CHAPTER 6 DISCUSSION OF QUANTITATIVE AND QUALITATIVE FINDINGS
6.1 INTRODUCTION
6.2.6 Participation at different stages of policy development
The nurse leaders were asked to share their perceptions on nurses and policy, their experience and how they have participated at different stages of the policy development process. The responses were grouped together in the discussion as they were talking to the same issues. A similar open-ended question was asked in the quantitative questionnaire.
6.2.6.1 Policy formulation
All data sources showed that none of the nurse leaders had participated in the initial phases of the policy development process, namely, problem identification and agenda- setting. Most participants stated that they had not been exposed to the health policy development process. Exclusion of important actors during the setting of the agenda limits the debating of issues. People feel powerless if they do not have any contribution to make to key decisions simply because they cannot find an arena to express their views or feel unable to express them.
The researcher experienced a difference between interviewing nurse leaders who were from national level and those who were from the institutions and the provincial office. The nurse leaders from national level had a clear understanding of the processes they were expected to follow, though no explicit policy development guidelines were reported. This could be because they had received training on policy issues, and by default because the positions that they occupied required them to participate in policy development, though not from the nursing perspective. However, there was limited understanding of these processes by the other participants from provincial down to facility level.
The data showed that nurse leaders had no confidence in their knowledge and skills at different stages of the policy development process. Their limited knowledge also resulted in low confidence in their research and analytical skills to provide evidence to inform policy.
Hence, they reported that they had never been involved in submitting evidence-based presentations that would inform policy to the policy-makers. Generally, the participants had limited participation in health policy development. The results of the study are similar to the findings by Akunja et al (2012) in Kenya, where nurses were found to be involved in HIV policy development at different levels but their involvement was negligible at provincial and national levels.
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The findings were also supported by a study that explored nurses’ engagement in the AIDS policy in six countries, namely, Canada, Jamaica, Barbados, Kenya, Uganda and South Africa. Nurses in all participating countries remarked about their lack of participation in policy development. Resources were usually not available to carry out the policy requirement (Richter et al, 2013). However, these findings differ from Shariff and Potgieter (2012), who found that in East Africa more nurse leaders participated at the national levels of health policy development, as compared to provincial, regional and global levels.
Analysis revealed that leaders were performing an interpretation and translation role.
However, results were similar in the sense that fewer nurse leaders participated throughout the health policy development process. Their contribution was greatest at the policy implementation stage.
The issue of being represented by people other than nurses was recurrent in all the data sources. Some participants reported that they did not even know the people who were part of the process. They stated that they were represented by nurse educators in the development of policies such as OSD. The health policy development process appears to be influenced largely by role-players other than nurses. Participants mentioned that policy- makers do not recognise their expertise and the valuable input they may have. This suggests that policy-makers do not know what nurses do or the actual dimensions of their role. It could also mean that nurse leaders from practice are still seen to belong to the bedside rather than the boardroom. This is congruent with the findings of a study conducted by Ditlopo (2014), where frontline nurses believed they were not included in policy processes because policy-makers did not recognise the importance of their clinical knowledge and expertise in informing policies. Nurse leaders’ jobs require them to be part of the policy development process at policy formulation and implementation levels, but their role is largely managerial. The low involvement in policy development is influenced by the fact that nurse leaders see their work as primarily that of supervising patient care (Sundquist, 2009).
The majority of participants had never participated in policy analysis. This aspect required a great deal of background knowledge on the national-level policy process, which they lacked. The findings also showed low confidence levels among nurse leaders in this phase.
Nurse leaders believed that they were not prepared, or might have had only a small role in the formulation and analysis phase of the policy process. Research skills are necessary in this phase, and the nurses had no confidence in that area. Furthermore, the questions
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in this phase were somewhat theoretical in nature and depended on having prior basic knowledge about policy matters.
6.2.6.2 Policy implementation
All data sources revealed that nurse leaders participated mostly at the level of policy implementation. This could be because policies are implemented in hospitals at different levels, and nurses are primarily responsible for putting policies into practice. Policy-making is still viewed as taking a “top-down” approach. Nurse leaders are receivers and implementers of policies. Therefore, they participate in various activities, such as communicating policies, identifying problems, observing and reporting on challenges and obstacles in implementation. The results from both quantitative and qualitative groups were consistent. These findings were similar to those obtained by Richter et al. (2012), where nurses in all of the participating countries reported lack of involvement in policy development. Policies were imposed from the top down for them to implement, despite not having participated in their development. The area of policy development has always been the area of slowest progress for nurses (WHO, 2011). The nurses’ role is perceived as that of implementing policies and programmes, rather than participating in and bringing the nursing viewpoint, experience, knowledge and skills to policy decisions and healthcare planning (Benton, 2012).
Both qualitative and quantitative data sources revealed that there were challenges with the implementation of policies. When policies were received, they were interpreted and implemented differently by various institutions. This could have resulted from the absence of implementation guidelines for policies. Jasen et al. (2010) confirm that the implementation process is insufficiently monitored. There is no clear direction showing what, where, when, how and by whom activities are to be monitored. According to the WHO (2015), the key to ensuring ownership of a policy by health professionals is the guideline development process. Ownership motivates them to buy in and to ensure successful implementation and improved quality of care. The guidelines need to be implemented through the use of relevant tools or products, such as clinical pathways, training, audit and feedback, linkages with quality indicators and, where appropriate, payment for performance arrangements. Guidelines have to be linked with the implementation and monitoring of activities. Technical support has to be provided (WHO, 2015). The findings also suggest that the challenges of implementation are partly due to
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lack of consideration of the key actors (nurse leaders) at the policy development stage that would provide input on the operational mechanisms required for implementation.
6.2.6.3 Policy evaluation
Data sources showed inconsistencies in responses to questions related to participation in the policy evaluation phase. Some participants reported that they did not participate at this stage. Others reported that they participated to a certain extent. This could be linked to a limited understanding of this phase. The issue of unavailability of guidelines for policy analysis and evaluation was raised. Participation at this stage was seen in terms of identifying gaps in policies during implementation. There was no clear direction on how those gaps would be addressed. However, they did acknowledge that they participated in policy evaluation at the institutional level. Jasen et al (2010) attest that many policy programmes are not evaluated at all. Even when evaluation is done the evaluation research results in many cases are not published or communicated as this might have implications for politicians.