Background

The current systematic review will explore the involvement of midwives and nurses in policy development in low- and middle-income countries (LMICs). Policy involvement includes participation in policy development processes such as identifying a policy issue, creating policy, implementing policy and evaluating policy as well as modifying the policies as needed. In health care, policies are generally concerned with fostering the wellbeing of the public.1 With regard to patient advocacy, being involved in policy development requires midwives and nurses to be knowledgeable about issues, laws and health policy.2

Calls for health policy and system reform in recent years have led to increased recognition of the need for greater policy involvement among midwives and nurses.3,4 This recognition began gaining traction in the early 2000s, as evidenced by a report in 2002 by the World Health Organization.5 Midwives and nurses comprise the majority of health personnel in most countries, especially in LMICs, and are often the health providers with the closest proximity to patients.6,7 Given this close interaction with patients and their families, midwives and nurses possess the necessary expertise and insight to influence policies geared towards improved healthcare delivery and quality care.8 Their presence at the bedside during significant life events including childbirth, illness and recovery puts midwives and nurses in the best position to provide critical policy information to patients.7,9-12 Several primary studies on this topic which are referred to in this review protocol have shown that midwives' and nurses' influence on policy is also essential for protecting patient safety, increasing quality of care and facilitating access to resources required to promote effective health care.13,14 Furthermore, nurses and midwives are key implementers of health policy at the point of patient care and health services delivery. Health policies affect midwives and nurses in their routine administrative and clinical duties, their professional practice and their overall work environment. Given their role at the nexus of health advocacy and healthcare delivery, midwives and nurses can provide critical input to the strengthening of health systems and to ensuring the availability of supportive working environments for healthcare delivery. Therefore, nurses and midwives are both morally and professionally obligated to engage in policy development and reform.15 This engagement is even more critical in LMICs in which resources are limited, and nurses and midwives represent the majority of the health workforce.8,15

Researchers suggest that successful policy involvement requires midwives and nurses to possess the power, time, will, energy and skills to meaningfully navigate policy processes.3 Yet systemic challenges to engaging midwives and nurses in policy development identified in the literature include a general lack of conceptual clarity regarding nurses' policy influence,3,16,17 disjuncture between nursing leadership and clinical staff regarding awareness of policies that influence conditions and delivery of nursing services,18 and limited exposure to facility, institutional or national level policy processes.9,19,20 Moreover, midwives and nurses sometimes perceive themselves as lacking the requisite competence, understanding and skill sets to contribute meaningfully to policy development and reform.21-23

Proximal barriers to midwives' and nurses' involvement in policy development include their own individual perceptions of being preoccupied with clinical or bedside responsibilities, inadequate time to engage in policy formulation, implementation or modification, a lack of understanding regarding the reasons or benefits of their involvement, and perceived professional role boundaries that do not include policy development.9,24 Further barriers include limited knowledge and skills, a lack of supportive structures and processes that promote policy involvement, and limited access to research evidence among nurses to meaningfully engage in policy development discussions.24,25 Limited policy involvement is linked to entrenched sociocultural perceptions regarding the nursing profession, particularly in LMICs, as one better suited to females of whom there is little expectation (or encouragement) of significant, let alone progressive, engagement in policy decision making for health.26 This is particularly prevalent in countries like Kenya, where women, who are considered traditional nurturers, are expected to be preoccupied with bedside care rather than policy affairs or decision making.27-29

Currently, no comprehensive synthesis exists on the experiences of midwives and nurses in policy development in LMICs. This systematic review of qualitative data will therefore provide critical information to support health system strengthening, effective policy development, efficient human resources distribution and sustainable quality of care in LMICs. A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, The Cochrane Library, CINAHL and PubMed revealed that there is currently no systematic review published on this topic.

Inclusion criteria

Types of participants

The current systematic review will consider studies that include one or both of two types of participants - nurses or midwives, with any length of practice, who are registered and licensed to practice midwifery and/or nursing by an accredited and authoritative organization, regardless of age, gender or cultural identity, and who have been involved in policy development in any capacity in or for LMICs.

Types of intervention(s)/phenomena of interest

The phenomena of interest for this review are the experiences of midwives' and nurses' involvement in policy development in and for LMICs. Low- and middle-income countries can be any of the countries defined and listed by the World Bank Group (The World Bank) as low- and middle-income economies. Examples of involvement in policy development include but are not limited to planning, partnership, collaboration, consulting, decision-making, strategy or policy formulation, implementation, monitoring and evaluation.

Context

The current review will consider qualitative studies that have explored the experiences of midwives' and nurses' involvement in areas or settings in which policy development, formulation, implementation or evaluation takes place in and about LMICs. Examples may include healthcare delivery settings, professional and government organizations, academic institutions, hospitals, clinics, communities, and local, jurisdictional or national levels of policy decision making.

Types of studies

The current review will consider English language studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, case studies and feminist research. In the absence of research studies, other text such as opinion papers and reports will be considered.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE (PubMed) and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies as well as Scopus, Google Scholar and Web of Science will be used to identify articles that cite the identified reports. Studies published in English will be considered for inclusion in this review. Studies published from 1990 to 2016 will be considered for inclusion in this review, given that attention to the issue of nursing representation in policy development began gaining momentum over the past two decades. The WHO in 2001, called for targeted interventions to develop nurses' capacity in research and knowledge translation, including strategies to increase their representation in policy development.

The databases to be searched include the following:

Anthrosource

CENTRAL (The Cochrane Library)

CINAHL

EMBASE

PsycINFO

MEDLINE (PubMed)

Social Services Abstracts

Sociological Abstracts

TRIP: Turning Research Into Practice

Latin American and Caribbean Health Sciences Literature

African Index Medicus

Web of Science.

The search for unpublished studies will include the following:

Google (country specific)

Angola: Associacao Nacional de Enfermeiros de Angola

Botswana: The Nurses Association of Botswana

Burkina Faso: Association Professionnelle des Infirmiers/eres du Burkina

Rep. democratique du Congo: Association des Infirmiers du Congo

Ethiopia: Ethiopian Nurses Association

Gambia: The Gambia Nurses Association

Ghana: Ghana Registered Nurses Association

Guyana: Guyana Nurses Association

Kenya: National Nurses Association of Kenya

Lesotho: Lesotho Nurses Association

Liberia: Liberia Nurses Association

Malawi: National Association of Nurses of Malawi

Morocco: Association Marocaine des Sciences Infirmieres et Techniques Sanitaires

Mozambique: Asociacao Nacional dos Enfermeiros de Mozambique

Namibia: Namibian Nursing Association

Nigeria: National Association of Nigeria Nurses and Midwives

Sao Tome and Principe: Associacao Nacional dos Enfermeiros y Parteiras de Sao Tome e Principe

Sierra Leone: Sierra Leone Nurses Association

South Africa: DENSOA

Swaziland: Swaziland Nursing Association

Tanzania: Tanzania Registered Nurses' Association

Togo: Association nationale des infirmiers/eres du Togo

Uganda: Uganda National Association for Nurses & Midwives

Zambia: Zambia Nurses Association

Zimbabwe: Zimbabwe Nurses Association

Conference Proceedings from Sigma Theta Tau International (STTI) Honor Society of Nursing Annual Research Conference, International Council of Nurses (ICN), Biennial convention and other National conferences in LMICs e.g. University of West Indies Annual Nursing Research conference, 2016 theme is "Translating Research Evidence into Best Practices: The Key to Healthy Public Policy and Quality Patient Outcomes"

GreyLit Network

Grey Source

Institute for Health and Social Care Research

New York Academy of Medicine Grey Literature Report

ProQuest Digital Dissertations and Theses

The Grey Literature Bulletin

LMIC Nursing and/or Midwife Organisations (Appendix VI)

The World Health Organization (WHO)

OAIster (through WorldCat)

Virginia Henderson International Nursing Library

Journals deemed relevant but not indexed in databases will be hand searched.

Initial keywords to be used will be: Nurs^*, Midwi^*, Nurse-Midwives, Nurses, registered nurse, midwi^*, nurse-midwives, LMICs, healthcare, MNCH, qualitative research, investigators; polic^* AND (maker^* or making or influenc^* or develop^* or participat^* or influenc^* or engage^* or process^* or implement^* or arena^* or strateg^* or perspectiv^*).

The search strategy will be adapted to the features and vocabulary of each database searched to ensure that a wide body of relevant literature is captured. An LMIC search filter developed by the Norwegian Satellite of the Cochrane Effective Practice and Organisation of Care Group will be tested and adjusted as needed for this search. (http://epocoslo.cochrane.org/lmic-filters).

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological quality before inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

In the absence of research studies, textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Qualitative data from papers included in the review will be extracted by two independent reviewers and by using the standardized data extraction tool from JBI-QARI (Appendix III). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.

In the absence of research studies, textual data will be extracted from papers included in the review using the standardized data extraction tool from JBI-NOTARI (Appendix IV). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

In the absence of research studies, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity of meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form.

Acknowledgements

We wish to gratefully acknowledge the Queen's Collaboration for Health Care Quality, especially the 2014 Institute Faculty, for their ongoing support and feedback.

Appendix I: QARI critical appraisal instrument

Appendix II: NOTARI critical appraisal instrument

Appendix III: QARI data extraction instrument

Appendix IV: NOTARI data extraction instrument

References