INTRODUCTION

Public policies (PP) are the concrete and tangible expression of political actions. Nursing considers them as the choices of society through their rulers; their objective is to represent public affairs and the forms of granting the resources to achieve it. For this, ordinary people, professionals, or groups' political participation allows continuous improvement to the PP formulation process¹.

The Adelaide declaration of 2010 (World Health Organization - WHO) opens the discussion. It proposes health in all policies, which highlights the work of the health sector and its importance in the development of PP. Also, as a strategy to achieve social, economic, and environmental development that favors the health and well-being of people. In this, professionals in the health sector, particularly nursing, have a fundamental role, given the skills acquired in their professional training, which undoubtedly contribute to formulating PP^2,3.

In this context, the WHO since 2002 periodically published the "Strategic directions for strengthening nursing and midwifery"², where, according to the historical context, it makes explicit the need for the participation of Nursing professionals in the definition of health PP, to make them more efficient and effective in achieving global health goals. The Situation of Nursing in the world 2020 report⁴⁾ mentions the need to invest in nursing education, employment, and leadership, providing a vision and a plan for policies. Paradoxically, the International Year of Nursing and Midwifery Professionals 2020 coincided with the coronavirus pandemic⁵.

Nursing professionals represent 56% of the total health workforce in the world and develop both specific actions for caring for people and complementary activities to other health areas⁵; being evident the possession of diverse competencies to support the processes of formulation of PP in Nursing^1)(2)(3)(5. Thus, supported by the pattern of socio-political knowledge of Nursing, they seek to respond to problems that arise in terms of access, quality of health care, and universal health coverage^2)(3)(5.

The role of Nursing associated historically with caring for the health of individuals and communities, marked transversely by the political activism pioneered by Florence Nightingale in the 19th century. The act of caring is based on constructed human values. The political dimension, proper to the profession's action, always takes place in a historically determined context. In this way, Nursing has a fundamental role as an integral part of the collective work¹.

Within the front-line workers, Nursing provides care addressing current social health challenges, such as emerging diseases, aging, sick and uninsured populations, increasing costs in plans and insurance, a shortage of providers, and the disconnection with political health and health reforms⁶. In this way, participation in the formulation of PP offers Nursing an opportunity to influence various socio-sanitary programs, which profoundly impact the provision of health and high-quality care practices in times of great current socio-sanitary crossroads⁵.

Thus, it would be favorable and advantageous for more nurses to be proactive developers of PP and implement them⁶. Nursing would have leadership and protagonist in the complex PP process by assuming an active role, strengthening the profession, and joint health.

Although Nursing began the path to achieve participation in the process and formulation of PP, it is a priority to develop a body of knowledge that strengthens the role of political participation as an expression of the pattern of socio-political understanding of the profession. Build forms of thought long-term strategy for the profession and motivate Nursing professionals to develop the political role that corresponds to them, as a strategy to expand social participation and contribute to humanized health and a more sustainable society.

In this context, the development of this research is necessary, which aims to analyze the scientific evidence available in the literature regarding the role of political participation in the nursing profession. To synthesize the evidence that supports the contribution of Nursing to the public policy process and build new knowledge in this matter that can help future investigative procedures.

METHODOLOGY

This study corresponds to a six-step integrative review of the literature. This type of reviews makes it possible to summarize a large amount of information regarding the subject under discussion, using various studies⁷.

Following the methodological path: 1) identifying the problem 2) determination of search strategy and determination of inclusion and exclusion criteria 3) definition of the information to be extracted from the selected studies/categorization of studies. 4) evaluate the studies included in the integrative review 5) interpretation of study results 6) presentation of the review/knowledge synthesis⁷.

The integrative review was guided by the question: What should be the Political Role that the nursing professional performs in the creation, implementation, and evaluation of PP between 2010 and 2020?

Regarding the eligibility criteria:

- Inclusion criteria (CI): scientific journal; full text online; the relationship between Nursing and politics or public policies or formulation of public policies; political analysis articles - critics, literature reviews, process evaluation studies, qualitative studies, and case studies.

- Exclusion criteria (CE): incomplete articles; Articles in a language other than Spanish, English, Portuguese; no relations between nursing with politics, articles with other health professionals studied.

The search for studies following search strategy was used: NURSING and HEALTH POLICY and POLICY FORMULATION, in English, Portuguese and Spanish, between 2010 and 2020. The databases were used: MEDLINE / PUBMED; ISI WEB OF SCIENCE, EBSCOHOST WEB, LILACS, and SCIELO. Search period: March - April 2020.

For data selection, modified PRISMA (Figure 1) was used to delimit the final texts and present them ⁸. Step 1: articles published from 2010 to 2020. Step 2: the title and abstract of the articles were read in detail, items of interest were selected according to CI and CE. Step 3: the texts were read in full, grouping the texts into two thematic areas 1) political participation of the nursing professional in PP, characteristics, and virtues; 2) strategies and Challenges regarding participation in PP. Finally, a Thematic analysis of Minayo⁹ was carried out, categorizing the findings with a qualitative synthesis and a narrative of the results.

Figure 1:  PRISMA flow Chart summarizing the study selection process 

RESULTS

Characterization of the studies

Of 75 documents found, 43 met the search criteria. Finally, 23 completed criteria (Figure 1) are presented in Tables 1, 2, and 3.

The descriptive analysis highlights 35% of the publications were made in the period from 2010 to 2012; 48% were carried out in the United States; 65% were obtained from PUBMED, and 26% are case studies. (Table 2) both categories highlight the interest of the research community in presenting the background of the value of Nursing in the different PP processes and the strategies necessary to apprehend this new knowledge to face the unique challenges that underlie current socio-sanitary dynamics. (Table 3)

Table 1:  Analysis matrix of selected articles. 

Source: self-made.

Table 2:  Qualitative - descriptive synthesis of the texts. 

Source: self-made.

Table 3:  Thematic axes emerged from the analysis 

Source: self-made.

DISCUSSION

When analyzing the scientific production on political participation and Nursing, the interest of the research community in presenting the background of the value of Nursing in the different PP processes stands out. Similarly, the strategies necessary to apprehend knowledge that allow us to face the new challenges that underlie current socio-sanitary dynamics are also highlighted. In this way, the conquest of spaces for political participation and the consolidation of the socio-political knowledge pattern from a continuous learning process and professional practice will favor the change and substantive improvements of the current socio-sanitary dynamics³.

Professional virtues and competencies to enhance the political participation of the nursing professional

Due to its historical and social importance, nursing's generalized insertion in the spaces for the production of individual and collective attention and the pattern of socio-political knowledge is it's own. It constitutes a social practice that can advance to compose forces capable of mobilizing broader social change³.

This profession characterizes by a high social benefit and its high contribution to healthcare quality and cost, outlining itself as safe, effective, patient-centered, timely, efficient, and equiTable^16,19. Nurses who possess a high educational standard can "read the world" ²³ and have specialized experience in essential topics of broad interest. Nurses are trusted by the public and recognized as major players in healthcare¹.

As a care-based disciplinary profession, nurses are in a unique position to advocate for patients and their families¹⁹, identify public health problems²⁰, and find solutions from the work they do¹⁹.

They can intensely develop political savvy as a vital aspect of the Nursing profession related to political participation. It includes understanding the legislative and public policy process, knowledge, and political skills necessary to advocate for people and communities, knowing who the policymakers are and how to communicate with them. Therefore, awareness of this role is the first step to improve the capacity of nurses to support government policies and have active participation in the political process²¹.

Involve Nursing in developing global health policies is vital to ensure the scaling up of effective health programs and sound global health¹². For this reason, participating in political matters given their understanding of the implications of normative, legislative, and organizational changes in the health environment¹⁹ and territories²⁴. It would require three strategies to influence the political process further: developing an in-depth knowledge of political subsystems, the construction of networks based on a democratic spirit, and participation in the policy area for extended periods ¹⁵.

Nurses can participate throughout the policy formulation cycle, promoting policies based on scientific evidence obtained from big data¹⁷ and empirical evidence obtained from clinical experience²⁶. It has given the understanding of more significant human aspects and impacts of proposed and existing policies at all health levels¹.

In this sense, it is necessary to work expansively on an approach beyond professional aspirations and advocate more for their work's political relevance than individual benefits¹⁹. The authors highlight the dialogue exercise^16,19 and the visibility of their work²⁷ through the use of social networks and communications¹. Could improve the ability of nurses to advocate in the political-legislative sphere for its populations of interest and, in turn, achieve the objective of improving the health outcomes of the communities²⁶.

Strategies and challenges to participate in politics and the development of PP

The authors position Nursing as one of the key professions in fulfilling the Global Health goals, thus playing a significant role in achieving universal access to health and the sustainable development of communities^26,27.

To effectively exert influence on PP, the authors reinforce the idea that nursing contributes to society's benefit by considering the context as an opportunity for visibility and expression, change and transformation³.

Based on the socio-political pattern, Nursing will find a way to advance and guarantee the profession³. However, it requires a regulatory framework that supports professional and union functions¹⁵. Also, continuing education for exposing concepts of policy formulation^{12)(15)(18)(21)(26)(27)(29}; raising awareness of political issues and developing political savvy, a sense of self-efficacy regarding participation in the political process^12)(15)(29; development of leadership and decision-making skills^11)(14)(27; communication, collaboration, and consensus⁽⁵⁹that challenges the ideological assumptions that drive superior policies, advocate for comprehensive reforms and reduce the vast and growing inequalities in education, income, and health between citizens and communities²³.

In times of significant changes in the management of PP, in which Nursing faces different political points of view, it is necessary to use empirical knowledge as a fundamental guide in combination with ethical and moral judgment to support the planning and implementation of public policies²³. In this sense, according to the authors, it is necessary to coordinate actions or coalitions between nursing congregations, groups, and interprofessional work¹² to establish an interdisciplinary regime with institutions, unions, and/or politicians who share the same concerns and have close objectives for the development of uniform and unified solutions in the face of windows of opportunity^17,18. At the same time, work to construct scientific evidence that allows strengthening the professional work³. Other authors also emphasize the use of technologies and the mass media to give testimony, actively communicate the perspective of Nursing and participate in social dialogue in the face of public events¹.

Likewise, professional training in public policies is essential to contribute to collective work¹. Other studies expose the training of lobbyist nurses²², communicators¹, knowledge intermediaries that connect science and society through the construction of networks, facilitating opportunities between producers and users of knowledge²⁷. And also as storytellers to support the public policy formulation process, taking into consideration various practical and innovative approaches to bridge the gap between research and policy formulation²⁵.

However, its impact on society challenges leadership development barriers and participation in political processes²⁷. Lack of support (bureaucratic walls), resources, and time for nurses to develop the role in their workplaces stand out. Some passivity, lack of coalitions, and ignorance in political matters are also revealed²⁹.

Therefore, to the extent that Nursing professionals become aware of the knowledge of the context and the opportunities offered by politics as a mediator of changes, this pattern of experience will become an enhancer of nursing practice and research³.

FINAL THOUGHTS

In "the year of Nursing," it is a priority to highlight the role carried out by these professionals towards the achievement of health, well-being, and the achievement of sustainable development objectives. The development of this review allowed us to analyze the evidence available in the literature on the nursing profession's political participation. To synthesize the evidence that supports the contribution of Nursing to the public policy process to build new knowledge in this matter and, at the same time, promote future research processes.

In this context, it is understood that Nursing, as defenders of quality, safety, and access to care, have a direct link with the defense of people, their families, and communities with a unique professional, ethical sense. However, for them to take their place at the decision-making Table and become deeply involved in the formulation of government policies and health reforms, they must develop the necessary knowledge, skills, and attitudes regarding public policy. In this sense, the significant historical burden that Nursing, its comprehensive representation in the health workforce. The high social esteem it has, and its extensive knowledge of current socio-sanitary dynamics give it great capacities to support and provide greater solidity. Consistency in public health policies and respond more efficiently to future health needs of the population.

Nursing constitutes a social practice that can advance to compose forces capable of mobilizing broader social changes. Undoubtedly, as Nursing sets its professional course by taking advantage of these windows of opportunity, it will have a constructive influence on human health and health equity worldwide.