for nursing participation in health policy making.
Methods: The present systematic review was designed on studies conducted between 2000 and 2019.
Four online databases including PubMed, EMBASE, SCOPUS and Science Direct were searched using comprehensive terms. Study selection, quality assessment, data extraction, and data analysis were independently done by two reviewers. Inclusion criteria included published studies in English language and between 2000 to 2019, participants such as nurses and the healthcare managers, mentioned influential factors, types of participants were included nurses and the healthcare managers, study designs and methods clearly defined. The methodological quality of included article was appraised using the checklists of CASP and MMAT. Finally, the data were analyzed using content analysis.
Results: After quality assessment, 11 studies, according to inclusion criteria, were retrieved. Nine studies had a good, two a medium, and non-articles was poor methodological quality. Three main identified themes were: nursing-related factors (4 sub-themes), management and organizational factors (8 sub-themes) and creating a positive work environment (3 sub-themes).
Conclusion: The designed framework in the present review can act as a facilitator of developing more participation on behalf of nursing staff in the processes of policy making about health systems.
Nurses can utilize this finding to develop empowering programs to play efficient roles and increase their participation in health policy making. Further studies are required to survey the relation between these factors and nursing participation in health policy making.

Background
In rapidly changing and developing health systems, nurses comprise the major group of health care personnel who are mainly responsible for providing people with qualitative care (1). The political, environmental, technological and financial pressures in healthcare systems affect all practical settings. These changes can make opportunities for all personnel, especially nursing staff to enhance their position and role in healthcare policies and management (2)(3)(4).
According to the definition by World Health Organization (WHO), health policies refers to decisions, plans, and actions undertaken to achieve specific health care goals within a society (5). The ultimate goal of health policies is to promote public welfare. It consists of three stages: formulation, policy implementation and policy reformation (6,7). Health policy is a tool which nurses must utilize to improve the safety and quality of healthcare (8).
When elaborating on health policies, there must be a motivation for nurses to participate in health policy-making processes. For example, nurses can have influence through their experiences on policies, laws, and regulations that govern the healthcare system (9,10). Nursing Staff are encouraged to participate in health policy for three reasons. First, nurses closely deal with patients and their families in a variety of settings; therefore, their comments can be considered as valuable sources for policy development. Second, different health policies have direct effects on nurses. Thus, policies should ensure a supportive work setting. Third, nurses play key role in professional development and can highly contributed to the formation of appropriate and efficient health policies (11,12).
The International Council of Nurses (ICN) strongly emphasizes and supports those efforts in improving nurses' readiness in developing policies (11). Different factors affect nurses' ability to be active in health policy development including gaining experience in policy development process, gaining knowledge on health systems, policy research and developing leadership skills (1,13). In recent decades, despite the fact that nurses have become increasingly knowledgeable, skilled, and welleducated, they have had limited involvement in policy making processes and political decisions, affecting the delivery of health services (12,14).
A study conducted in Thailand showed that most nurses are involved only in the implementation of health policies while it is essential issue that they must gain perception over the issue and actively participate in it (1). Abu-Al-Rub & Foudeh conducted a study to evaluate the level of involvement of Jordanian nurses in the development of health policy and perceived benefits, barriers, and impacts on health outcomes of involvement in health policy process. Their results indicated that the low level of Jordanian nurses' involvement in health policy can be attributed to the fact that most participants, beside their roles in workplace, had family roles making them to allocate little time for health policies activities. Lack of mentoring by nursing leaders could also negatively affect their involvement in health policies development (5). In study by Shariff  Thus, there is a need to enhance their ability in understanding, generating, and utilizing research knowledge that is beneficial for making changes in policy (13,16,17). Several studies have emphasized that contemporary nurses influence health policies. The purpose of this systematic review was to designing a framework for nursing participation in health policy making.

Search strategy and data sources
The present systematic review was designed and conducted in a time span of 5th to 10th of July, 2019. We searched using a modified form (18)    Inclusion and exclusion criteria exclusion criteria included: (1) outcome reported were ambiguous and was ineligible for the data synthesis (2) evaluation results fall within the scope of low quality research after using the checklist quality assessment tool (3) editorials (4) letters to the editor (5) protocol (6) commentaries and (7) conference abstracts. Moreover, if an articles did not unavailable full-text download link the corresponding authors were contacted via e-mail to ask for full-texts and was excluded in case of nonresponding.
Study selection and quality assessment mixed method studies was also implemented. MMAT is a critical appraisal tool designed for the appraisal stage of systematic mixed studies reviews, i.e., reviews that include qualitative, quantitative and mixed methods studies (20). In case of disagreement, third-party opinions were asked to reach consensus. To scoring the quality of the final studies, they were divided into three categories: poor (0-3), medium (4-7) and good quality (8)(9)(10). Finally, studies with poor quality were excluded.

Data extraction
Data extraction

Results
Results of the search strategy 7 The search yielded for studies has been summarized in  Table 2. Content analysis was conducted for each three main themes and was categorized into fifteen sub-themes. The results of content analysis are presented in Table 3. This Table also shows the frequency of extracted factors.

Study quality
All 11studies were classified to have poor, medium or good in quality. After quality assessment, nine studies (81/82%) had good quality, two (18/18%) had medium quality. Also the quality level of nonarticles was poor.

Conceptual framework
The present study showed that there is a logical relation between the extracted factors (Fig. 2).
According to the presented framework, the three main themes were mutually related. The connection is illustrated by the arrow. These three themes are depicted by related pictures. As it can be observed, the establishment of incentive organizational structure includes leadership styles, creating making (12,15).
Lack of resources was most frequently mentioned factor in studies. Lack of available resources was identified as a factor for the participation of nursing leaders in health policy making (5,15). According to our findings, gaining external support was mentioned as one of the sub-themes for creating a positive work environment. Lack of support on behalf of different sectors such as the political sector, government officials, or professional organizations were obstacles in low involvement of nurses in policy making (1).
Based on the results of our review, education and research system, as a nursing-related sub-theme could affect nurses' participation. Researches in, PhD curriculum in nursing and training were regarded as the facilitators of nurses' involvement in policy making processes in LMICs (26,30). Also, Parallel to our study, the study of O'connor (29) showed that education and research are necessary to develop nursing workforces' participation.
Most of the factors that affect nurses' participation are related to management and organizational factors, to which the included studies point to their importance (12,13). Supportive organizational structure is a prerequisite for the establishment of policy making activities.
Establishing communication networks was identified as one of the factors affecting nurses' participation in the policy making processes (13). This network largely focuses on interacting with internal organizational members and interested external publics. Leadership styles are categorized as one of the sub-themes of management and organizational factors (1). This factor is dependent on the organizational structure according to the framework presented. Based on the findings, health policy outcomes and impacts are considered as a supportive system for establishing organizational structure. Many studies have mentioned the importance of this factor in increasing the nurses' participation (28).
The results of this study provide a framework for decision makers and policymakers to engage nurses in their affaires. Understandings factors that affect nurses' participation in health policy making can offer insight about strategies to strengthen nurses' role in health policy.
Nurses' inadequate participation in policy-making processes is going to continue in the future and in

Limitations
Lack of fluency in other languages to use the results of non-English language studies was one of the most important limitations. Another limitation was inaccessibility to some other databases such as CINAH and Web of Science. Also, we had no access to unpublished dissertations and full-text of some articles.

Conclusion
In the health care providing systems, due to the fact that different health policies can directly affect the role of nurses, thus, they need to have more participation in health policy making. Nurses' failure to involve in policy making has led to be a concern of WHO and ICN. Increasing the capability of

Consent for publication
Not applicable.

Availability of data and materials
Datasets are available through the corresponding author upon reasonable request.