research article kenyan nurses involvement in national...

Research ArticleKenyan Nurses Involvement in National PolicyDevelopment Processes

Pamela Atieno Juma,1,2 Nancy Edwards,3 and Denise Spitzer4

1 Nursing Department, Aga Khan University, P.O. Box 39340, Nairobi 00623, Kenya2 African Population and Health Research Center, P.O. Box 10787, Nairobi 00100, Kenya3 School of Nursing, University of Ottawa, 1 Stewart Street, Ottawa, ON, Canada K1N 6N54 Institute of Feminist and Gender Studies, Faculty of Social Sciences, University of Ottawa, 1 Stewart Street, Ottawa,ON, Canada K1N 6N5

Correspondence should be addressed to Pamela Atieno Juma; [email protected]

Received 10 May 2014; Accepted 14 September 2014; Published 2 October 2014

Academic Editor: Linda Moneyham

Copyright © 2014 Pamela Atieno Juma et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The aim of this study was to critically examine how nurses have been involved in national policy processes in the Kenyan healthsector. The paper reports qualitative results from a larger mixed method study. National nonnursing decision-makers and nurseleaders, and provincial managers as well as frontline nurse managers from two Kenyan districts were purposefully selected forinterviews. Interviews dealt with nurses’ involvement in national policy processes, factors hindering nurses’ engagement in policyprocesses, and ways to enhance nurses’ involvement in policy processes. Critical theory and feminist perspectives guided the studyprocess. Content analysis of data was conducted. Findings revealed that nurses’ involvement in policy processes in Kenya waslimited. Only a few nurse leaders were involved in national policy committees as a result of their positions in the sector. Criticalanalysis of the findings revealed that hierarchies and structural factors as well as nursing professional issues were the primarybarriers constraining nurses’ involvement in policy processes.Thus, there is need to address these factors both by nurses themselvesand bynonnursing decisionmakers, in order to enhance nurses engagement in policymaking and further the contribution to qualityof services to the communities.

1. Introduction

With the global debates around health policy reforms, therehave been increasing calls for nurses to be actively engagedin national policy processes [1–3]. This engagement has beenencouraged for two main reasons. First, nurses comprisethe majority of the global health care workforce, workingclosely with patients and their families in a variety of set-tings. Thus, nurses’ experiences and insights may help guideimprovements in the quality of health service delivery andinform health systems strengthening. Second, many healthsector policies have an impact on nurses’ work environ-ments and consequently their professional practice. Thus,nurses’ input on health sector policies could help ensurethat supportive work environments for clinical practice aretaken into account when policies are reformed. Given nurses’

pivotal role in health care delivery, their engagement in policychanges in the system has been described as both a moraland professional obligation as well as a responsibility to thepeople they serve [2, 4].The engagement of nurses in nationalpolicy processes is especially important in lower incomesettings where nurses comprise an even larger proportion ofthe health sector workforce and where the largest burden ofillness exists.

Historically, nurses have had limited involvement innational policy and political decisions that affect healthservice delivery [5–8]. For instance, a quantitative study ofnational nurse leaders and hospital based nurses in Thailandrevealed that majority of nurses were not involved in policyformulation or modification stage. Rather they were involvedin policy implementation. Literature further reveals several

Hindawi Publishing CorporationNursing Research and PracticeVolume 2014, Article ID 236573, 10 pageshttp://dx.doi.org/10.1155/2014/236573

2 Nursing Research and Practice

reasons for nurses underengagement in policy including lackof awareness of policy related issues and processes, inade-quate knowledege and skills on how to contribute to policies,and lack of opportunities to contribute to policy decisions[9–11]. Nurses’ limited participation in policy processes hasalso been attributed to gender differences in the healthcare system [12, 13]. Nursing is predominately viewed as awoman’s occupation involving caring for others, while menare typically seen in positions of power and decision-making[14–16].Thus,men aremore likely thanwomen to be involvedin public policy and to influence policy decisions. In Kenya,nurses’ underengament has also been attributed, in part, toan inadequate policy focus in undergraduate and graduatenursing programs [16].

Studies provide several strategies that can be appliedto enhance nurses’ engagement in policy processes. Severalstudies have emphasized that nurses can engage in policyprocesses directly by assuming formal leadership positions inthe health care system, and indirectly through lobbying andadvocacy with policy-makers via professional organizations[12, 17]. The nurse leaders can identify issues strategically,work with decision-makers, and understand who holds thepower in the health care organizations and who controls theresources for health care in order to influence them [18].Another strategy is to build nurses’ understanding of andcompetencies in policy and politics by integrating pertinentcourses in nursing training and fellowship programs [17–20]. Examples of programs developed to enhance nurses’competency in leadership and policy influence exist mainlyin developed countries [21, 22]. For instance In the USA aprogram was developed to train nurse leaders who wouldinfluence policy change [17]. The training helped the nurseleaders to understand how policy reforms affect health care,the policy formulation process, and the challenges affectinghealth care including access, quality, and care as well as therole of media.

Several authors have emphasized the need for nurses toutilize research as credible evidence to inform policy deci-sions. However, the studies have found that nurses have notbeen adequately supported to generate evidence to informhealth policies [23–26]. Furthermore, nurses from low- andmiddle-income countries (LMICs) have inadequate trainingand mentoring in research as well as scarce resources forconducting research [27]. Thus, there is a need to strengthenLMIC nurses’ research abilities to enhance their ability tounderstand, generate, and utilize research knowledge that isuseful for policy change.

Very few emperical studies have examined extent ofnurses’ involment policy developemnt process in the Africancontext. A survey of nurse leaders involvement in healthpolicy process in East Africa found that nurse leaders’participation in all stages of policy development was lim-ited and inconsistent [28]. Another study looked at nursesinvolvement in HIV/AIDS policy in four LMICs includingKenya and Uganda [29]. The study revealed nurses’ lackof involvement in policy processes, poor communicationof policies from the national level, and a lack of resourcesfor nurses to implement the policies. Published studies aremainly descriptive reviews and have not used a critical theory

lens to analyze nurses’ contributions to policy processes. Fur-thermore, studies have rarely compared the perspectives ofnurses and other decision-makers regarding nurses’ engage-ment in policy development and implementation processes.This study applied a critical theory perspective to examinehow nurses had been involved in national health policyprocesses in Kenya, eliciting the perspectives of nurses anddecision-makers working at various levels of the health caresystem.

2. Theoretical Underpinnings

This study was guided by critical and feminist theories.Critical theory aims to examine hierarchies, power and dom-ination inherent in policy processes [30]. These hierarchiesmay influence how people participate in policy decision-making. Feminist theories are related to critical theorybut focus on gender domination and discrimination withinpatriarchal societies [28, 29]. From feminist perspectives,analysis examines formal power structures that create ormaintain gender inequality, thereby systematically elevatingmen above women [31, 32]. In this study, critical theoryhelped interrogate historical hierarchies and structures aswell as gender-related issues affecting nurses’ participation inpolicy processes.

3. Methodology

The overall study applied a two-phased mixed method(qualitative/quantitative) design to examine the influenceof policies on nurses’ work as well as how nurses wereinvolved in policy processes in theKenyan health care system.This paper focuses on the qualitative results, describing hownurses were involved in national policy processes in theKenyan public health sector. The perspectives of nonnursingdecision-makers, national level nurse leaders, and frontlinenurses and managers were sought. The specific objectiveswere (1) to analyze the extent of nurses’ involvement in thenational policy development processes in the health sector;(2) to analyse the reasons for nurses’ inadequate involvementin the national policy development in the health sector; and(3) to describe mechanisms though which nurses’ involve-ment in policy development processes can be improved.

3.1. Study Setting. The study was carried out in the Kenyanpublic health care system, since this sector has primaryresponsibility for policy development andprovides about 55%of health care services [33]. The health delivery system isorganized in a pyramidal structure with six levels of care.The community is the first level, followed by dispensariesand medical clinics, health centers and nursing homes,district level hospitals, and provincial level and national levelhospitals [34]. Decision-making structures exist at national,provincial, and district levels, all of which include nurserepresentation.

Nurses comprise 45.3% of the public health sector work-force in Kenya [16]. Although these nurses work at all levelsof the health care system, the majority are employed at thedistrict levels [16]. The majority of nurses entered the health

Nursing Research and Practice 3

care service with diploma or certificate level preparation untilthe early 1990s when the country started training degreelevel nurses. Kenya’s nursing data base for 2011 indicates thatamong those employed in the public sector, themajority werecertificate nurses (53%), followed by diploma nurses (46%),with a small minority of degree level nurses (1%) [34].

3.2. Sampling. Decision-makers at national, provincial, anddistrict levels were purposively sampled based on theirpositions involving policy development or implementation.National level nonnursing and nursing decision-makersemployed by the Ministry of Health were eligible for selec-tion. Two provinces (Nyanza and Central) were purposivelyselected because of their varied geographical locations anddifferences in health indicators. Nyanza province had poorhealth indicators and few health service resources, whilethe Central province had better health indicators and morehealth service resources [35]. One district was then purpose-fully selected from each of these provinces and the two maindistrict public hospitals were the sites for sampling district-level nurses and managers. Nurses and nurse managers inthese district hospitals were selected based on a sufficientlylong work history in the system and 2 years or more inthe facility which gave them potential familiarity with manyof the policy changes affecting nursing and health systemreforms in Kenya.

3.3. Data Collection. Open-ended interview guides tailoredto participant groups were used with all key informantinterviewees. The groups included national level nursing andnonnursing decision-makers, decision-makers at provincialand district levels, and frontline nurses and managers atthe hospital level. Participants were asked questions aboutnational level health policy-making processes; extent towhich nurses engaged in policy-making and implementationprocesses; and ways to improve nurses’ involvement in policyprocesses. Data collection was stopped when saturation wasreached. Additionally, the researcher kept field notes duringthe visits. Interviews took 45 to 60 minutes and were audiotaped with participants’ consent.

3.4. DataAnalysis. Audio-taped datawere transcribed verba-tim and they were analyzed simultaneously with data collec-tion. Transcripts from each participant were read repeatedlybefore and after coding to gain a sense of the whole interview.Interview data were clustered in three groups includingnonnursing decision-makers, nurse leaders and frontlinenurses, and nurse mangers; then all the data sets and fieldnotes were triangulated as the analysis proceeded. Contentanalysis of data was carried out. Data was initially codedand divided into contents including nurses’ engagement inpolicy, reasons for under engagement, and ways to improvenurse’ engagement. Matrices were then used to comparecategorized responses of national level nonnursing decision-makers, national nurse leaders, and frontline nurses andmanagers [36, 37]. Similarities and differences in the par-ticipants’ responses were also compared by these groupings.Further analysis and interpretation of findings was then doneusing critical and feminist lens to identify hierarchies and

gender related factors that influenced nurses’ engagement inpolicy development.

3.5. Rigor. Credibility was enhanced throughout the studyprocess by maintaining accuracy in data collection, analyz-ing, and reporting. Audiotapes and verbatim transcriptionpreserved the accuracy of the data. Critical reflexivity involv-ing cyclical and continuous comparisons of data collectedwere used throughout data collection and analysis. Theseincluded journaling and writing reflections on processes anddecisions [36, 37]. Transferability was enhanced through thepurposive recruitment of participants at different health caresystem levels. These participants had a range of experienceswith national policies. Triangulation of data from differenttypes of respondents was done making it possible to compareand confirm similar perceptions across different groups.

3.6. Ethical Approval. Ethical approval was obtained fromUniversity of Ottawa Health Sciences and Science ResearchEthics Board in Canada and Great Lakes University ofKenya Ethics Review Committee. Administrative approvalwas also obtained from the Ministry of Health in Kenya,and appropriate authorities in provincial health offices,district offices, and the two district hospitals where studyparticipants were recruited. Informed consent was obtainedfrom each participant. Participants’ privacy was maintainedduring interviews by interviewing them in a private room.No personal identifying information was included in thetranscripts.

4. Findings

A total of 32 interviews were conducted (Table 1). At thenational level, five interviews were conducted with nonnurs-ing decision-makers at the Ministry of Health, one interviewwith the World Health Organization country representativeand three interviews with national nurse leaders. Each ofthe three national nurse leaders had risen up the ranks fromthe district level to the national level and had worked formore than 20 years in public service. At the provincial level,two nonnursing decision-makers and two nurse leaders wereinterviewed in Nyanza and one nonnursing decision-makerand two nurse leaders interviewed in Central province. At thedistrict level, one nurse manager in each district office andseven frontline nurses and managers in each district hospitalwere interviewed.

4.1. Nurses’ Involvement in National Policy Processes. Mostrespondents were of the opinion that nurses were not ade-quately involved in the health sector policy developmentprocesses at the national level. They mentioned that onlythree nurse leaders from the offices of the Chief Nurse, theNursing Council and the, National Nurses Association hadbeen invited to participate in national policy committees aspart of their jobs. The nurse leaders’ input on these commit-tees was described as revolving around representing nurses’issues at selected policy tables, communicating policies tonurses, and regulating nursing education and practice. TheChief Nurse was charged with the highest responsibility


Table 1: Study participants.

Levels Nonnursing decision makers Nurse leaders Front line nurses and managers TotalM F M F M F

National 4 2 1 2 — — 9Provincial —

Nyanza 2 — 1 1 4Central 1 1 1 — 3

District —Nyanza — — 4 4 8Central — 3 5 8

Total 7 2 3 4 9 7 32

of representing all Kenyan nurses at policy meetings. Theother two nurse leaders indicated that they attended fewermeetings. Two of the nonnursing decision-makers felt thatKenyan nurses were adequately involved in national policy-making processes through the nurse leaders’ representationat the national level. In contrast with this view, all nursingparticipants felt that this representation was inadequate giventhe large number and diversity of nurses in the country.

Generally nurses have not been fully involvedin policy formulation. I believe nurses needto know the reason behind the formulationof specific policies. Many a time nurses areinvolved after policies have been formulated, andmaybe just a few nurses [national nurses leadersare involved in the policy formulation stage];the province is just informed later that this ishappening, but really there has been no goodinput from nurses. (National nurse leader)

Furthermore, the contributions of these three nursingleaders to the national policy formulation processes wereconsidered inadequate by both the nurse leaders and non-nursing decision-makers but for different reasons. Whilenonnursing decision-makers emphasized the limitation ofnurse leaders’ singular focus on nursing issues, the nurseleaders described the problem of inadequate representationof nurses on a wider set of national policy committees.They described representation on these committees as beingprimarily heads of departments, the majority of whom weredoctors. The Public Health Act, which allows doctors to bethe heads ofministerial departments, aswell as provincial anddistrict health offices, affords doctors this role.

Normally the heads of the various departmentssit down; many of them are headed by doctorsbecause of the Public Health Act, and otherswould be the technical people. Nurses andother health officers are not well represented.(National nurse leader)

The findings also revealed nurse leaders’ uneven partic-ipation in policy meetings. According to the nurse leaders,nurses only attended those policy meetings requiring reportson nurse situations, while doctors were active in every policy

meeting regardless of the policy content. Furthermore, nurseleaders noted thatmany of the final policy decisions had beenmade without nurse leaders being present.

Frontline nurses and nurse managers at district levelsdescribed their primary policy role as being implementersof national policies. Even though policy-making was con-sidered a national level activity, nurses at the frontline wereconcerned that they were not involved. They added thattheir contribution could be important since nurses betterunderstood the care environment.

Nurses should be consulted before policies arestarted because we are the majority, but theydecide for us (. . .). Nurses have everything thatthey need, . . . education, brains, but they lackchance to air views. They stamp on what isalready decided. We should decide and givethe feedback at national level from lower level.(Provincial nurse leader)

A common view, among frontline nurses, was that theywere excluded from policy decisions even in the workplace.

We are not involved, yet we are the ones whoreally are on the ground, we are the backboneof the hospitals. The other people come to writepapers and go away (. . .). We are like a motherin the kitchen, we are the ones who know howmuchwe need, sowe should be really involved inevery step, because you cannot just tell me “nowcook” and even I was not there in the shoppingbut youwant to seewhat I amcooking;we shouldbe involved from the word go. (Frontline nurse)

Due to their limited involvement, frontline nurses andmanagers felt that their priority work-related issues such asstaff shortages, motivation, and resource inadequacies werenot being addressed. Yet, theywere expected to deliver qualityservices. They felt that policies were just pushed on them, sothey sat back and watched or did only what they could, as onenurse manager commented:

Lack of nurses’ involvement in formulation is thecause of poor policy implementation. Policiesare pushed on them, owning them becomes achallenge. They are not positive towards it, but


since they have to comply, they do it, but notin the right way. When you are involved fromthe beginning, you understand and own it, andduring implementation, you have inward driveto accomplish what you planned (. . .). We feellike we are pushed at the corner, so we remainthere and watch things as they are done, or dothings because they must be done, not that wefeel motivated to do them.

4.2. Reasons for Inadequate Involvement of Nurses. The par-ticipants gave several reasons as to why there was inadequatenurses’ participation in national health policy processes. Onereasonwas that policy-making primarily followed a top downapproach, emanating from the national level. Respondentsfelt that this approach denied nurses opportunities for directinvolvement in national policy decisions becausemost nursesare employed at lower levels of the health care system. Nursesviewed policies as prescriptions from above that they weresupposed to follow. As one nursemanager said “for me policy-making is a thing for those at the top, whether they are doing theright thing or not, to them it does notmatter.”Another frontlinenurse commented that “policies are made from above, they arenot made according to how you want things to be done, they arejust brought and you are supposed to follow them.”

Other reasons for nurses’ lack of engagement in policyformulationmentioned by nonnursing decision-makers weretheir lack of knowledge about the policy-making processand lack of skills to engage in this process. Nurse leadersconcurred that nurses did not generally understand thebroader issues outside nursing that were necessary to influ-ence policies.They largely blamed this on the omission of anycurriculum related to policy issues in basic nursing training.Others felt that nurses’ low participation was due to thegeneral design of the health care system, which excludednurses from policy-making structures.

It is by design of health system that nurses arenot brought at the policy tables. . . [The]majorityof nurses lack knowledge and skills (. . .) tosupport that policy. The thing is to bring peoplewho would add value at the table. Thereforenurses should be made to add value when anopportunity comes for them to sit at the policy-making tables, not to be a passenger but to be aparticipant. (National nurse leader)

Nurses were also perceived as being isolated from otherprofessionals. Nonnursing decision-makers blamed the nurs-ing profession for its tradition of being a “closed” professionalgroup, concerning themselves only with professional issuesand not broader issues affecting the health care system. Afew of the decision-makers felt that nurses had failed tomarket themselves as important providers in the health caresystem. In addition, they felt that nursing had a hierarchicalsystem that hindered junior nurses from participation. Onenational nonnursing decision-maker was particularly stri-dent in his/her remarks:

Nurses are allergic to change. They behave likethe military in uniform, taking orders. Nursing

profession discourages nurses from thinkingbecause it’s the matron who decides, (. . .). Theyhave put a self-imposed mind block by relyingon another person to make decisions (. . .). Theygo through a very hierarchical system unlikeother professions. While a nurse will still reportto a nursing officer, she cannot make decisionson her own, it is the biggest weakness, there isno freedom, and they maintain the status quo.(Nonnursing national decision-maker)

Another reason expressed for nurses’ nonengagementwas the inability of nurses to bring forward research evidenceto inform policy formulation. Nurse leaders commented thatnurses had inadequate skills for generating and utilizingresearch evidence to influence policy decisions at nationallevels. Frontline nurses complained that a further impedi-ment was the failure of nurses to take united action to influ-ence policy. They had different professional associations (theKenyaRegisteredNurses’ Association andKenya ProfessionalNurses Association), which served different nursing groupsand tended to divide nurses and their leaders.

4.3. Enhancing Nurse Participation in Policies. Participantsgave several suggestions regarding how nurses’ participationin the policy process could be enhanced. They mentionedactions to be taken by decision-makers to enhance nurses’participation in policy-making.These included creatingmoreopportunities for nurses to contribute to policy processes,increasing nurses’ representation on policy-related struc-tures, and reviewing the public health law to allow nursesto compete for leadership positions in the system. In addi-tion, frontline nurses felt that national policy-makers shouldconsult frontline nurses when developing national policies. Itwas their view that this would enhance bottom-up input onpolicy-making. As one frontline nurse said:

I believe there is a way of channeling sugges-tions until they reach the national level, maybethrough the nurses in charge of hospitals to theprovincial then to the national level throughwriting and meetings.

As their representatives, the frontline nurses felt thatnurse leaders should come to the ground more often and getviews from frontline nurses to include in policies:

Nurse leaders are at the top,when there are issuesto be discussed, they can come down, involveus in discussions and gather information, sothat when they make these policies they knowit is something that has been discussed, it hasbeen understood and it is needed, because occa-sionally policies have been made [and] whenthey come down here they do not even work.(Frontline nurse manager)

Some nursing participants mentioned that the opinion offrontline nurses could be sought through research and regularmeetings and then brought to policy-making processes.

Participants also described actions to be taken by thenursing profession. In particular, they identified the need to


empower nurses through training to enable them to betterunderstand and participate in policy formulation. Whilethe experiences of nurses were thought to be importantassets for this input, a broader knowledge of the health caresystem, of policy-making, and of decision-making processes,were described as essential prerequisites for constructivecontributions.

The bottom-line is that you must be knowledge-able, you may be a real nursing guru, (. . .) yourcontribution should not only be based on care,of course care is very critical, but you must havegeneral knowledge like how the governmentoperates (. . .). Majority of nurses do not knowanything apart from nursing, you are supposedto have general knowledge, like InternationalMonetary Funds policies, how does it affect us?,what happened? [sic]. (Nurse leader 2)

Other areas identified for skill-building included politicalskills needed to engage the government to address policy gapsthat affected nurses’ work as one nurse leader said that “nursesin this country lack political skills, they should have politicalskills in order to dialogue with politicians and other leadersin this country.” In addition the participants mentioned thatnurses need data management and research skills to bringevidence to policy. They mentioned that nurses could bringevidence to policy meetings and conferences.

Finally, they mentioned actions to be taken by nursesthemselves to enhance their ability to participate in policy-making. Nonnursing decision-makers strongly suggestedthat nurses should take the lead to change their situation.They mentioned that nurses should market themselves,progress in their careers, diversify, venture outside the nurs-ing profession, and broaden their curriculum in order tounderstand broader policy related issues.

Nurses build empires around themselves (. . .).Nurses must be free to venture into other areasand be competent in those areas and not tiedto nursing. The ball is in nurses’ court. Weare ready to embrace and support (. . .). Themedical profession is much more marketizedthan nursing. More often, you find doctors inareas, which are not related to medicine andthey fit well. They do not have to link stronglyto their profession, they are more independent.(National nonnurse decision-maker)

Congruent with this decision-maker’s opinion, some ofthe nurse leaders interviewed added that more nurses shouldposition themselves to take up leadership roles in the system.They indicated that nurses should diversify their knowledge,be united to build a strong voice, collaborate and networkwithin and beyond the country, and be assertive about whatthey wanted. They added that the nursing council and theprofessional association should be strengthened to enhancetheir respective roles in influencing national policies thataffect nurses’ work.

Frontline nurses added that nurse leaders should bemoreproactive in policy activities so as to influence policy-makers.

They called for nurse leaders to advocate for better workconditions for nurses. Some frontline nurses felt that this typeof advocacy would be an incentive for front line nurses toparticipate in decision-making in the health care sector.

5. Discussion

From a critical perspective, two major issues influencingnurses’ involvement in policy processes emerged.These issueswere hierarchies and structures influencing decision-makingin the health sector and nurse and nursing professional issues.These issues are discussed below.

5.1. Hierarchies and Structures. Three intersecting hierarchieshindered nurses’ active engagement in policy processes inKenya: health systems hierarchies, interprofessional hierar-chies, and intraprofessional hierarchies. The Kenyan healthsystems decision-making structure is organized followingpolitical administrative levels including central headquartersand provincial and district levels. The political structuresmandate the central administration as the policy-making andservice planning level. The Kenyan health policy frameworkof 1994–2010 emphasized that policy formulation was therole of the central office [38]. This top-down policy-makingprocess limited nurses’ opportunities to engage directly inpolicy formulation in the health care system. This policyframework delineates a policy implementation rather thana policy formulation role for nurses. Given the top-downnature of policy-making processes in the health sector,particularly with the many stakeholders and foreign donorsinvolved, the findings speak to the importance of findingwaysto give nurses some voice in decision-making at all levels.

The interprofessional hierarchy described within thehealth sector identified medical doctors as being the dom-inant policy decision-makers at various levels of the healthcare system. Social constructs of racialized status and genderimbue health care hierarchies and are grounded in the legacyof Kenya’s colonial period that ended in 1963 [16]. Whitecolonialists developed health care institutions that favoreda male- and white-dominated medical profession over afemale- and African-dominated nursing profession.The edu-cation system prepared physicians with first degrees whilenurses acquired certificates and later diplomas. Althoughbaccalaureate degree nursing education in Kenya began inthe late 1990s, only one percent of nurses in the public healthcare sector have baccalaureate degrees. Resultantly, medicaldoctors have higher status and are granted more decision-making authority in the system as opposed to nurses whoseeducation and status were, and are considered low, furtherprecluding nurses from higher decision-making positions.

The interprofessional hierarchy is further sustained bythe legal system, specifically the Public Health Act, whichled to the systematic exclusion of nurses from senior lead-ership positions at various levels of the health care system.According to the Act, physicians were to serve as the headsof various departments, administrative directors of districtsand hospitals, and managers of various programs, whilesenior nurses could only be placed in positions to representnurses, thus limiting their participation in policy and other


health care decisions. This legislation thus legitimized thegendered professional hierarchy and further limited the typesof issues that nurse leaders could bring to the policy table.Nurse leaders’ participation at policy tables was considerednursing centric by both nursing and nonnursing leaders.While the majority of decision-makers blamed nurse leadersfor nursing centric participation, this kind of participationwas also shaped by the system, which mandated nurseleaders to report only on nursing issues. This is consistentwith a global study [39] of nurse leaders focusing on ChiefNursing Officers, which revealed that, even though thesenursing leaders had varied responsibilities associated withtheir positions, they were only asked to provide nursing-related advice.

The study revealed how an intraprofessional hierarchywithin the nursing profession played out in the policy arena.Nurse leaders at the national level were recognized as the soleprofessional representatives of other nurses in the countrywho would provide input on national policy decisions. Theintraprofessional hierarchy influenced channels of policycommunication to frontline nurses who received new policydirectives from their supervisors at every level of the system.This hierarchical pattern of decision-making within nursingmay have been exacerbated by the fact that there are only afew nurses in key national level positions, limiting the scopeof their policy influence at the national level and precludingthem from engaging nurses more proactively at the districtlevel or on the front lines in policy-oriented discussion. Inaddition, nurses at lower levels felt oppressed by senior nurseswho made most of the decisions. From the findings, thenonnursing decision-makers had more to say about nurses’oppression than nurses themselves. Nonnursing decision-makers indicated that nursing was a profession where theoppression of lower level nurses was a problem. However,they were generally pessimistic, indicating that nurses werenot yet ready to make a change. The oppression of lowercadre nurses by higher cadre nurses in decision-making hasbeen documented in other studies [40–42]. In the absence offeedback from the grassroots on policy implementation, asidentified by participants in this study, the voices of nursesat lower levels might be suppressed further. Given the factthat Kenya has a decentralized health care system, moreparticipatory approaches could be introduced to enhancenurses’ potential engagement in policy-making, thus improv-ing bottom up planning and decision-making. This wouldincrease the way in which those who have less power in ahierarchy get voice.

5.2. Nurses and Nursing Profession. Both nursing and non-nursing participants attributed nurses’ underengagement inpolicy to issues related to the nurses and the nursing pro-fession. Respondents consistently indicated that nurses hadinadequate knowledge and skills required to contribute topolicy processes. They described this deficiency in nurses’knowledge as being attributable to a failure of the nursingprofession to incorporate policy issues andpolicy process intonurses’ training curricula, thus maintaining the status quo

for nurses’ role in decision-making. Studies in other contextshave revealed how lack of policy content in nursing trainingcontributes to nurses’ lack of understanding of policy [43].Given the need to strengthen nursing leadership to influencepolicies, other programs have emerged to train nurse leadersin ways to influence policy. In the African context, manynurse leaders have been enrolled and trained in a leadershiptraining program offered by International Council of Nurses[16]. This participation may help strengthen nurses’ compe-tency in engaging in national health care decision-making.

Study findings also revealed that nurses had inadequateadvocacy, research, and political skills required to influencepolicies. These issues are similar to what has been identifiedin studies from higher income countries [12, 17, 23]. Inthese studies, the profession is seen to have been slow inincorporating these issues in nursing education. Nonnursingdecision-makers in this Kenyan study felt that the professionhad reinforced its own weaker professional status by failingto enhance nurses’ abilities and competencies to influencedecisions at strategic levels in the system. Their commentsreflected an openness to incorporate nurses’ views if nurseswere competent in national policy processes andmore knowl-edgeable about general health care system issues.

The findings also revealed that nurses have worked inisolation from other professionals in the system. With theemphasis on professional transformation towards equalityand diversity [44, 45] nurses cannot continue to build wallsaround themselves. This would require nursing championsto take up leadership in working with other health cadres toinfluence policy change.While leadership competencies havebeen recognized as key attributes to shaping and influencingpolicy [46, 47], in this study nursing leadership was viewedas internal to the nursing profession, with concerns aboutthe focus on nurses’ work issues and not general health careissues. Nursing champions should not focus on the professionalone; they must be educated in the broader health systemsissues and become patient advocates for health care as theyengage with other professionals in leading policy change[48]. This engagement would contribute to health systemsimprovement.

6. Study Limitation

We only collected data from Kenyan context. Therefore, thefindings are only applicable toKenya. Kenya hasmany districtlevel hospitals but data from frontline nurses was mainlycollected from two districts given the limitation in funding.

7. Conclusion and Recommendations

In conclusion nurses in Kenya have not been adequatelyinvolved in national policy development. Applying criticaltheory perspective in the analysis has revealed importanthealth system structures and hierarchy as well as nursingprofessional factors hindering nurses’ participation in poli-cies making processes. These factors must be addressed ifnurses’ input in policy-making is going to be significantlyaltered. To enhance nurses’ participation in policy processes,the policy-makers should address hierarchies, domination,


and gender issues inherent in the health care system andestablish mechanisms through which the views of nursescould get to national level decision-makers when policies arebeing formulated.This can be achieved by enacting legislationin Kenya that would allow nurses with competencies inleadership and policy to hold senior positions in the healthcare system just like doctors. With governance opportunitiescreated through decentralization of power, there is a needfor all health professionals to have equal opportunities to bein leadership and management positions that are embeddedwithin the decision-making structures in the health caresystem. To enhance bottom-up policy-making, national leveldecision-makers should solicit the views of nurses at thefrontline with regard to policies that might affect their workand quality of care. There arewell-described processes for thispurpose [49, 50] but they cannot be implemented in isolationof process changes at the district and national levels, whichbuild mechanisms for continuous quality improvement.

Leadership and advocacy skills should be developedwithin nursing to enhance nurses’ abilities to carry out policyadvocacy at all levels. ICN has developed programs aimed atbuilding the capacity for such leadership in societies aroundthe world [51]. These programs include the Leadership innegotiation program, the global nursing leadership institute,and the leadership for change program. Nurses in this regioncan benefit from these programs. To enhance their role inadvocacy, nurses should unite to build a strong voice toadvocate for improvements in national policies that affecttheir work and quality of care. Working in collaboration withother health professionals, nurses can influence decisions tostrengthen the health care system, resource allocation, andprimary health care as well as patient care.

In addition, nursing regulators and educators shouldbe clear that policy involvement is part of nurses’ scopeof practice. Nurses, particularly at the frontline, should begiven orientation on existing national policies in the sectorand how these policies are affecting their work environmentand patient outcomes. This would be an important steptowards better communication of policy impact, creating amuch needed feedback chain between those implementingpolicy and those formulating policy. As members of nursingassociations, frontline nurses should encourage and supporttheir nurse leaders to speak for nurses at the national policytables. In their workplaces, decision-makers should allowother nurses to actively engage in organizational policydecisions during policy implementation.

The nursing profession should consider and implementstrategies to strengthen nurses’ capacity to contribute topolicy decisions that would enhance service delivery. In orderto effectively do this, nurses in Kenya will need to understandthat the policy cycle is complex and influencing policydecisions depends on having a sufficient understanding of thebroader issues in the health care system, as well as knowledgeand competencies in policy formulation, implementation,and evaluation. To enhance nurses’ awareness, literacy, andcompetency in policy, nursing educators should introducea course on policy and policy processes, as well as policyinfluencing in the nursing training curriculum.

Finally, the nursing profession should carry forwardthe notion of evidence-based policy-making. They shoulddevelop skills in research and conduct both health systemsand clinical research to inform policy-making decisions.Research courses should be linked to policy courses andtraining curricula should include current and locally relevantexamples of how evidence can be used to shape policies.This would include strategies and tools for communicatingresearch to policy-makers, like writing policy briefs andposition statements based on research evidence. Sharing ofpolicy relevant research would contribute to policy changeand resource allocation to improve nurses’ work.

8. Further Research

This is one of the first studies examining the perspectivesof both nurses and nonnurses at different system levelsregarding nurses’ involvement in national policy-makingprocesses. With the continuing health care policy reforms,further examination of issues of hierarchy, gender, and powerinherent in the health care system should be conducted in abroader context in Africa.The question is how do we unravelthe deeply embedded hierarchies and power processes thatsustain nurses’ status quo in policy change process? Ofparticular importance is how the hierarchies affect the roleand performance of nurses at lower levels and how can nursesinfluence national leaders to enhance participation in healthpolicy change processes. Furthermore, this study did notcarry out an in-depth examination of the competencies heldby nurse leaders that would be useful for policy change; thusfuture research should examine these aspects.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgments

The first author would like to thank the University of Ottawafor providing the funding and support for her doctoral study.This work was supported by a doctoral award to PamelaAtieno Juma from the International Development ResearchCenter (IDRC), in Canada (Award no. 104655-99906075-077). The authors thank the Ministry of Health Kenya, forgiving them permission to conduct the study and providingaccess to the health facilities and staff. The authors thank allthose who participated in the study.

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