Nurses’ Political Participation: Going Back to Our Roots

Background

The relationship between nursing and politics goes back to the very roots of the discipline. From Florence Nightingale, who positioned nursing as an agent of change through her extensive collection of statistical data (Robertson & Baldwin, 2007), to Lillian Wald—a pioneer in public health nursing in 1893—whose work framed health as inseparable from social justice, providing care for entire communities regardless of individuals’ health status (Buhler-Wilkerson, 1993). Take Nancy Milio, for instance, who looked at the potentially harmful health impacts of policies across sectors, mobilized for political change, particularly at the local level (May et al., 2003). In fact, Milio was the first scholar to conceptualize the term “healthy public policy” (Milio, 1981; Reutter & Duncan, 2002), which later became one of the main action areas of the Ottawa Charter for Health Promotion (May et al., 2003; World Health Organization, 1986). Lavinia Lloyd Dock also deserves recognition for linking the fight for women's rights with nurses’ professional autonomy. As both suffragist and historian, she organized demonstrations and authored History of Nursing to advance the political visibility of the profession (Garofalo & Fee, 2015). Another pivotal figure for her major contribution to the inherent feminism in our discipline was Margaret Sanger. She transformed her work as a public health nurse into a political campaign for reproductive rights and her activism led to the establishment of Planned Parenthood and sparked ongoing debates about women's bodily autonomy and state regulation (Katzive, 2015). Finally, Mary Eliza Mahoney, stands out as the first professionally trained African American nurse. Through her leadership in the National Association of Colored Graduate Nurses, she promoted racial equality and gender justice, fostering inclusivity within nursing organizations (Baptiste et al., 2021).

Although nursing has a proud history of political pioneers, there's still a significant gap between the active engagement of earlier generations and the involvement we see today (Benton et al., 2017). Despite the discipline's inherently political origins, nurses’ participation in policymaking is still far from what it could be (Benton et al., 2017; Han et al., 2025a; Rasheed et al., 2020). Some authors have even described nursing's political apathy as a kind of ‘pandemic’, rooted in the widespread belief that politics lies entirely beyond the discipline's reach (Taylor, 2016). And it might be, considering that the global nursing workforce has grown from approximately 27.9 million in 2018 to 29.8 million in 2023, making nurses the largest professional group within health systems worldwide (World Health Organization, 2025). Voting in elections seems to be the extent of political involvement for most nurses (Wilson et al., 2022), and nurses’ political participation is primarily characterized by their role as implementers, adopting a passive role in the development of health and nursing-related policies (Rasheed et al., 2020).

To situate this article, a focused and non-exhaustive search of the nursing literature was conducted using the terms (“policy process” OR “policy making process” OR “policymaking process” OR “policy-making process” OR “political process” OR “process of policy”) combined with “nursing” and (participation OR influence OR development) limited to titles and abstracts. This search yielded 1,190 records in PubMed and 1,408 in CINAHL. The majority of these publications address health policy, describe barriers and facilitators to nurses’ political participation, or emphasize the value of nurses’ involvement in policymaking. However, despite the volume of literature, there remains a conceptual gap regarding how nurses’ political participation is theoretically grounded within broader policy process frameworks. To explore this gap, key contributions from political science and public policy scholarship were examined alongside the nursing literature. These perspectives informed the organization of this article into three sections: (1) the need for nurses’ political participation and its practice context; (2) understanding policy, politics, and the policy process; and (3) developing nurses’ political competence and influence. The article concludes with recommendations for clinical practice, education, and research.

The Need for Nurses’ Political Participation and Its Context of Practice

Nursing involvement in politics matters for two main reasons. First, nurses need representation in decision-making spaces that shape their discipline and foster excellence across academic, managerial, clinical, and research settings (Wilson et al., 2022). Second, as the profession most attuned to the health impacts of policy and in close contact with communities and people alike, nurses should actively contribute to ensuring that health is prioritized in all sectoral public policies (Iriarte-Roteta et al., 2020). This final nuance is crucial, since discussion on nurses’ political participation is often associated with health policies—mainly within the healthcare system.

Wilson et al. (2022) found that nurses’ political involvement can yield benefits at multiple levels. Individually, it builds political capacity, confidence, and a sense of accomplishment, while inspiring and educating peers and students. Professionally, it enhances the visibility and influence of nursing as a discipline. At the macro level, it helps shape policy outcomes, ensuring that legislation and healthcare decisions reflect nursing expertise and promote a fairer, more effective healthcare system.

Evidence also suggests that nurses’ participation in political decision-making is associated with reduced morbidity and mortality, decreased disability, and improved quality of life across the lifespan (While, 2014). Such involvement can also reduce costs in the healthcare system by minimizing medical treatments, hospitalizations, and dependency-related social services (While, 2014). Moreover, nurses can contribute to raise cross-sector awareness of how policies influence social determinants of health—an ongoing challenge, as this framework remains difficult to grasp in the political sphere (Hernantes et al., 2022).

However, despite research highlights the potential benefits of nurses’ political participation, few tangible outcomes can be clearly linked to it (Wilson et al., 2022). The lengthy timelines of policy creation and the many actors and steps involved make it difficult to attribute specific changes directly to nursing engagement. A professional culture that discourages self-promotion further obscures nurses’ contributions. As a result, their impact on policymaking is often indirect and long-term, reflected in outcomes such as the preservation of essential healthcare services (Wilson et al., 2022). Consequently, assessing the impact of nurses’ political participation continues to be a pending challenge.

And yet, the political role of nurses is theoretically grounded in ethical practice, the profession's social contract with the public, core professional values, and social justice (Chircop, 2011). Alberdi-Castell (2019) went further, suggesting that nurses’ lack of political participation may amount to moral negligence, as failing to develop political competence may limit the profession's ability to address both disciplinary needs and public health challenges. However, we cannot call for increased political participation from nurses without taking into account the historical and contextual forces that have shaped nursing.

Over the years, scholars have pointed to a range of barriers that have kept nurses on the sidelines of political life. These obstacles have not only slowed the profession's political growth but also narrowed their access to the political arena (Benton et al., 2017).

One major barrier lies in the profession's history as a predominantly female field, shaped by the same social constraints and organizational norms that have long limited women's political presence and economic advancement (Deschaine & Schaffer, 2003; Groenwald & Eldridge, 2020; Han & Kim, 2024; Montalvo, 2015). These limitations have, in turn, diminished nurses’ political influence and power (Wilson et al., 2022).

Another barrier stems from nursing's place within a healthcare system long dominated by paternalism and medical profession-driven hierarchy (Groenwald & Eldridge, 2020; Montalvo, 2015). In this context, nurses often struggle to reconcile professional values with political action. The profession's identity—rooted in service, competence, and trust—contrast sharply with politics, often associated with protest, power struggles, and conflict (Des Jardin, 2001).

Some internal critique is also needed. Evidence suggests that when certain nurse leaders entered the political sphere, they tended to “eat their young”, displaying unsupportive or exclusionary behaviors toward junior nurses (Rasheed et al., 2020). Rather than providing mentorship or encouraging participation, some nurses in leadership positions relied on hierarchical dynamics, refusing to mentor or deliberately ignoring their subordinates as a means of asserting dominance. Such leaders may also be reactive, rather than proactive, in shaping policy processes and motivating junior colleagues to engage in these initiatives (Rasheed et al., 2020).

Political education in undergraduate nursing curricula is minimal or non-existent, with most content focused on hospital-based care (Ellenbecker et al., 2017). This lack of exposure makes it harder for future nurses to view politics as a field of action, navigate political discourse, and engage effectively (Han et al., 2025b; Whitehead, 2003). Although political education improves at the postgraduate level (Spenceley et al., 2006), undergraduate curricula still falls short in preparing students for political engagement early in their careers (Ellenbecker et al., 2017). Nursing research has likewise focused on nurse-patient relationships and the profession itself, leaving political processes largely unexplored (Benton et al., 2017; Wilson et al., 2020).

Understanding Policy, Politics, and the Policy Process

In the political sphere, three key terms deserve consideration: politics, policy, and policies. Politics refers to the activities of those who govern or seek to govern public affairs, including the competition between parties and ideologies as described in political science (Smith & Katikireddi, 2013). Policy, on the other hand, refers to the actions of individuals, professionals, or groups to intervene in public affairs and policies through opinion, voting, or other means of participation (Kingdon, 1995). Finally, policy or policies provide a framework that guides action to address issues affecting societies, communities, and institutions. A policy represents a decision on how resources are allocated and reflects the commitment of those who put it into practice (Milio, 2001).

Clarifying these terms is crucial for understanding nurses’ potential political participation. Han and Kim (2024) define political participation as a range of activities aimed at shaping or influencing government decision-making and policies—through campaigning lobbying legislators or signing and organizing petitions. At first, all this may sound like something “big”, yet much depends on how the term politics is understood. It can be seen narrowly—as the domain of politicians and decision-makers—or more broadly, as a sphere of action within primary care, where nurses advocate for patients’ rights to health, mobilize communities to improve living conditions, and help create environments that promote health.

Political participation can take many forms—from decision-making roles such as local councilor or ministry positions to engagement through clinical practice, education, or research. Nurses advocate directly alongside patients and communities, prepare future nursing graduates as activists, and/or evaluate outcomes to raise awareness of nurses’ involvement. These roles mirror the intervention strategies proposed in the Ottawa Charter of Health Promotion (World Health Organization, 1986): mediating among patients, communities, and healthcare professionals; enabling individuals by empowering patients or supporting policymakers in health-related issues; and advocating for health through activism and evidence-based proposals. The ultimate aim is to influence political processes that affect both population and societies’ health, as well as the discipline itself. But how abstract does the political process seem to nurses? Very much so. And in fact, it truly is.

The political process can be conceptualized as a complex cycle with distinct stages (Howlett et al., 2015) each offering opportunities for nursing engagement:

The first is agenda-setting, the crucial stage where certain problems or issues gain the government's active attention as potential public policy matters (Ramírez Brouchoud, 2007). At this point, nurses can help identify and define the issues that deserve policymakers’ attention. In the next stage, entitled consideration of policy options—where decision-makers may propose solutions to address a problem—nurses can assess and recommend solutions, highlighting their practical real-world implications and feasibility. The third stage—policy decision—marks the moment when governments commit to a specific course of action. Here, nurses can become catalysts for consensus, bridging sectors, or mobilizing support, and their voices can influence the direction of the decision-making process. The fourth stage—policy implementation—focuses on how governments put these policies into action. In this phase, nurses can collaborate by raising awareness among those affected by these policies and contribute to facilitating or analysing the implementation process. The final stage—policy evaluation—involves assessing a policy's effectiveness and impact. In this phase, nurses can provide evidence-based data and give voice to the individuals, communities, and professionals affected by these measures, shedding light on their on-the-ground consequences. Each nurse should reflect on how their role allows them to take part in these phases, and approach thit reflection with creativity

Some examples illustrate how nurses can influence policy in practice. One nurse led an intervention to strengthen a municipal government's capacity to advance Health in All Policies approach. She gained access to the local government by sending an email through the citizen's mailbox. Then she brought together workers from different sectors to increase understanding of health determinants and raise awareness of how local policies affect them—ultimately strengthening the group's capacity to promote health. Her role as a health broker proved central to the initiative (Hernantes et al., 2022).

Nurses have also participated in parliamentary or advisory forums that provide scientific and technical input, fostering spaces of convergence between scientific knowledge and public policy, and promoting dialogue among policymakers, experts, and the broader society (Santillán-García et al., 2021). In this context, they can act as political knowledge brokers (Santillan-Garcia et al., 2020).

Another example comes from the United Kingdom. In December 2022, the Royal College of Nursing (RCN) organized its first strike in 106 years, calling for fair pay and safer patient conditions. Around 100,000 nurses joined 12-hour strikes across England, Wales, and Northern Ireland, in response to real-terms pay cuts, rising workloads, and safety concerns. The RCN rejected the government's offer as insufficient to address the NHS crisis (Royal College of Nursing, 2022). This example illustrates how collective mobilization can act as a form of political participation.

In terms of individual leadership, Dame Yvonne Moores stands out as the only person to have served as Chief Nursing Officer for Wales, Scotland, and England. Her policy influence was substantial: she advised the Prime Minister and Secretary of State for Health, helped establish the NHS Quality Framework, clinical governance, National Institute for Health and Care Excellence (NICE), and the Care Quality Commission, and championed nurse prescribing and NHS Direct.

Additional examples can be seen in Zalon et al. (2024), who also outline levels of political participation and provide examples of concrete actions that can be taken at each level. These range from joining a civic, community, or workplace committee or contributing time and expertise to issues of importance within an organization or political cause, to running for and serving in elected or appointed positions within organizations or government (for example, township commissioner, coroner, or member of a water sanitation board).

Developing Nurses’ Political Competence and Influence

Whether at local, national, or international level, nurses must be able to exert political influence, which represents the highest level of involvement in the political arena. Political influence has been defined as the ability to shape decisions and agendas by utilizing political competence (Arabi et al., 2014). Yet it is precisely within political competence that nursing faces one of its greatest challenges.

This competency combines policy knowledge with advocacy skills and to exercise it effectively, nurses must cultivate the expertise, strategies, and abilities needed to influence policies (Han & Kim, 2024). Key aspects include analyzing policies, understanding legislative processes, and actively engaging in advocacy initiatives (Han et al., 2025a). Some authors also link political competence to nurses’ ability to intervene in the drafting, development, and management of public policies (Alberdi-Castell, 2019). However, before reaching this level of intervention, it is crucial to consider other components identified in the evidence—elements that enable nurses to fully realize this competence.

Among these elements, political literacy is a requirement for understanding how policies impact patients, communities, populations, and nursing practice itself. It represents an essential first step towards engaging with policies (Arabi et al., 2014; Keepnews, 2017). Equally important is political astuteness—the ability to read, interpret, and analyze policies within the political process and to understand how they are created across governmental levels. It also involves recognizing the importance of political agendas and power networks in this field (Arabi et al., 2014; Persaud, 2018). Another component is political advocacy, defined as advocating or arguing for a cause, idea, or policy to advance the capacity of communities, systems, individuals, or families to act in their own interest (Persaud, 2018). Advocacy is closely linked to nursing leadership and political activism, which entails taking an active role in creating, influencing, and advocating for policies, to improve health outcomes (Jaurigue & Schmidt, 2020). Beyond improving population health, advocacy and activism also encourage nurses to engage more deeply in the political process and its inherently negotiable nature (McFarland & MacDonald, 2019; Reutter & Duncan, 2002).

Recently, Han et al. (2025b) summarized existing knowledge on political competence and proposed a framework—that synthetizes the most repeated terms—in four dimensions. The first, political knowledge, includes both general political knowledge and political astuteness. The second, political efficacy, reflects an individual's sense of political effectiveness and level of interest. The third, political interaction, refers to skills and characteristics such as networking, negotiation, and persuasion. Finally, political activity involves various forms of engagement, including political participation, involvement, engagement, and advocacy. The same authors have recently developed a scale to assess political competence (Han et al., 2025a).

Final Recommendations

As a profession, we are becoming increasingly active in political life, and it is essential to remember that such involvement has been part of our origins. We must build on the social advancements and developments of our time—feminism, the Sustainable Development Goals, the planetary health movement, the establishment of advanced nursing roles, and the creation of more equitable collaborations. Together, these issues offer a powerful opportunity to expand our political participation.

Considering all the above, several recommendations can be proposed to advance nurses’ political participation:

Within clinical and professional practice, engagement with nursing organizations should not be understood solely as individual participation but also as a structural condition for collective influence. While professional associations can provide important platforms for advocacy and collaboration, their capacity to effect change varies considerably across healthcare systems and political contexts. For this reason, efforts to strengthen nurses’ political participation in practice should combine organizational involvement with strategies that address power imbalances within healthcare institutions. Encouraging early-career nurses to assume leadership and political roles requires not only motivation or values alignment but also institutional support, protected time, and recognition of political work as legitimate professional activity. In this sense, emerging nurses, partly as a result of generational change, may contribute to challenging entrenched medical paternalism; however, expecting them to do so without addressing existing hierarchical constraints risks placing responsibility on individuals rather than on systems, thereby making collective action strictly necessary.

In education, recognizing the political nature of nursing should not be framed as a uniform expectation of political activism, but rather as an invitation to critically engage with the social and institutional conditions that shape professional practice. While nursing curricula can benefit from integrating contemporary theoretical developments on political competence, such integration must consider existing curricular constraints, faculty preparedness, and variability across educational systems. Active and experiential learning methodologies—such as policy analysis exercises, simulations, or engagement with real-world decision-making processes—may facilitate the development of political competence, provided they are meaningfully embedded within broader pedagogical strategies rather than treated as isolated components. Recently developed assessment tools offer promising ways to evaluate political competence; however, their use requires careful contextual adaptation to avoid reductive or purely instrumental interpretations. At the postgraduate level, deeper engagement with policy processes and evaluation may help consolidate political competence, particularly when linked to students’ own research and professional trajectories.

In research, advancing the study of political competence requires balancing conceptual refinement with attentiveness to context, practice, and power relations. Further clarification of the concept remains necessary, but it should be accompanied by reflexive consideration of how research questions, methodologies, and dissemination practices are themselves politically situated. Documenting and disseminating empirical examples of nurses’ political engagement can contribute to making such practices more visible and legitimate; however, these accounts should move beyond celebratory narratives to critically examine the conditions that enable or constrain participation. Assessing the impact of nurses’ political involvement—whether in economic terms, policy change, or health and social outcomes—poses significant methodological challenges, including issues of attribution and time lag. Addressing these challenges will require diverse and complementary approaches, such as prospective designs, comparative and case studies.

Finally, we must remain conscious of—and reclaim—the full power of our discipline. It is time for nurses to stop waiting for permission to enter decision-making spaces or allowing others to define who we are. Instead, we must take the initiative to open these doors ourselves, create new paths of influence, and proving that our place within these arenas is both rightful and essential.