The objective of this study was to explore nurses’ and midwives’ participation in policy review and development. Thirty nurse leaders were interviewed. Eleven out of the thirty were males and nineteen were females. Participants’ ages ranged from 31 to 58 years. Seven of the participants had diploma as their highest qualifications, seventeen had first degree as their highest qualifications and six of them had master’s degrees as their highest qualifications. All the participants occupied key leadership positions at their places of work. Their positions ranged from hospital unit heads to heads of health institutions.
Two main themes and six sub-themes emerged from the data. The main themes included; Participation in national health policy development and perspectives on policies that need reforms.
Participation in national health policy development
This theme describes the participation of nurses and midwives in policy development at the national level. Two subthemes emerged from this; Nurses being overlooked and unacknowledged and Etic and emic of nurses.
Nurses being overlooked and unacknowledged
According to most participants, nurses and midwives have the experience and skills and are involved in some national policy development activities in areas such as reproductive health, code of ethics, health bill, acute emergency care and policies on nursing and midwifery curriculum development. Even though they are involved in developing some policies, few of them are invited as compared to the medical doctors who form the majority of the policy development team and the few that are involved are mostly not acknowledged as authors of the policy document.
“…about three years ago I was called to join the team where we would have the reproductive review policies done… almost all of them were doctors and that was what saddens my heart… After the document came out, I was not even acknowledged”. (P11-Midwife)
“I mean, I remember the health bill, I was part of but I was not really recognized, but, most of the other team members were medical doctors”. (P4-Nurse)
A participant narrated that before a policy is developed or reviewed, the grass-root which majority are nurses and midwives must be consulted because they are the implementers but that is not the case in Ghana.
“I think that, since nurses and midwives are the implementers of most health policies, we should be given the chance to have a major voice in the development of health policies at the national level”. (P15-Nurse)
It was emphasized that even though some nurses and midwives are involved in policy development, they are mostly not recognized. The credit is mostly given to medical doctors and that makes them feel that they are not part of the team.
“…they will mostly seek your inputs during the development process but at the end of the day …. you won’t see or hear your name once the policy is developed”. (P21-Midwife)
One participant stated that, the office that was given to nurses for policy development at the ministry was not even recognized officially.
“At the Ministry of Health in Ghana, though we used to have an office for nurses that under the normal circumstance is to be involved in policy development and other issues for nurses and midwives specifically, it is even not legitimately recognized”. (P7-Nurse)
Some also disagreed with this assertion and believed that recognition would be given to a nurse during policy development depending on the perceived value of his or her contribution which draws attention to the need for nurses and midwives to strive to make their voices heard at the policy development table.
“I disagree to a large extent when nurses perceive that, they are not recognized during policy development. It depends on… the value you place on yourself. For example, you just saw a letter being brought to me to go and represent the ministry. Why will the minister ask a nurse to go when there are doctors?”. (P28-Nurse)
Etic and emic of nurses
Some of the participants indicated that nurses and midwives are not involved in national policy development and review and cited various reasons for this non-participation such as inadequate knowledge in policy formulation and substantive areas of policy being developed, being inferior to other health professionals and non-participation in politics.
“I think that we nurses are perceived not to be knowledgeable… So the public assume that "oh as for nurses... they are not intelligent" they even respect teachers more than us when it comes to the level of policy development (P19-Midwife)
“Yeah, we nurses are not knowledgeable. That is the perception. Not publicly but … comparing us with other health care workers, the nurses are considered as least knowledgeable”. (P24-Midwife)
“Nurses shy away from policy development because one, they don’t have the knowledge and two, they don’t think it is important for them to participate in the policy process” (P15-Nurse)
Some participants attributed the perceived lack of knowledge among nurses and midwives to the low educational level. This calls for nurses and midwives striving to pursue higher education.
“I think it has to do with the educational level of the nurse, some nurses have not been… trained to be nurses…and even people go in for a degree and they still lack knowledge in policy development so they should pursue further studies. (P8-Midwife)
Some participants said even if nurses are called to participate in policy development or review, they would not make any impact because they lack knowledge in the substantive areas that the policy focuses on.
“But in terms of the policy, we nurses don’t make any impact. … even when the principals of nursing schools are invited into policy review meetings, they all listen quietly to the minister of health, whatever he says is final and they don’t make any impact. They can’t question anything because they don’t know”. (P17-Nurse)
Some participants were of the view that there are nurses who can help develop health policies, but the policymakers do not invite them. Most top positions in the Ministry of Health are held by medical doctors who represent health workers at the national policy development table.
“I think it’s because the authorities that see to this policy development have not yet recognized nursing and midwifery. …if you get to clinical practice, the highest person in nursing at that unit, works within the clinical care and that unit is headed by a medical doctor. You go to public health the highest rank in nursing in public health is under a medical doctor, So, if there is any policy development it is the top person there who would be part”. (P25-Nurse)
The history of nursing is also identified to affect the way nurses are treated in Ghana as people still perceive nurses not to be on top of issues even though nurses have acquired higher degrees including terminal degrees. With nurses and midwives being Professors and doctors, some participants believed that policy developers must involve nurses and midwives in developing and reviewing national health policies.
“Basically, it has historical antecedents. It is about the perception people have that we nurses don't have …good… material that will be able to make input in national policy development or decision making So because of this perception and ignorance on the part of the citizenry and even policy formulators, they tend not to rely on nurses…for their input”. (P14-Nurse)
“…it saddens my heart that gone are the days when they thought nurses and midwives should sit behind the benches …It is because of the old historical image? It saddens my heart”. (P11-Midwife)
According to a participant, the way nurses and midwives are trained also influences their confidence and assertiveness for fear of victimization and deprivation of opportunities.
“nurses end up kowtowing and then keeping to their shells because of the fear that when they speak out they will be deprived of certain things and so they will not speak. And so the doctors will continue to bully us”. (P15-Nurse)
The gender disproportions in nursing where females form the majority were identified as a key factor that prevented nurses from holding national leadership positions in the health sector in Ghana. Almost all the participants asserted that policy development is a leadership role and nursing being the female majority is perceived to play subservient roles only.
“…it saddens my heart that gone are the days when they thought nurses and midwives should sit behind the benches …It is because of the old historical image of females and nursing being a female-dominated profession is seen as a subservient role. So how will they take us seriously and involve us in policy development? Because policy development is seen as a leadership activity” (P11-Midwife)
“Throughout history and now, nursing has always been female-dominated and females are not respected in our part of the world. Therefore, no one thinks that anything good can come from females so why would they involve us in national policy development?” (P25-Nurse)
Perspectives on policies that need reforms
This theme generated sub-themes such as: Pre-service preparation, influence on admission into nursing schools, staff development and motivation mechanisms.
Pre-service preparation gap
Participants perceived that, there is a theory-practice gap in the pre-service preparation of student nurses before they entered fully into the profession. Both clinicians and educators lamented about the phenomenon and believed that if nothing is done, the future of nursing and midwifery will be in a mess. While the nurse educators complained that clinicians do not teach students when they go for clinical practice, clinicians also narrated that students are also taught by inexperienced tutors/lecturers who are unable to impact the students as expected.
“…there are few clinicians at the post, who are willing to help or supervise these students, so we all contribute to some of these things and when they graduate it becomes a bit difficult because the foundation wasn’t that good”. (P22-Midwife)
Some participants called for policies that would ensure strong collaboration between nurse clinicians and educators to improve clinical practice.
“Yes, I think there should be policies that would ensure strong collaboration between the clinical side and the institutions to help improve the competency so that we don’t train incompetent nurses. (P17-Nurse)
It was reiterated that the theory-practice gap problem can be solved if nurses are obliged by certain policies to work in the clinical area for some years before they can pursue higher education.
“…as soon as the person finishes nursing school, that same year he/she starts schooling again. He/she is not eager to work. …almost all the nurses are on night shifts. Some have finished their RGN, she has already had her masters so before you realize she’s gone. So we are not focused on picking the skills and to grow with it”. (P23-Midwife)
All the participants in academia, administration, and clinical practice strongly suggested the theory-practice gap to be bridged.
“…… yet the care at the clinical area is nothing to write home about and so that in itself paints a particular picture. We claim we are academically endowed but when it comes to the clinical work we are lacking; so, this must be corrected with all seriousness”. (P24-Midwife)
A participant compared the dual role medical doctors play as lecturers and clinicians which she recommended nurses and midwives should emulate so they can keep their skills up to date in both spheres.
“When you take medical school, you would have the same consultants or clinicians who are teaching as adjunct lecturers or full time at the university… that is more of interactive teaching and learning, but our module of teaching in nursing education is not in that format and so that is where the gap is that needs to be bridged… (P3-Nurse)
Others also complained about the number of years nurses spend on the ward before joining academia. Some complained that most of the people teaching in the various training institutions are not practically inclined to be able to teach the students. This further limits their confidence to practices in the clinical area.
there are a lot of people teaching in nursing schools; those teachers themselves are not good practically, they did not have any practical exposure and so it is difficult for them to demonstrate especially when there is an aspect of a practical component in the courses that they are doing”. (P29-Midwife)
“I think from the training if we have experienced tutors teaching them and adding these morals that we were taught I believe it will help a lot”. (P9- Nurse)
Influence on admission into nursing schools
This subtheme describes how people in governance and other higher offices influence the admission of people into nursing training institutions. Participants reported that most of the people who are admitted into the schools of nursing are not interested in nursing and midwifery but are pushed into it by their members of parliament as a way of getting them jobs. There is a need for a stringent admission policy.
“When it comes to the selection of people into these training colleges they are manned by Ministry of Health, the protocol bit sometimes is killing and so we have people who are enrolled in these schools who may necessarily not have the passion and are sort of compelled.”. (P15-Nurse)
Some believe that politics has taken over nursing education. Politicians are said to have used nursing institutions as a job creation avenue for their constituents. Politicians, according to some participants, have capitalized on nurses’ weakness to infiltrate the profession. This limits the authority of nursing and midwifery leaders to make policy reviews or reforms.
“…politicians began penetrating into the profession and it also became an avenue for job creation,…Politicians felt that when they push people into nursing, then it's like they have created employment or a job opportunity for their constituents”. (P14-Nurse)
“…when I saw that the registrar of N&MC withdrew that letter which was meant to stop the training of auxiliary nurses, I was like; is this man having his own power to work or is he politically being manipulated? our current situation is such that politics have taken the center of nursing education”. (P3-Nurse)
The students who come in through protocol are said to disobey school rules. There are times higher powers step in when these students misbehave and prevent lecturers/ from disciplining them. Thus, if the were clear policies and there was freedom to implement, these issues will not arise.
“… Like I said if a student does something wrong and the tutor tries to punish that student, because the student is connected to a higher authority in the school, that student may report to the higher authority. So, we need policies on all these and the freedom to implement them” (P2-Midwife)
The number of students admitted into the training institutions is said to be too much, and for which reason, they think it negatively affects the quality of teaching and learning. People who come in through protocol are not screened properly because their interviews are just formalities.
“you go to the Nalerigo, where they admit 2000 students, what type of quality teaching are you going to do? What supervision are you going to do? So eventually they come out and so they cannot perform.” (P17-Nurse)
Staff development and motivation mechanisms
This sub-theme expounds nurses and midwives’ concern about their working conditions, promotions, and how to climb to leadership positions to get their voices heard in policy development and avoid being disrespected by other members of the healthcare team. The participants believed nurses and midwives need to hold each other’s’ hands as they move up and help others to grow to be able to change policies.
“Let’s go to the ministry and the health training unit if you look at its majority of the schools are nurses but if you go to the leadership you will see that most of the leaders there are not nurses”. (P17-Nurse)
Clinical nurses and midwives said the tedious work they do under stressful conditions, medical doctors are given priority treatment and when they try to question such unfair treatment, they are victimized by hospital management with transfers. To them, such treatment could be abated if more nurses are found at the policy table.
“There was a midwife who renovated the hospital’s residence on her own when the room was completed, she moved in for about just three weeks or a month and this same midwife now had a message that they now have a doctor who had accepted to be resident so she should move out. This would not have happened if those at the hem of policy development were nurses”. (P29-Midwife)
“Doctors are given accommodation; they are given allowances and all that but Nurses are left out due to our inability to be part of policy development’’. (P5- Midwife)
“…where I live is quite far from this place, but then there is a hospital bus that goes around to pick just Doctors and then the management, yes so I have to pick three cars before getting to this place every day, and this is because few nurses are part of policy development. ”. (P5-Midwife)
Nurses who go to school on their own are being demoralized because after they struggle to use their annual leaves and weekends to school, their certificates are not recognized by the Ghana health service for promotion. Nurses and midwives believe the regulator should be the mouthpiece for nurses and fight for them on that with a policy that will help them to upgrade themselves and their certificates would be recognized.
“…look at the universities all over somebody would even go with leave, they come present certificate for promotion, they would tell you this one we don’t recognize it because we did not give you study leave, my sister can you imagine this how painful it is and now the young ones are crying within them”. (P11-Midwife)
“…you see that our salary is quite low, yes our salary is quite low and all these can change if nurses are promoted to participate in policy development”. (P26-Nurse)