Different studies highlight the engagement of nurses as a way to expand political advocacy regarding health issues5,18,19 and also highlight institutional support, as well as
the support provided by other members of the multiprofessional and nursing teams, as enhancers of this engagement, by providing greater commitment to care.3 It is noteworthy that nurses with less training time are often more likely to engage in political advocacy, which reinforces the need to build effectively and coherently the capacity to act in political advocacy as an essential component in the practice of nurses from graduation onwards, happening especially at higher levels of training such as master's and doctorate.19
Regarding the clusters that emerged in this study, almost all nurses in cluster 3 work with secondary care, are younger and are less experienced than those in the remaining groups. This group, however, concentrates the highest number of nurses with a doctoral degree. In addition, there is a great predominance of female doctor nurses among the participants of this group. The study shows that the involvement of nurses in political advocacy is more recognized according to the level of education of each nurse, but it is not very relevant with respect to their age, according to the clusters analyzed.
In order to reinforce the findings of the research, a study indicates that nurses with master’s degrees or higher levels of education are politically more active than those with lower levels of training,19 in addition to recognizing that professional nursing organizations give greater freedom to more qualified professionals to influence the construction of institutional policies.4,19 This translates into the need for engagement of nurses since the beginning of training in health policies, with potential to influence health and public policies.8 Building effective and coherent ways of acting in political advocacy is considered an essential component of nursing education, both at the undergraduate, master’s and doctoral levels.19
Thus, involvement in political processes to promote sound and effective policies in health care practices is a direct extension of how the nurse can seek to defend the interests of health system users. Political advocacy in nursing can benefit users, communities and professionals from nurses’ leadership skills through active involvement.20
Cluster 2 has the highest average age among clusters and the longest professional career, divided between primary and secondary care nurses, with a higher number of graduates than the other levels of training. Nurses managers have a higher level of commitment to political advocacy, largely because they work in the administration of health services, which favors a broad and global view of health needs, without being limited to one or another user specifically, as often happens among nurses who are directly involved in providing health care.21
Work in the administration of health services also expands the ability of nurses in leadership positions to influence their staff in order to achieve objectives that are shared by the group to meet the health needs of the population.21 Additionally, nurse managers who are in key positions should be a model, qualifying and motivating nurses to become involved with health policies, by establishing healthy and ethical work environments, organizing actions focused on health policies, providing training and continuing education, in order to facilitate the understanding of workers with regard to their skills in the development of health policies and strategies influencing political decision-making. With this in mind, the International Council of Nurses proposes that nurses should significantly contribute to the development of efficacious health policies based on their knowledge and experience.8
It is worth noting that, through leadership, nurses become able to reconcile organizational objectives with the objectives of the nursing staff in order to improve professional practice and the quality of care delivery, which is an element that facilitates the work of health teams.22 Another important facilitator in cluster 2 is related to these
individuals’ professional experience, the longest duration experience among the four clusters, which consequently means greater experience with political performance, knowledge of health systems and research, and involvement in political issues, possession of leadership skills, qualification, having structural support and greater knowledge, availability of resources, and a positive image of nursing, as reinforced by an international study.8
There are other characteristics differing among clusters. All participants in cluster 3 are nurses who provide tertiary care and presented the highest mean of all the clusters, and the second highest mean concerning professional experience, reinforcing these professionals as highly likely to engage in political advocacy, especially in factors related to the advocacy of patients’ rights, quality of care, preventive care, and mental health care, which obtained the highest means in this cluster.
One Brazilian study highlights the constant transformations and advancements in health practices, especially in the hospital sphere, which requires workers, especially nurses, to have specialized knowledge of management. Thus, universities are supposed to provide workers with theoretical and practical knowledge to support human aspects in the quality of nursing care.22
Nurses perform tasks that include activities from directly providing care to patients, to management tasks, so they have greater autonomy to act and impact the organizations’ decision-making.23 Thus, nurse act as the integrating link of the team and, therefore, are able to work well with other professionals and plan actions that permeate care, as recommended by the legal material governing professional practice. Additionally, by performing teamwork, the nurse professional enables the group to be trained to better deal with conflicts and challenges, as well as managing activities in an environment of trust and satisfaction.22
Cluster 4 was composed of nurse practitioners, who differ in the fact that they work in primary care, a health setting known by the vast number of opportunities to establish positive exchanges between nurses and patients, family and the community. That is, there is the unique opportunity to promote health during interactions.23,24 A given study indicated that changes in community health demands and the need for changes in health services lead to exponential growth in primary health care nursing both in Australia and in other countries25, besides the fact that quality of care provides a considerable increase in interest in identifying the factors that can effectively hinder concrete health action.25–26
Another study that explored the contribution of nurses in advocacy and health policies noted that nursing leaders should provide users with the information necessary for their treatment, encourage their empowerment, respect their beliefs and values and, above all, be a voice to defend them when necessary.27
Therefore, nurses should play an essential role in the public aspect of political decision-making and encourage staff members to become involved in political advocacy.8 Developing interpersonal influence helps nurses provide health care and promotes greater proximity to the care provided to the population as a resource for political advocacy.20
Thus, as members of health teams, nurses need to be qualified to deal with diplomatic, humanitarian and political issues. Thus, academic curricula need to address aspects related to national and international policies concerning health diplomacy, in addition to training and qualifying these workers to be political agents in the context of world health.28