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How and why nurses became involved in politics or political action, and the outcomes or impacts of this involvement

Published:September 04, 2021DOI:https://doi.org/10.1016/j.outlook.2021.07.008

      Abstract

      Background

      Nurses’ political engagement is needed for societal advancements.

      Purpose

      The purpose of this study was to explain why and how nurses became politically active, and what they achieved.

      Methods

      Qualitative, constant-comparative data analysis was used for this study. After 10 elected or politically-active Canadian nurses were interviewed, data saturation was confirmed.

      Findings

      All were motivated by early life events to realize the importance of social justice and good government. Their nursing education and work equipped them to be capable of engaging in political spheres. All had developed knowledge of relevance for political purposes; in addition to confidence, communication skills, and other abilities to be effective politically. All highlighted the importance of being encouraged and assisted to engage politically. Positive micro-, meso-, and macro-level benefits of this involvement were identified.

      Conclusions

      More nurses should be inspired and helped to become active politically.
      It is critically important for nurses to inform and advance public policy, through direct political activities.

      Keywords

      Despite nurse leaders advocating over the years for more politically-active nurses (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Harkless G.E.
      Prescriptive authority: Debunking common assumptions.
      ;
      • Hinkle J.
      • McQuide P.
      Political power for neuroscience nurses.
      ;
      • Hodges L.C.
      • Hardy G.R.
      Policymaking, politics, and the neuroscience nurse.
      ;
      • MacPherson K.I.
      Health care policy, values, and nursing.
      ;
      • Misener T.R.
      • Alexander J.W.
      • Blaha A.J.
      • Clarke P.N.
      • Cover C.M.
      • Felton G.M.
      • Sharp H.F.
      National Delphi study to determine competencies for nursing leadership in public health.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Stanik J.A.
      Individual actions to improve nursing's image: A step toward surpassing tomorrow's expectations.
      ), only a few nurses are active politically (
      • Fyffe T.
      Nursing shaping and influencing health and social care policy.
      ;
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Santillán-García A.
      Propuestas para la participación política de las enfermeras españolas.
      ;
      • Wilson D.
      Testing a theory of political development by comparing the political action of nurses and nonnurses.
      ). In fact, voting may be the extent of political involvement for most nurses (
      • Chan S.W.
      • Cheng B.
      Political participation in Hong Kong: A study.
      ;
      • Gesse T.
      Political participation behaviors of nurse-midwives.
      ). The historical background of nursing has long influenced nurses to keep away from politics (
      • Albarran J.W.
      Should nurses be politically aware?.
      ), and also contributed to the nursing voice not being heard nor heeded (
      • Salvage J.
      • White J.
      Nursing leadership and health policy: Everybody's business.
      ). Among the historical and social factors behind this reality is that: (a) nursing is a highly stereotyped and predominantly female profession with feminine-associated values, (b) nurses have had long-standing passive roles in the traditional paternalistic medical model of health care in which patriarchal doctor-nurse and male-female relationships have been predominant, (c) there has been a lack of collectiveness, professional identity, and unity within nursing, and (d) political behavior by nurses has not been considered appropriate (
      • Albarran J.W.
      Should nurses be politically aware?.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ). Moreover, nurses, like other members of the general public, tend to have a general distrust, if not dislike, of politicians and political processes (
      • Bertsou E.
      Rethinking political distrust.
      ;
      • Mason D.J.
      Nursing and politics: A profession comes of age.
      ), with this view also keeping them away from politics and political action.
      A recent literature review revealed the invisibility of politically-active nurses and their important work for fostering or revising micro, meso, and macro policies (
      • Wilson D.M.
      • Anafi F.
      • Kusi-Appiah E.
      • Darko E.M.
      • Deck K.
      • Errasti-Ibarrondo B.
      Determining if nurses are involved in political action or politics: A scoping literature review.
      ). This invisibility is a concern, as nurses are often thought of, by themselves and others, as apolitical (
      • Arabi A.
      • Rafii F.
      • Cheraghi M.A.
      • Ghiyasvandian S.
      Nurses’ policy influence: A concept analysis.
      ;
      • Benton D.C.
      • Al Maaitah R.
      • Gharaibeh M.
      An integrative review of pursing policy and political competence.
      ;
      • Mason D.J.
      Nursing and politics: A profession comes of age.
      ;
      • Schrock R.A.
      On political consciousness in nurses.
      ;
      • Wilson D.
      Testing a theory of political development by comparing the political action of nurses and nonnurses.
      ). Yet, compelling reports of effective political action by nurses and nursing groups exist (
      • Fyffe T.
      Nursing shaping and influencing health and social care policy.
      ;
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Leavitt J.K.
      Leaders in health policy: A critical role for nursing.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Wilson D.
      Testing a theory of political development by comparing the political action of nurses and nonnurses.
      ). Some nurses have even been elected to a political office, where they fulfill important governmental functions (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ).
      There are various mechanisms for nurse political participation (
      • Oestberg F.
      Policy and politics: Why nurses should get involved.
      ;
      • Santillán-García A.
      Propuestas para la participación política de las enfermeras españolas.
      ). Whether through direct political action such as by running for elected office or through other forms such as giving scientific advice, or via public action or through scientific and professional associations or unions (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Oestberg F.
      Policy and politics: Why nurses should get involved.
      ;
      • Santillán-García A.
      Propuestas para la participación política de las enfermeras españolas.
      ), nursing leadership and political engagement are paramount for society and for the nursing profession (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Leavitt J.K.
      Leaders in health policy: A critical role for nursing.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Santillán-García A.
      Propuestas para la participación política de las enfermeras españolas.
      ;
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      ). However, as pointed out by
      • Leavitt J.K.
      Leaders in health policy: A critical role for nursing.
      , nurses do not realize “how much [their] practices are dependent on decisions made in the public policy arena and how [they] as nursing experts can shape those decisions” (p. 73).
      Nurses not only have key roles in the care of ill, disabled, and dying people in a variety of settings, but they also work “to enable individuals, families, groups, communities and populations to achieve their optimal levels of health” (, p. 5). Nurses in their daily practice witness how social determinants of health and budget allocation decisions affect communities as a whole and individual lives and health (
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      ). One nursing imperative is building healthy communities while supporting families and individuals to live healthier lives; but to make this happen, shifts in the allocation of resources and budget are needed and hence, changes in public, social, and health policies (
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      ). In this respect, nursing knowledge and their unique, broad-based scientific perspectives ideally place them in a position where they could make a substantive difference in the design of health and social policies to improve and advance the health and well-being of people (Institute of
      • Institute of Medicine
      The Future of Nursing: Leading Change, Advancing Health.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      ).
      Furthermore, resonant with their codes of ethics and practice standards: nurses have an obligation to speak out and get involved in one of the most important moral imperatives of our day: promoting the health of families and communities by shaping (…) nation's health and social policies to end disparities in health and create healthy places to live, work, and play. (
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      , p. S50)
      Given the public service mandate of nursing, political activity by nurses is essential for the good of society (
      • Mason D.J.
      • Backer B.A.
      • Georges C.A.
      Toward a feminist model for the political empowerment of nurses.
      ;
      • Mason D.J.
      Promoting the health of families and communities: A moral imperative.
      ). Hence, nurses have an obligation to be aware of, if not actively engaged in political processes that stem from their professional, ethical, if not moral responsibilities (
      • Albarran J.W.
      Should nurses be politically aware?.
      ;
      • O'Connor T.
      Wanted: Politically aware and involved nurses.
      ). As there are few politically-active nurses now (
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Santillán-García A.
      Propuestas para la participación política de las enfermeras españolas.
      ;
      • Wilson D.M.
      • Anafi F.
      • Kusi-Appiah E.
      • Darko E.M.
      • Deck K.
      • Errasti-Ibarrondo B.
      Determining if nurses are involved in political action or politics: A scoping literature review.
      ), understanding why some nurses engaged in politics and public policy advocacy would help to find ways to increase the involvement of nurses in political spheres. Therefore, with the aim of learning how and why Canadian nurses became active politically, and what was gained through this activity, an exploratory qualitative research study was carried out.

      Methods

      Design

      A grounded theory approach involving a constant-comparative analysis of data as they were collected, an approach first advised by
      • Glaser B.G.
      • Strauss A.L.
      , was used to construct a road map (
      • Tie Y.C.
      • Birks M.
      • Francis K.
      Grounded theory research: A design framework for novice researchers.
      ). Road maps are like theories in that they are helpful action guides; they illustrate significant concepts and concept relationships in linear or other formats to depict how a phenomenon can be assisted to occur (
      • Shepherd D.A.
      • Suddaby R.
      Theory building: A review and integration.
      ). In this study, after recruiting and interviewing participants, the data were analyzed to identify and validate road map concepts and concept relationships (
      • Noble H.
      • Mitchell G.
      What is grounded theory?.
      ). This gathering and analytical exploration continued until data saturation; when no new findings or understandings of the data were occurring (
      • Noble H.
      • Mitchell G.
      What is grounded theory?.
      ). Research ethics approval was gained in advance from a university research ethics approval committee (Pro00073303). The following further describes the research methods used for this study.

      Data Collection

      Recruitment

      Study notices were distributed through Canadian nursing organizations to gain volunteers. Word of mouth advertising also occurred, as some participants said that they were told of the study by a nursing colleague. An online search of media outlets and federal and provincial government websites was also done to identify nurses who had been elected to a political position or were said to be a spokesperson or leader of a political action group. All potential participants were asked (by email) to volunteer for an interview. An information letter was emailed to each nurse who responded to this request. This letter advised them about the study, that a verbal consent was necessary, that one telephone interview would occur on a day and time of their choice, and that no names or other identifying information would be shared in any research reports. They were informed that three open-ended questions would be asked of each participant:
      • 1.
        Why did you seek to be elected to a political office or to engage in political action?
      • 2.
        How did you get involved in political action or become elected?
      • 3.
        What were the outcomes or impacts of this involvement?

      Procedure

      After five nurses who had been elected to office were interviewed in early to mid-2020, data saturation was reached on why and how they had become active politically. These findings were confirmed when five non-elected but politically active nurses were interviewed in mid-2020. The second set of interviews gained additional needed insights on what was gained by their political engagement. No participant asked for a second interview to talk about new matters or change responses to questions. None withdrew from the study.
      The interviews were all undertaken by the Principal Investigator (PI). All (40-95 minute) interviews were conducted by telephone, with these conversations audiotaped and almost immediately transcribed by a verbal-to-text software conversion program. Each transcript was checked within three days by the PI to ensure no names or identifying information were present, and to screen for completeness and accuracy against the tape.

      Data Analysis

      The analysis of each transcript was conducted within 3 days of receipt, for a rapid understanding of the data and to prepare for subsequent interviews. Braun and Clarke's (
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ) six-step analytic method was used as it is an iterative approach that allows for theory-informed (not theory-driven) data examination. After the analysis of transcripts had revealed a common core set of concepts and validated them, with their interrelationships identified and confirmed, the draft road map was discussed by the research team. After revisions, this map was confirmed and select quotes identified to illustrate components and their relationships. A draft report was developed by the PI, with team members independently reviewing, refining, and approving the final version.

      Findings

      Common reasons were identified for why and how these nurses became involved in politics or political action. The political gains were more varied, in keeping with the nature and aims of the political work undertaken by each nurse. All gains were positive; no negative outcomes were identified, such as personal repercussions. In the following, each nurse is identified by a number reflecting the order of interviews; P1-P5 denote elected nurses and P6-P10 denote non-elected nurses who were otherwise politically active.

      Early life experiences and education are key for nurses’ political involvement

      All were informed by early, mostly school and family-related life events, and by self-reflection to realize the importance of social justice and good government. For instance, one reported that their mother, who worked outside the home for many years, was paid less than the males who were doing the same job (P4). This lower pay was viewed as unjust, with no union or legislation then to correct it. Another participant reflected on their growing up feeling racism and discrimination at school because of the color of their skin (P10). Their entire family also felt separate from the community. Every time they went outside the home, they stood out from the other people around them. They knew they were being looked at; sometimes with suspicion as if they were “gangsters” or “poor immigrants, on welfare and therefore a drag on society.” Similarly, another participant (P7) reported how their family's faith had set them apart. They knew their faith was different from others around them, and they felt separate because of their distinctive dress and because their faith-related events throughout the year were not recognized by the people around them. This difference resulted in their being careful about how they lived and what they did outside of their home, as they were “scrutinized” by their neighbors and others in the community (P7).
      A related consideration is that all were the product of a public school system and a justice system that were both “designed or intended to be fair to all people in Canada” (P6). They grew up knowing that they had “rights as individuals” and “opportunities that were equal or purported to be equal to the people around them” (P3). One said “even if I was poor and did not dress as nice as the other kids around me, my teacher did not allow anyone to put me down; she would say – ‘we are all (emphasis added) equal here’” (P7). Another reported that their parents would say Canada is not perfect, but the law is the same for one and all, as compared to the country where they grew up where people could buy off police and government officials (P10). All recognized they could “thrive in Canada” (P4); “if they worked hard, they could succeed” (P1).

      Nursing values, education, and practice paramount for nurses to engage in politics

      Most research participants reported that caring for others was “a major nursing education emphasis” (P3). Their subsequent work as nurses was defined by “caring for others” (P9). This caring for others was motivating and compelling, as they would “advocate for patients” (P5) and they felt a strong professional obligation to “speak up and act to help others” (P8). That value encouraged them to engage in political spheres for public benefit.

      Becoming aware of policy decision-making implications and being encouraged to get involved in politics or political action

      Although all had relevant backgrounds for political activity, an important step in their process of becoming politically active was a developed awareness of the social relevance of and need for politics or political action. One said “the government's healthcare funding cuts taught me I should be keeping track of what the government was thinking and doing” (P6). Another said, “I went to a forum where representatives of the political parties and a nursing professor talked about healthcare privatization, and it got me thinking about politics” (P7).
      This awareness was critical, as the possibility of their political engagement had not been obvious before. One highlighted this by saying “my family was always interested in politics and often talked about it over the dinner table, but politicians were all older men, and it was not until I saw women were getting elected that my eyes were opened to the possibility of a female and maybe even a female nurse becoming a politician” (P3). Another reported: “I went to a nursing meeting, and a nurse who had been an MLA [Member of the Legislative Assembly, an elected provincial politician] talked about the need for nurses to be politically active. Seeing her is what got me thinking about politics. I had never met anyone who was elected to government, and this was a nurse, just like me” (P10). Moreover, politics was initially foreign to them; few had much political knowledge or experience. One said “we never were taught about politics in nursing school, and the closest I ever came to a politician was when I looked after one when I had been a nurse for about three years” (P7). Another said, “I don't think I ever met a politician until I was in my 30s. I did not get encouraged in my nursing program or work after as a nurse to become a politician” (P5).
      A triggering event was therefore required to move them into politics. This trigger was when they were noticed and encouraged to run for office or engage in political action. One said “at a public forum on health care, I asked a question, and afterward one speaker thanked me and asked me to come in some time to meet him and talk to him about health care at his government office; he encouraged me then to run for his party, and I did” (P2). Another said “I was able to talk to the nurse MLA about what it took for her to get elected, and she gave me concrete advice and a lot of encouragement to run for office” (P3). Another noted: “I helped out on a campaign to get a friend elected, and I saw the importance of media. I formed a political action group to stop the government from shutting down a hospital and the media was all over it” (P6).

      Being mentored and feeling supported to be politically active

      Following a trigger event, an assisted engagement process was required for each nurse to become involved in politics or political action. All participants emphasized the importance of being mentored and helped to run for election or otherwise become politically active. One said “when I ran for election, I was given a seasoned campaign manager and had great support from the party; without them I would not have known how to run and I certainly would not have been elected” (P1). Another disclosed “I said I would run for office, and I then learned that funds had already been raised for my campaign expenses, and that an experienced team was ready” (P5). A politically-active nurse also said “Our organization is political, its people and services is what made me politically astute and politically active, and very successful in our political efforts” (P10).
      Another major factor for how they became active politically was the positive reception they received from the media and from individual or group political entities. One said “over a week, I think I had seven interviews for TV, radio, and the local newspaper; this was after I was on a public forum where I presented my evidence that the large hospital was needed. If it closed, small hospitals would fill up with people with severe illnesses and with no one there capable of helping them. Looking back, the respect that I got from the media and from the public made it easier to keep going politically” (P6).

      Wining battles and feeling recognized as a source of energy to keep politically active

      Nurses reported that their victories, small or big, encouraged them to continue being involved in politics. For instance, one said their political activities “stopped the government from closing the hospital; that decision was invigorating” (P6). Another said “we went up against a government and a rich company, and we won. We got an Act stopped from being passed. It took over a year, but we had wins along the way, including the positive attention we got from opposition politicians, reporters, my nursing association, and members of the public who realized how bad this Act would be for our healthcare system” (P7). Elected nurses also commented on how important it was to be noticed, such as for “small things, like seeing your name in the paper, or being invited to talk to a powerful group” (P1). Another elected nurse said, “I was appointed to a major government committee, I could have stayed a backbencher. This was like an affirmation of me, I had made it” (P4).

      Bringing nursing education and practice background skills to politics

      All participants recognized that their nursing education and subsequent nursing work had equipped them to be capable of engaging in political spheres and being successful there. They appreciated this educational foundation and the challenging work of nursing for developing themselves into strong individuals. They respected themselves for passing a tough nursing program and then being effective at work, as “nursing is demanding” (P4). Many illustrations of the importance of their nursing backgrounds were revealed, including the common view that their nursing program and nursing work taught them to listen; a “majorly important life skill” as they were able to “really (emphasis added) listen to others” (P2).
      Many also reported the caring value of nursing and the caring work of nurses were important for developing essential political relationships. One said: “patients, who I had just met, needed to quickly trust me and work with me; so I had to think about how to approach people and gain their trust and their willingness to do what I advised them or needed them to do” (P4). Another similarly said, “when you are doing things to people who are hurting, you have got to be able to get them to work with you; at the heart of it is a caring about them and a respect for them. They are important, and each is different; you cannot just use one method to gain their attention and trust, you have to develop a toolbox of skills to work well with people” (P1). These gained abilities were considered highly relevant for and easily transferrable to political spheres.
      All politically-active nurses had also developed a “very involved” (P3) or “deep” (P8) understanding of health, health care, and the Canadian healthcare system; a sector of “fundamental importance in society” (P2). Moreover, they possessed a broad baseline of societally-important knowledge (P4, P6, P9); one participant highlighted this by saying “nurses have a wonderful generalist background, they know a lot about many things, and that makes them an excellent (political) resource” (P1). These nurses also learned that they could share their knowledge effectively, as they could “use everyday language, and assess and see if they [the patients] were understanding me, so I could see if my teaching had been understood” (P7). Another commented on the political applicability of the nursing process: “assess, plan, implement, and evaluate; one of the most important skills I learned in nursing school” (P1).

      Nurses’ political involvement achievements

      All nurses could report benefits of their political work when asked if they would consider specific impacts in relation to: (a) themselves, (b) the nursing profession or other nurses, (c) health care or the healthcare system, and/or (d) their province or Canada, or Canadian society. No negative impacts were identified. However, few had easy-to-describe outcomes to report as a result of their political involvement. One nurse's response explains this issue: “It is hard to describe your political impact, as policies take such a long time to create and pass, and there are so many players and steps… I know I had a part” (P2). Another said “nurses are not encouraged to talk about their accomplishments, so it is hard for me to talk about what happened through my political activity; clearly it had impacts but it could be summed up by one thing – the government did not shut down the hospital” (P6). Another key finding was that the identified outcomes varied in keeping with their different political aims and activities. Regardless, these outcomes could be grouped into micro (personal/individual), meso (organizational), and macro (societal) benefits.

      Micro benefits

      Some benefits were oriented to themselves as individuals. One said “it can be tough going, so the wins are important for building your political capacity and confidence in yourself as a legislator” (P2). Another said “I am directly involved in government decisions; that makes me able to influence what is done to our healthcare system… I should take some pride in that, but have not thought of it…. It is a rush though to hear you are elected, as it is hard work running for office and you put yourself out there to be judged” (P3). Another said, “as a bedside nurse, there is not much recognition of you or much appreciation for your thoughts or views on things. Getting all that media attention kept me going for other political-action goals” (P6).
      The micro benefits were also oriented to other nurses and nursing students. These nurses considered that they could be a source of knowledge and inspiration with the potential to involve and awake the interest of fellow nurses and nursing students in politics or political action. One politically-active nurse said “when nurses volunteer to help on a campaign of mine, I think of how great that is for me and how much those nurses learn. It is a way of paying it forward” (P10). An elected nurse said: “I am asked to speak to every nursing class each year about my work as a federal politician, and I do this as some of those students will be inspired to run in the future, but all will know more about the political system” (P4). However, another elected nurse said “I am no longer asked to speak to nursing students at the local school, because the political party I represent is not the same as for the instructor; that means I can no longer demonstrate to future nurses that nurses have value in government” (P5). So, as revealed by this participant, the political party a nurse is aligned with could be a constraint for informing nursing students how to contribute to policy making or change.

      Meso benefits

      Most of the interviewed nurses indicated that the nursing profession benefits when nurses are active politically. One said “I always say I am a nurse, that has made it easier to meet politicians and focus their attention on health care. I always say I am a nurse, because nurses should be seen and heard whenever healthcare issues occur or developments are needed; that is important for nursing” (P6). Another said “I am a nurse and always will be a nurse, that is my identity first and foremost; everyone who sees me at work in the legislature and outside of it should know I am a nurse, and that is critical as the public needs to see nurses impacting policy, as nursing has a major role for the success of our society” (P3). Another said, “every time a nurse is involved in politics, in one way or another, that is a win for nursing. Nurses have unique knowledge and perspectives that should be impactful in government decisions” (P7). That professional view was shared by others: “every time I am quoted in the media and I am identified as a nurse, I think that is a win for nursing” (P2).
      Other meso-level benefits were also identified. The politically-active nurse who talked about keeping a hospital from closing reported “many jobs were saved, the local economy would have been really impacted, but the big win was that people with severe illnesses could be in a hospital that specialized in illness care” (P6). The elected nurses reported program and organizational impacts, such as “an addiction program was started in my province, that program is needed and the need for it has grown” (P3); “I was able to get onto a committee that examines aging and needed changes so older people can get around easier in this province; we now have more age-friendly services” (P3); and “I worked with my party when a resolution came forward; I spoke in favor of it and my party accepted the resolution and is now known for being proactive on it; that could be a factor for our party to be reelected again” (P1).

      Macro benefits

      Macro-level benefits were also described: “drafted federal legislation was not likely to pass until the Canadian Nurses Association (CNA) endorsed it. I made sure the CNA was informed about it, and they were able to act in time to save the legislation and improve it” (P1). Another said, “there are always challenges for our healthcare system; it is expensive and people wait when they do not have urgent health concerns. Having an informed nurse who can talk about its value to Canadian society is essential. Without that advocacy, I don't know what would have occurred when our government was keen on privatizing health care” (P6). Others indicated nurses should inform and advance policies for social good; such as one who said “having nurses active at the federal level, or even provincial and municipal level, is fantastic, as nurses serve the public good; they serve all people” (P4).

      Discussion

      Clearly, some nurses are active in political spheres. The interviewed nurses had early family and life experiences, and self-reflected learning of importance for their later political involvement, such that this led them to engage in politics or political action in different ways. Among the reasons why nurses sought to be involved in politics or political action, nurses highlighted the injustices and grievances they experienced as a consequence of feeling early-life gender discrimination, racism, and faith or culture differences. Likewise, in line with a study by
      • Gebbie K.M.
      • Wakefield M.
      • Kerfoot K.
      Nursing and health policy.
      , their childhood education had a prominent place for explaining why they engaged in politics. Their acquired understanding in public schools of social values like fairness, equity, or equal opportunities for all were very important, and later emphasized in nursing schools as a core value in nursing (
      • Rooddehghan Z.
      • ParsaYekta Z.
      • Nasrabadi A.N.
      Equity in nursing care: A grounded theory study.
      ). Another contributing factor for their political involvement was their concern for caring about and thus advocating for patients. Hence, advocacy, which has a central role in nursing practice (
      • Gaylord N.
      • Grace P.
      Nursing advocacy: An ethic of practice.
      ;
      • Mason D.J.
      • Dickson E.
      • Perez A.
      • McLemore M.R.
      Policy and Politics in Nursing and Health Care (8th edition).
      ), was a further reason for these nurses to engage in politics.
      Moreover, the interviewed nurses, as did those in the study by
      • Gebbie K.M.
      • Wakefield M.
      • Kerfoot K.
      Nursing and health policy.
      , identified their nursing education and subsequent nursing work as being critical for gaining requisite knowledge and skills of prime value politically. As such, it could be said that “nurses bring to the policy arena (valuable) knowledge and skills gained in basic nursing education and in practice” (
      • Gebbie K.M.
      • Wakefield M.
      • Kerfoot K.
      Nursing and health policy.
      , p. 309). Another important consideration is that interviewed nurses became politically engaged after they had become aware of policy decision-making implications and they have been encouraged to get involved in politics, and then were mentored and supported by others. In this respect, it is important to highlight that mentorship can significantly influence political careers (
      • Pérez G.A.
      • Mason D.J.
      • Harden J.T.
      • Cortes T.A.
      The growth and development of gerontological nurse leaders in policy.
      ). This point is critical, as Gebbie et al.’s (
      • Gebbie K.M.
      • Wakefield M.
      • Kerfoot K.
      Nursing and health policy.
      ) study also found no nurse had planned a career in politics, and their political involvement was a gradual evolution influenced by their personal and professional life experiences.
      Given that nurses are experts in health care with a special commitment for patient advocacy, more nurses should extend their expertise to the policy arena (
      • Leavitt J.K.
      Leaders in health policy: A critical role for nursing.
      ). This activity would positively shape their profession and achieve benefits for the general public (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ). Otherwise, non-nurses will play a key role in matters that are paramount to the nursing profession and also for public health and wellbeing (
      • Hall-Long B.
      Nursing and public policy: A tool for excellence in education, practice, and research.
      ). Yet, despite critical knowledge and expertise on nursing and health care, there is much concern that nurses are not adequately prepared for politics or public policymaking (
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ). Many initiatives would help to ensure all nurses are informed about politics, political processes, and public policymaking; and also aware of the need for nursing engagement in political spheres.
      For instance, to gain more politically-active nurses, all nursing students should be educated about politics. Indeed, it is widely considered a responsibility now of nursing educators to teach students about politics (
      • Gebbie K.M.
      • Wakefield M.
      • Kerfoot K.
      Nursing and health policy.
      ;
      • Leavitt J.K.
      Leaders in health policy: A critical role for nursing.
      ;
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ). The educational methods and content may vary, but it should include evidence gained on how and why nurses becoming politically active, such as the triggers and assistance for successful political entry identified in this study. Class presentations by politically-active nurses are also likely to be important, as this study found nurses are inspired by “political” nurses. Above all, this education should be non-partisan, as all politically-active nurses are important to nursing (
      • Villeneuve M.
      • Betker C.
      Nurses, nursing associations, and health systems evolution in Canada.
      ). Many politically-astute nursing professors exist and they can interest and inform students about politics and the engagement process including the political and legislative systems, public policy, available mechanisms to participate in politics, and the important contributions that nurses can make.
      However, the emphasis should not only be on students. After graduation, nursing unions, nursing interest or specialization groups, and political parties must become more active in helping practicing nurses to become politically engaged in one way or another. These entities can build on the civic mindedness of nurses to encourage and enable their political activity (
      • Verba S.
      • Schlozman K.L.
      • Brady H.E.
      Voice and equality: Civic voluntarism in American politics.
      ). Given the value of the work of politically-active nurses, nursing associations also need to recognize their obligation to build and support human political capital. This obligation could be realized through profiling nurses who are active politically and their important work, having politically-active nurses speak at association meetings, and hosting meetings on current developments or issues for politically-active and politically-interested nurses. Nursing associations can also host workshops to teach nurses how to run for election, provide information to members on healthcare trends or nursing profession priorities, maintain contact lists of elected people to share with members for lobbying purposes, and provide a venue on association websites or newsletters for politically-active members to post political surveys or political information briefs. Annual tallies of politically-active nurses could also be kept by nursing associations, with trend reports shared. Hopefully, these reports will demonstrate a rising number of elected and politically-active nurses over time. If not, strategic planning is needed to target select nurses, as the political involvement of practicing nurses is often contingent upon their time availability and specific clinical interests or professional concerns (
      • Vandenhouten C.L.
      • Malakar C.L.
      • Kubsch S.
      • Block D.E.
      • Gallagher-Lepak S.
      Political participation of registered nurses.
      ;
      • Verba S.
      • Schlozman K.L.
      • Brady H.E.
      Voice and equality: Civic voluntarism in American politics.
      ).
      International nursing organizations also need to build on their current efforts to increase the global number of politically-active nurses and also help to ensure their political effectiveness. Programs like the International Council of Nurses’ policy leadership development education have already been designed to prepare nurses to drive policy for improved population health, enhanced health care, and nursing profession advancement (
      • Salvage J.
      • Montayre J.
      • Gunn M.
      Being effective at the top table: Developing nurses' policy leadership competencies.
      ). Efforts such as the “Nursing Now Campaign” launched by the World Health Organization and the International Council of Nurses (Nursing
      • Nursing Now
      ) are initiatives that could be parlayed to help more nurses become politically engaged. Above all else, increased visibility of politically-active nurses is critical so more nurses and non-nurses recognize that nurse activism is important and beneficial for public health and wellbeing.
      Programs of research and centers of excellence are also advisable. Focusing on macro-level public policy may be critical, as socio-demographic and societal challenges arising from the COVID pandemic, global climate change, and other issues require nurses to drive public policy reforms (
      • Nicholas P.K.
      • Breakey S.
      • Tagliareni E.
      • Simmonds K.
      • Sabo K.M.
      Climate change and population health: Incorporating stages of nursing's political development.
      ). In political arenas, individual nurses and the nursing profession can be recognized and appreciated for its body of knowledge and distinct set of professional values that are highly relevant and important for social good. (Figure 1)
      Figure 1 -
      Figure 1Road Map for Nurses to Engage in Political Activities.

      Conclusion

      This study focused on nurses who are active politically to learn why and how they became active politically, and what benefits were realized through this activity. Through interviewing politically-active nurses, a road map was developed, one which should help more nurses plan for and undertake political activities of one kind or another. In the future, more nurses should be politically active, as nurses have the requisite personal and nursing knowledge, aptitudes, and skills for political engagement and also for essential public policy and other reforms. To help reach that point, an evidence-based action guide of personal antecedents, nursing education programs and nursing work to gain knowledge and skills relevant for politics, triggers, and supported assistance to enable successful political engagement was developed for international use.

      Acknowledgments

      Donna M. Wilson: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – First Draft, Final Draft. Leah Underwood: Validation, Writing – Reviewing and Editing. Sungmin (Christine) Kim: Writing – Reviewing and Editing. Mary Olukotun: Writing – Reviewing and Editing. Begoña Errasti-Ibarrondo: Conceptualization, Methodology, Investigation, Formal Analysis, Validation, Writing – Reviewing and Editing.

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