Original Manuscript

Nursing Ethics
2021, Vol. 28(5) 723–733
Nursing, advocacy ª The Author(s) 2020
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and public policy 10.1177/0969733020961823
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Shane Matthew Scott and P Anne Scott

National University of Ireland Galway, Ireland

Abstract
This article draws attention to the nature and importance of public policy. It argues that if nurses are to
influence the quality of healthcare effectively, they must be engaged with policymakers to get nursing care
issues on the policy agenda. There is an ethical imperative to do so, driven by the advocacy role of the nurse
and rooted in the values base of nursing. In addition, it is argued that if one takes the role of patient advocacy
seriously, as core to the nursing role, two things are required of nurses: We must (a) broaden the
conceptualisation of patient advocacy beyond the individual patient to the system of healthcare
resourcing and provision and (b) see systemic change as important as change at the bedside.

Keywords
Nursing, advocacy, public policy, agenda setting, resource allocation

Introduction
The importance and impact of public policy on public health has become increasingly obvious as the
COVID-19 crisis has evolved across the world, in terms of its impact on public health, the economy,
employment, social life and civil society. This seems an important insight that should be taken on board
by both practising nurses and nurse leaders and managers, as members of one of the largest healthcare
professions internationally. The World Health Organization (WHO) has emphasised the key role of nurses
and midwives in the development of health policy, in order to ensure high quality care for patients.1
However, the reality is that nurses’ participation in policy development is recognised as low compared
with other healthcare providers such as physicians.2
Given the power and impact of public policy on public health, and the key role which nurses play in
public health, combined with the relative dearth of nursing influence on policy development, it is timely to
engage in discussion regarding the nature of public policy. It is timely to consider such questions as, ‘Why
should nurses engage with public policy?’ ‘Is there an ethical imperative for nurses (or the nursing pro-
fession) to engage in public policy?’ ‘How can nurses engage effectively with and shape the development of
public policy, in particular health policy?’
At its most fundamental, public policy has been described as ‘anything a government chooses to do or not
to do’.3 But this does not tell the full story; there are opportunities for non-governmental forces, such as

Corresponding author: P Anne Scott, Vice President for Equality and Diversity, National University of Ireland Galway, University
Road, Galway, H91 TK33, Ireland.
Email: anne.scott@nuigalway.ie
724 Nursing Ethics 28(5)

pressure groups, to shape public policy. It is a political as well as a technical process, where actors articulate,
and act to achieve, objectives.4
The policy-making process can be articulated via the policy lifecycle, which is a cyclical process of four
interlinked phases (Figure 1):
With this framework in mind, we can see public policy as a set of decisions by governments, and other
political and public sector actors, to influence, change, or frame a problem or issue that has been recognised
as in the political realm by policymakers and/or the wider public.5
It is also noteworthy that judgements, decisions and choices in public policy, at each stage of the policy
lifecycle, have an important ethical dimension, because they presuppose that some things are more impor-
tant than others, that some actions will have a positive, and some a negative, impact on society.6 For
example, the decision of governments, during particular stages of the COVID-19 crisis, to prioritise the
protection of the health of the public over that of a country’s economy – as portrayed in decisions to ‘lock-
down’ and stay at home while closing all but the most essential services and retail outlets – was an ethical as
well as a political decision, with significant impacts on public health, social life and the economy. Public
health experts were at the heart of these government decision-making processes; groups inputting into
governments’ agendas, policy formulation and implementation processes are likely to have significantly
more influence on the policy outcome than groups that do not.
This is an important insight in terms of moving nursing care concerns onto the health policy agenda,
ultimately impacting our ability to perform our roles adequately, and assist nurses in maximising the quality
of care we can provide.

Why should nurses engage in public policy?

Nursing is a values-based profession committed to the provision of high-quality, humane, respectful patient
care. It operates from a framework that values all people in a holistic way and seeks to foster and advance
people’s health throughout their lifespans and across all levels of society.7
To achieve these objectives, it is essential that public health policies exist that define and integrate appropriate
standards for delivery of care and facilitate the creation of conditions necessary for that care to occur.8 Through
policy work, nurses can influence practice standards and impact resource allocation to support the delivery of
adequate healthcare at a societal level.9 The expertise in several core nursing skills such as communication,
clinical expertise and empathy, and the ability to manage conflict with a host of differing players, are skills which
are transferable to policy development and public advocacy. Registered nurses use these complex skills in their
everyday work. This suggests that nurses, as a professional group, are well equipped to be valuable potential
partners working with policy experts, analysts, elected officials and coalition partners in the political arena.10
If nurses are not involved in the policymaking process, proactively advocating for patients at a societal
level, in terms of resource allocation and appropriate standards of care at each stage of the policy lifecycle,
can they as a profession be confident that others will do this work effectively? There is evidence to suggest
that more than two-thirds of non-nursing patient advocacy groups are partially, some heavily, funded by
private industry, with opaque conflict of interest policies, raising concerns around independence.11 If nurses
are serious about fulfilling their commitment to high-quality, humane, respectful patient care, in a scope
wider than the individual nurse–patient relationship, it seems that they may need to take on more of this
advocacy work themselves. This commitment to high-quality, humane, respectful care is a commitment
rooted in the values base of nursing itself. It is an ethical commitment to our current and future patients. It
provides the ethical imperative to engage in public health policy influence and development in addition to
policy implementation. The ethical obligation of nurses to engage in public policy proactively has been
described as increasingly urgent,12 particularly as pressure mounts on healthcare systems to reform in
response to a variety of intersecting influences and chronic resource constraints.13
Scott and Scott 725

Figure 1. The policy lifecycle.

As an indication of how much progress needs to be made, results of a survey exploring health managers’
and authorities’ perceptions of the influence of various health professions on public health policy shows that
nurses are way down the ‘pecking order’ in terms of impact, by comparison to other professions.14,15 In fact,
some authors suggest ‘a nursing-wide under-appreciation for the importance of nurses’ role in policy
development’.16
Similarly, despite the ethical drivers for involvement in the policymaking process, nurses already active
in the policy space have observed that nursing advocacy at the policy level is essentially non-existent.12,13,17
A precondition to policy engagement is the recognition that nurses must shift their focus outward, from the
nurse–patient relationship to system-level thinking, an uncomfortable transition for many nurse caregivers,
which may partially explain the absence of nursing advocacy at the policy level.18–20
Factors such as heavy workloads, understaffing, powerlessness in institutional settings and lack of time
are likely to have contributed to the ‘pandemic’ of political/policy apathy among members of the nursing
profession.12,21 Nurses are steeped in risk aversion from their earliest socialisation into the profession;
acculturation to silence and conformity in the face of conflict or confrontation continues even today.13,22
This is at odds with what policy advocacy requires; advocacy entails taking a stand and putting oneself out
there. It is inherently politicised and usually engenders conflict.23,24
This ‘anti-policy’ professional socialisation may be rooted in nurses’ education. Nursing students’
discourse reflects a view of policy as a barrier, largely disconnected from their experience. It may be that
we are undermining the political actions and potential influence of nursing with the way we construct and
communicate policy issues in nursing discourse.25 If nurses are to really fulfil their mandate by advocating
for patients on a societal level, they should be helped to see policymaking as a vehicle for change rather than
something to be avoided or combated. Nurses are better prepared to act when they understand how and
where policy is formed.17,18 Public policy may therefore need to feature more prominently in nurses’
education.
726 Nursing Ethics 28(5)

Nurse advocacy: setting the policy agenda

Recognising the pervasive view, among individual nurses and nursing organisations, that patient advocacy
is a core part of the nursing role,26,27 why this reluctance or dearth of nursing input in the development of
public policy?
A qualitative examination of the career experiences and observations of a sample of 27 American nurses
active in US health policy was conducted to determine nurses’ views of public policy. The study showed
that nurses viewed their role in policy as speaking for patients in arenas where those in need of care had
limited voice. This highlights an understanding of nurses’ crucial role as patient advocate in the
policymaking process.28 However, while many nurses see patient advocacy as integral to good nursing
practice, they see policy as a strange and opaque phenomenon, far removed from the largely patient-centred
nature of nursing practice13,18 and/or they lack the training to become involved effectively in policy
development.14 This would seem to be an important issue to address.
Advocacy is a key part of any policymaking process. However, preconceptions about nurses’ advocacy
role has led nurse scholars to focus almost entirely on the individual nurse–patient relationship.13 A
reconceptualization of advocacy in nursing, which asserts that the object of advocacy stems from the
profession’s purpose and promise to society to engage in practice with the intent of improving health at
the individual, health system and societal levels, is crucial in broadening nursing’s advocacy role9 and
aligns with codes of nursing practice, such as that of the International Council of Nurses (ICN), the
expressed values base of nursing internationally.
Focusing nurse advocacy on the individual has had the effect of limiting nurses’ assessment of the root
causes of injustices and poor patient outcomes, driving us to focus on discrete solutions to the individually
experienced effects of systemic issues.13 Without examining these issues through a public policy lens,
nurses risk missing the bigger picture, where advocacy for more structural and long-term change can occur.
Practising nurses as expert clinicians and as patient advocates have a duty to engage with public policy
development and implementation, particularly those related to resource allocation including access to the
resources of nursing care and nursing time. If one does not understand the mechanisms and structures that
provide and allocate resources, we run the risk of being drowned out by other, more organised bodies that
do. This suggests that both under-graduate and post-graduate nurse education programmes should help
equip nurses to engage with and learn how to influence the development of public policy, particularly those
that drive resource allocation decisions across all levels and elements of the health system.
Shifting nurses advocacy work from almost entirely patient-centred to a more balanced view of advo-
cacy, which accounts for the role nurses can have on the policymaking process, can help nurses impact the
government’s agenda-setting (see Figure 1). It will also make nurses more effective patient advocates.
As an example of the importance of agenda-setting in public policy, it is clear that the emergence of
health issues onto policy agendas is not closely linked with criteria that many observers would call rational
or equitable. Diseases of the affluent are more likely to appear on health agendas than those of the poor. The
health problems of wealthy countries attract more research funding than those of less-developed nations.
Generally, hospitals and other tertiary care facilities that serve curative functions, often directed towards
members of wealthier socioeconomic classes, command larger percentages of national health budgets than
do local-level primary healthcare facilities that might address the health problems of the poor, and the basic
health education and health promotion requirements for society at large.29
We understand why such imbalances exist; the distribution of power within and across societies heavily
shape which issues get on the agenda, including which health conditions are identified as problems, which
health problems receive attention, and which health causes receive public and private resources.29
This is a key issue for the nursing profession. Staying neutral does not guarantee, or even imply, neutral
outcomes. Policymaking does not occur in a vacuum, where the government controls all of the levers of power,
Scott and Scott 727

is in total control of its agenda, and allocates resources most efficiently and virtuously as a matter of course.
Without an advocate for nurse-specific objectives in the policymaking process, these objectives are likely to be
crowded out by more vocal interest groups, ranging from the pharmaceutical industry to doctors’ unions.
Nurses need to think about the agenda-setting aspects of public policy in particular, if they are to have a
more direct role in fulfilling their objectives, such as the provision of holistic, humane, respectful, clinically
effective patient care. If nurses believe that nursing is important for good patient care, and if nurses accept
professional autonomy, then advocating and lobbying for such care, at a public policy level, is an important
element of the nursing role – as important an aspect of the role as is educating the next generation of nurses
and growing and applying the evidence base to support good nursing practice. Without influencing the
policymaking process, and impacting on agenda-setting in particular, nurses can find themselves making
seemingly illogical decisions with regard to patient care and resource allocation in order to comply with
rules and expectations made without nurses’ objectives and priorities in mind.30
In summary, practising nurses as expert clinicians, as members of an autonomous profession and as
patient advocates have a duty to engage with public policy. There is an ethical imperative to do so, which is
rooted in the values base of nursing. This suggests that both under-graduate and post-graduate nurse
education programmes should help equip nurses to engage with, and learn how to influence the develop-
ment of, public policy. Waddell, Adams and Fawcett31 point out that (a) clear communication, (b) knowl-
edge of how policy is made and (c) passion for policy are strong determinants for nurses’ engagement in
policy development and advocacy.

How can nurses engage with the policymaking process?

How then do we facilitate such engagement with and influence on policy making? Focusing on topical
phenomena such as a nursing care left undone/missed nursing care may provide a useful working example to
examine how nurses can engage with the policymaking process. Recognition of the phenomena of missed
care/care left undone/covert rationing of care (hence forth called ‘care left undone’) can be traced from
initial work in 200132–34 through state-of-the-art reviews35 to more recent work.36–38
Care left undone is often a direct consequence of demand out stripping supply – the needs for care exceed
the ability of the available nursing resource to provide the quantity of care required.35
The drive to examine these phenomena is currently rooted in the patient safety and quality of care
literature.32,34,35 More recent work has begun to show an interest in the ethical concerns linked with, and
emerging from, an increasing realisation of the existence of care left undone.36,39,40 Some of this literature
draws attention, for example, to the reality that care left undone is undermining patients’ rights to health-
care,38 and impacting negatively on patient and nurse outcomes.41,42 Nurses as patient advocates should be
actively and visibly drawing attention to the impacts of care left undone on patient (and nurse) outcomes.
In considering the issue of care left undone, there are at least three key actors involved: The patient(s)
who is receiving less than the required care or delayed care, the nurse(s) involved in missing/delaying/
rationing their care, and the manager allocating and/or charged with managing the nursing resource –
locally, institutionally or nationally. Whether they are aware of it or not, the latter two individuals/groups
are making ethical decisions, in addition to clinical and resourcing decisions. Thus, each of these three
actors may be described as ‘interested parties’; key stakeholders in the discussion on missed care/care left
undone/rationed nursing care. However, these three ‘actors’ are not the only relevant stakeholders in this
discussion. Members of the general public may also be described as ‘interested parties’ – as tax-payers
funding our health services, as potential future recipients of nursing care, and/or as relatives and family
carers of such recipients. As indicated above, it is becoming increasingly clear that nursing care left undone
is negatively correlated with positive patient outcomes41,42 – therefore we all have some interest in this
discussion; as funders and/or recipients of care/victims of lack of required care.
728 Nursing Ethics 28(5)

Because the general public has a stake in the discussion, it can be argued that, from an ethics per-
spective, this discussion is not only one about the rights of patients, duties and rights of nurses, and the
allocation of scarce resources, it is also a discussion that should focus on questions of public interest and
public welfare. If an issue raises questions of public interest or public welfare, there may be a requirement
to have a public policy answer to the issue. How then do we get from a focus at the bedside and on the
individual nurse and patient to a realisation of the need for a policy response to issues of nursing care left
undone?
A brief review of high-profile health service scandals over the past 10 years in the United Kingdom and
Ireland8,43–47 may help us begin to map the route from issues at the bedside to the need for a system-level
approach rooted in policy development, implementation and evaluation. One after another, these reports
draw attention to poor care, inadequate care and negligence – to what is in fact being described in the
nursing literature as care left undone.
The consistent message emerging from these investigations is that it is not only individual practitioners
who are to blame for providing at best insensitive, disengaged ‘care’ and at worst causing distress, danger
and even death to very vulnerable people. There is a clear message that the causes of poor care are often
structural in nature.48
The leadership, culture, structures and financial imperatives within which practitioners and resource
allocators work may be the primary candidates for blame. We are referring not only to leadership and
management in specific hospitals and centres of care, but also to government departments, arms-length
bodies and other organisations directly or indirectly responsible for resource allocation.
This is a message we as nurse academics, leaders, stakeholders and potential patients must engage with.
If we do not understand the mechanisms and structures that provide and allocate resources, we run the risk of
being drowned out by other, more organised bodies and professions that do, impacting our ability to
adequately perform our roles, never mind maximising the quality of care we can provide. In the words
of the report into peri-natal deaths in Portlaoise Hospital in Ireland,

In order to fairly hold people to account, we must ensure that they have the tools, capabilities, authority and
supports they need to be accountable. It is simply not good enough for the system to place people into such
difficult and challenging roles without also putting in place the sustained supports they require to carry out their
responsibilities. (p. 53)8

A common response to major health service scandals involving nursing is for the government or
regulatory bodies to try to exercise further control on the profession, professional activities and the values
base of the profession (so-called intentional ‘rounding’ in United Kingdom is an example of this type of
reaction,49 as is the work of the Nursing and Midwifery Board of Ireland (NMBI) in Ireland in reinforcing
and seeking recommitment to nursing values)50 to improve nursing care, rather than to provide additional
resources. The idea that nurse registration and regulatory bodies, nurse educators, chief nurses and depart-
ments of health articulate, educate for and require the commitment of registered nurses to a set of ethical
principles and core moral values50 seems reasonable, other things being equal. However, the matter of
‘other things being equal’ is both important to the reasonableness of the required allegiance to the stated
core values and principles by the individual nurse and cannot be taken for granted in reality.
Fair treatment of nursing staff in these contexts requires that the structures, ethos, culture and resource
context within which they work support nurses’ efforts in providing compassionate, committed patient care.
If it does not, we are placing supererogatory demands on nursing staff. Demands which on occasion not only
abuse the good nature, and sense of compassion, commitment and care of these nurses, but which blatantly
and unjustly isolate, marginalise, scape-goat and blame them for the provision of inadequate care, in an
Scott and Scott 729

environment in which it is almost impossible to do otherwise – because of lack of support and insufficient
resources.
In Ireland, the Chief Nursing Officer and the DoH, stimulated by significant unrest among the nursing
profession and critical difficulties in recruiting and retaining nursing staff in the Irish Health Service
following the financial crash of 2008 and implementation of vicious austerity measures, moved to tackle
these issues at a policy level through the establishment of a taskforce on nurse staffing and skills mix. This
ultimately led to the development and implementation of the Framework for Safe Nurse Staffing and
Skills Mix.51 The Task Force includes representation from health service planners, clinical nurse man-
agers, nursing unions and researchers with expertise in nurse workforce planning. The Framework for
safe staffing works from a multi-factorial analysis to determine the required nurse staffing levels on acute
medical and surgical units in acute adult hospitals in Ireland. Pilot studies have shown significant positive
impact of framework implementation on both patient and nurse outcomes.52 This framework is now being
extended to and refined for use in A&E departments. Only with this kind of considered approach can it be
assumed that the demands placed on individual nurses, via codes of conduct, regulatory bodies, health
systems and employers, do not visit significant injustice or unfairness upon those individual practitioners
(Figure 2).
In order to address the causes of care left undone, via public policy, it needs to be on the government’s
agenda. For this to happen, collective work at the level of the profession, in the form of pressure groups or
unions, for example, is important. This collective work develops the case for policy intervention by stating
and refining an understanding of the issues at hand; collecting, building and evaluating the evidence; and
developing a set of proposed recommendations on the basis of the evidence.53
In other words, it is up to nurses, as patient advocates, to set out why extra nursing resources to maintain
or improve patient outcomes should be prioritised alongside, or instead of, a government’s need to invest in
medical research, educational reform or the development of a green industrial policy. The expertise to
develop and communicate such a case is based both in the day-to-day experience of practising nurses and in
the growing evidence base regarding the impact on patient outcomes of nursing care left undone.
While research is one tool available to guide policymakers it rarely drives decisions to support or not
support specific policies on its own. Policymakers frequently look to interest groups advocating for policy
change to shape their decisions18 – again emphasising the need for nurses to look outwards, engage in
systems-level thinking and organise into effective pressure groups. There is scope for nurses to become
more involved in the policymaking process, but this must be driven by the profession itself.
How to go about this? Understanding the sources of health policy helps to inform nurses and facilitate
their involvement and political competence through (a) identification of the numerous formal and informal
stakeholders in the health policy arena, (b) depiction of the many routes through which health policy
develops, (c) recognition of the different places where policy happens (organisations; health systems; local,
national or international level) and (d) identification of the points of access for policy influence. Under-
standing that many sources of health policy are open to influence encourages nurses’ engagement in health
policy development.18 Recognising the duty to engage with health policy and policy development, as part of
the advocacy role of the nurse, rooted in the values of nursing as a profession, provides the permission and
the motivation to do so.
Deep technical knowledge is not necessarily the most important factor when attempting to influence
policy. There is substantial evidence that the knowledge brought to bear on policy is of secondary impor-
tance to the establishment of relationships with policymakers13; it may be more about who you know than
what you know.
However, establishing these important relationships is easier said than done. In recent years, public
policymaking, including public health, has become more complex involving a wider, less predictable range
of interest groups including civil society organisations. National governments are also increasingly subject
730 Nursing Ethics 28(5)

Agenda

Policy Development:
Agreement over how a policy will be evaluated develop a policy approach internally, including via a government's

The Framework for Safe Staffing and Skills Mix in General and Specialist
being implemented across the acute hospital medical and surgical care
research. A further phase of the Framework is under development and
certain criteria. This can involve a cost-benefit analysis, for example.
Task Force on Nurse Staffing and Skills Mix established (2014). The
Framework for Safe Staffing and Skills Mix in General and Specialist

throughout the Irish acute adult hospital system. developed.

Once agreed the policy is implemented by turning

requirements which will apply to relevant bodies, ranging from

The Framework for Safe Staffing and Skills Mix in General and Specialist

implemented in 6 pilot wards across three hospitals selected for

of the Task Force was published in April 2018.

Figure 2. A worked example of nursing care left undone is used to show the policy-making lifecycle in action.

to external and trans-national pressure not just from trans-national corporations but also from emerging
global civil society.54
Having an impact on systems-level public policy will almost always demand greater numbers of, and
organisation by, nurses than impacting local organisational policy. Working with colleagues or professional
organisations will extend an individual nurse’s potential impact. Any nursing strategy for policy change
requires that the nurse knows how that policy came into existence, what body or bodies perpetuate it, and
where the opportunity for policy change rests.18 To have a public policy impact nurses must organise;
otherwise, their influence will invariably stray towards a bias for these more local contexts.
Once these relationships are established, nurses need to be able to advocate for their proposed policy
effectively, in order to first get the issue on the agenda and then their policy proposals implemented. Nurses
can then participate in these policy activities and so more effectively compete for resources or cooperate
with other interest groups throughout the policymaking process. If nurses are to really advocate for patients,
if they are to be a real voice for the importance of safe, humane, competent care and good patient
experience, then engagement on agenda-setting, policy development, implementation and evaluation can
be seen as a professional and moral duty.

Conclusion
Health systems are rapidly developing and changing. Nurses, as a part of these systems, should move
forward to engage with and influence these changes. For this purpose, nurses need to influence the for-
mulation of health policies rather than simply implement them. This requires nurses to be active in the
development of health policies in order to be better able to control their practice.15 If nurses are not
involved, there is a crucial stakeholder missing in the public health policymaking process, given nurses’
unique role in healthcare provision and resource allocation.
More than ever, nurses are present in every healthcare setting and can possess a unique role in formulat-
ing policy. The WHO1 called for nurses internationally to take a leadership role in sustaining and increasing
Scott and Scott 731

the quality of patient care. If nurses are interested in reaping the rewards of influencing patient care at a
strategic level, rather than continuing to struggle at the bedside, there is a requirement to become patient
advocates beyond the bedside. There is a clear requirement to engage in both lobbying and policy devel-
opment at regional and national as well as local levels. The ethical imperative to do so is driven by the
advocacy role of the nurse and rooted in the values base of the nursing profession.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD
P Anne Scott https://orcid.org/0000-0002-5790-8066

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