IntroductionActive involvement of nurse leaders in policy advancement is considered crucial, particularly in Africa, where nurses constitute most of the health workforce. This review was conducted to determine factors that influence African nurse leaders' participation in policy development.MethodThe databases CINAHL and MEDLINE were searched to answer the review question. The search parameters were adjusted to include studies in English and between 2012 and 2025. The review partially followed the JBI methodology for evidence synthesis. Two reviewers conducted data extraction and independently assessed all included studies. The PRISMA guideline guided study selection reporting. Results were thematically analysed.ResultsSeven studies were identified. The review reveals a spectrum of challenges and opportunities impacting nurse leaders' involvement in policy development. The main theme that emerged from the included studies was enablers and constraints in health policy development, with four subthemes. Namely: enablers of nurse leaders' engagement, perceived value, knowledge and gendered influences, limited and peripheral participation, structural, organisational and individual barriers.ConclusionPersonal, structural and institutional factors were enablers and bottlenecks that limit involvement of African nurse leaders in health policy. Implementing strategies such as leadership support, education, professional recognition, organisational empowerment, and governmental support could elevate the role of nurse leaders in policy development, contributing to a more robust and inclusive healthcare policymaking landscape in Africa. Additional case studies and longitudinal research are needed to examine the factors influencing nurse leaders' involvement in policy development across different African contexts.
Forty-one states in the United States that adopted Medicaid expansion through the Affordable Care Act reached historically low rates of uninsured that have endured through 2025. The One Big Beautiful Bill Act (OBBBA) signed into law on 4 July 2025 contains numerous provisions that place Medicaid expansion coverage at risk. Resulting changes to Medicaid expansion include work requirements, a decrease in federal match funds for expansion programs, cost-sharing fees for recipients, stricter eligibility requirements, more frequent re-enrollment periods, and limitations on family planning services provided by organizations that also provide abortion services. Because each state with Medicaid expansion has implemented this program differently, states will be impacted differently and with various timelines. The impact of OBBBA on Medicaid expansion in the state of New Hampshire is discussed in detail and examined from the perspective of a community mental health center. Nursing implications are discussed within the framework of Fawcett and Russell's conceptual model of nursing and health policy. Recommendations for advocacy and the nurse's role as an important stakeholder are discussed.
Background: U.S. state licensing restrictions requiring written practice agreements for certified nurse-midwives (CNMs) lack evidence of improved patient safety and instead contribute to maternity care workforce shortages. The objective of this study was to examine restrictive state licensing and practice policies for CNMs to identify the problem they were intended to solve. Methods: This was a qualitative content analysis of state policies that require CNMs to obtain written practice agreements, collected in January 2022, using the "What's the Problem Represented to be" framework. Analysis was completed by two midwife researchers with interpretation assistance from a panel of expert midwives. Results: Variation in written practice agreement requirements across states demonstrated that the regulations echoed historical physician complaints about the "midwife problem" first articulated in 1912. Effects of this problemization are inaccurate workforce data and persistent maternity care shortages. The problemization is maintained by the physician organization's advocacy against midwifery autonomy. The COVID-19 pandemic policy modifications demonstrated that states could eliminate restrictions when prioritizing access without compromising safety. Conclusions: Restrictive CNM licensing regulations perpetuate professional gatekeeping rather than ensuring public safety, directly contributing to maternity care shortages. State legislatures should eliminate written practice agreement requirements for CNMs and adopt evidence-based criteria focused on practitioner qualifications rather than supervisory relationships. National nursing organizations should advocate for regulatory reform, prioritizing healthcare access. Removing these barriers can expand the maternity care workforce and improve access to reproductive healthcare, particularly in underserved communities.
Nurses are central to palliative care, yet their community contributions remain undervalued. This study aimed to clarify how political and professional documents conceptualize nursing autonomy in community palliative care. Using the READ (Reading materials, Extracting data, Analyzing data, Distilling findings) methodology, a comparative documentary analysis was conducted in the Netherlands, Portugal, Spain, and the United Kingdom. Sixty-eight strategic documents, identified through systematic searches and expert consultation, underwent targeted qualitative content analysis, combining deductive coding with inductive theme generation. Results reveal a multilevel framework of professional representation: (1) micro-level interventions; (2) meso-level contextual determinants; and (3) macro-level systemic dimensions. A critical tension exists between technical visibility and formal authority. In Portugal and Spain, robust taxonomic infrastructures provide high clinical visibility, yet legal frameworks prioritize "system breadth" over specialized nursing roles. The UK and the Netherlands emphasize "vertical career trajectories," where specialty recognition and advanced education act as levers for clinical agency and nurse-led care. While all country policies prioritize home-based care, differences in how they improve autonomy may influence workforce sustainability and professional migration. These findings suggest that failing to formalize-specialized roles creates "gray zones" of responsibility. Strengthening the structural conditions that support nursing autonomy, including clear role recognition and aligned policy mechanisms, is essential for ensuring timely access to care and the long-term viability of community-based models. This study provides a roadmap for policymakers to reconcile professional agency with the universal right to high-quality care at the end-of-life.
Fuel2Flourish is a nurse-led initiative designed to center the voices of nurses, who are active leaders within the National Association of Hispanic Nurses (NAHN), as trusted messengers and role models in advancing the nutritional and emotional well-being of school-age children. Operating across nine local chapters in different states, this community-rooted program was built in partnership with national policy stakeholders and community leaders to respond to what children and families need most: support they can trust from people who understand their lived experiences. This study employed qualitative methods to gain feedback from chapter program leads to examine implementation processes and early perceived impacts. Through bilingual education toolkits, culturally relevant storytelling, and nurse-led workshops, nurses engaged directly with students, parents, and educators to create safe, inclusive spaces for learning and connection. Despite limited budgets and varied local conditions, Fuel2Flourish thrived by aligning clinical nursing expertise with community insight and action. This article describes the partnerships formed, and the early signs of impact seen on the ground. Fuel2Flourish shows what's possible when nurses are equipped and empowered to lead, bringing creative, locally tailored solutions to the forefront of child health promotion.
The United States continues to struggle with the opioid crisis, exacerbated by shifting political priorities and the aftermath of the COVID-19 pandemic. This critical review analyzes the One Big Beautiful Bill Act (OBBBA) and its implications for opioid use disorder (OUD) treatment through the lens of the Multiple Streams Framework. Drawing on Medicaid data, and evidence from state-level implementation, most notably Arkansas, this article evaluates how work requirements and administrative restructuring threaten access to medications for opioid use disorder (MOUD), harm reduction services, and continuity of care. Medicaid expansion has been influential in increasing treatment availability, reducing overdose deaths, and supporting rural health systems; however, OBBA's mandated community engagement requirements threaten the progress made in combatting this epidemic. These restrictions are projected to cause 11.8 million Americans to lose health insurance, disproportionately affecting individuals with OUD who already encounter significant barriers to care. Prior evidence demonstrates that similar policies failed to increase employment, generated widespread confusion, and produced significant losses in coverage. The losses in coverage lead to delayed care, medication interruptions, and worsened health outcomes. There are also substantial financial and operational burdens associated with national implementation, including an estimated $200 million in administrative costs, diversion of resources away from clinical services, and reduced capacity for evidence-based treatment. This analysis concludes that OBBBA is likely to undermine progress in reducing overdose mortality, amplify health disparities, and place added strain on healthcare systems, particularly in rural communities, which have experienced the most significant effects of the opioid epidemic.
AimIn the United States, 82% of American Indian/Alaska Native (AI/AN) women face violence during their lifetimes, compared to 45.1% of women from all other racial groups. We examined the evolution and impact of the Violence Against Women Act (VAWA) on AI/AN women.Design and MethodsA policy analysis of VAWA and its impact on AI/AN women survivors of violence was completed through the lens of the Tribal Critical Race Theory.ResultsThe findings identified that prior to VAWA (2013), there were significant legal gaps regarding the prosecution of non-Native offenders on tribal lands. Following multiple reauthorizations of VAWA, there has been a reported increase in services for AI/AN women, yet challenges persist due to limited data and jurisdictional complexities. While VAWA has made strides in addressing violence against AI/AN women, systemic issues such as historical trauma, racism, and invisibility continue to hinder effective responses. The complexity of jurisdictional frameworks further complicates law enforcement efforts on tribal lands.ConclusionThis policy analysis underscores the need for continued advocacy for comprehensive data collection and more robust legislative measures that prioritize the unique circumstances of AI/AN communities. Additionally, the analysis can inform policymakers, community leaders, and advocacy groups on the necessity of addressing systemic factors that contribute to violence against AI/AN women, such as the jurisdictional complexities on sovereign Native lands. To enhance policy effectiveness, we must take a collaborative approach with tribal communities and ensure that AI/AN voices are integral to the conversation on violence against women.
Nurses’ involvement in public and policy debates is increasingly recognised as essential for shaping health care systems, yet their voices remain largely invisible. When nurses do engage publicly, they may act as public opinion leaders, using their professional expertise and credibility to influence policy discussions. Little is known, however, about how public opinion leadership (POL) manifests in practice and what motivates nurses to take on such a role. A proposed health care reform in the Netherlands, known as the BIG2 proposal, triggered an unexpected wave of nurses speaking up in national media and on social platforms. This study explores how POL manifested during this reform and what motivated nurses to raise their voices. A qualitative design was used, combining a thematic and abductive approach. Twelve semi-structured interviews were conducted with Dutch nurses who publicly responded to the reform through newspapers or social media. The findings show that nurses who engaged in POL acted from moral conviction and professional credibility, rather than formal authority. Their motivation stemmed from feeling misunderstood or undervalued, which evoked emotions such as frustration and anger. Responsibility, encouragement, and solidarity sustained their engagement. Nurses used social and traditional media to connect with peers, journalists, and politicians, making their leadership visible and collective. POL appeared as a collective process grounded in moral conviction, professional expertise, and mutual support. These findings highlight how nurses can extend their influence beyond clinical settings and contribute to shaping health policy debates.
Objective To examine the legal, ethical, and policy issues associated with gig work in nursing across the United States, the United Kingdom, and Canada.Methods Narrative review and cross-country comparative analysis.Results Sixteen studies were included. While the term "gig work" is not generally applied to nursing in both the United Kingdom and Canada, the availability of flexible, temporary, short-term work is common, manifesting primarily through either bank nursing or agency nursing mediated by various digital platforms. The phenomenon of internal banking was observed across all three countries. Despite the increasing trend of gig work, legal ambiguities exist regarding the classification of nurses as employees or independent contractors which has significant ramifications for liability and accountability. With the short-term nature of gig work, patient safety concerns also exist, particularly for nurses navigating new healthcare contexts. Compounding these challenges, many gig platforms lack standardized mechanisms to verify nurses' credentials or enforce compliance with scope-of-practice regulations. Ethically, this regulatory vacuum perpetuates systemic inequities, as gig nurses may face substandard wages, exclusion from benefits, and exploitative contractual terms.Conclusion While gig work offers nurses unprecedented autonomy and flexibility, its unchecked growth risks normalizing precarious labor conditions, eroding workplace protections, and raising patient safety concerns. To sustainably integrate the gig model, legislators must close classification loopholes. Healthcare institutions should implement registries for vetted gig workers and enforce standardized onboarding protocols to maintain care quality. Simultaneously, gig platforms require regulatory oversight to mandate real-time credential verification, wage guarantees, and scope-of-practice safeguards.
When a person chooses assisted dying, the impact on their family can be profound. Legislation and professional guidelines not only regulate and standardize practice, but also support the delivery of high-quality care. Within this framework, bereavement care plays a vital role by helping families prepare for the death and potentially reducing the risk of prolonged grief. This study explored how current legislation and clinical guidelines on assisted dying address the role and needs of family members, particularly regarding bereavement care. It examined the frequency of the term "family" and its synonyms, as well as the extent to which bereavement support services for relatives are described. A content analysis was conducted on legislative and guideline documents from countries where physician-administered assisted dying is legal. Documents were collected between August 2022 and June 2023, and both quantitative and qualitative analyses were used to assess references to families and descriptions of bereavement care. In total, 22 legislative frameworks and 38 clinical guidelines from nine countries were analyzed. References to family appeared far more often in guidelines (N = 1,213) than in legislation (N = 147). The frequency of these terms varied significantly, with guidelines ranging from two to 83 mentions, and legislation from zero to 18. Eight key themes related to bereavement care emerged, though specific guidance was often lacking. To improve quality care, there is a clear need to better integrate family support into assisted dying guidelines by establishing best practices for bereavement care. Future research should focus on family members' perspectives and needs.
Family caregivers provide essential unpaid care to millions of older adults and individuals with chronic illness or disability in the United States, yet federal support policies have historically been fragmented and underdeveloped. The Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act of 2018 (Pub. L. 115-119) established the first national framework to coordinate federal actions, disseminate evidence-based practices, and institutionalize caregiver recognition. This study analyzed the RAISE Act using Walt and Gilson's Health Policy Triangle and Kingdon's Multiple Streams Framework to understand how its structure, political origins, and implementation mechanisms institutionalize caregiving support and create opportunities for nursing leadership. Primary data included legislative text, congressional records, and federal implementation documents; secondary data comprised policy briefs, nursing literature, and grey reports from 2016-2024. Analysis revealed that the Act reframes family caregiving as a coordinated national responsibility through recurring strategy updates, multi-sector collaboration, and public transparency, ensuring sustainability without new appropriations. The convergence of social need, feasible policy alternatives, and bipartisan support created a durable policy window (an opportune moment when conditions align for policy enactment). Nursing has substantial opportunities to shape implementation through care coordination, caregiver education, evaluation, and advocacy. The RAISE Act demonstrates how modest, consensus-based policy can generate structural impact, creating expanded opportunities for nursing to lead caregiver integration, strengthen care transitions, and advance equitable aging policy.
Nurses' political participation plays a crucial role in shaping how health-disease processes are understood and addressed, as well as in developing both our discipline and the profession. Yet, despite its importance, this area requires further advancement. This article explores key factors that influence nurses' involvement in political life, paying particular attention to the historical barriers that have limited our progress. Also, it examines the political process itself, and the different roles nurses can take on it. It also delves into the available evidence regarding the components of nurses' political competence. Finally, a series of recommendations is proposed to advance nurses' political competence across clinical, educational, and research fields.
BackgroundNurses have professional responsibilities to advocate for environmentally healthy practices and have rights to work in healthy environments. Many medical supplies are made with polyvinyl chloride, which is softened and made more flexible by adding phthalates, such as di(2-ethylhexyl) phthalate (DEHP). Patients, nurses, and other health workers are exposed to these toxins through dermal, inhalation, ingestion, and/or parenteral administration. Phthalates are classified as carcinogenic, mutagenic, reprotoxic, and endocrine-disruptors.PurposeThe purpose of our project is to develop a nurse-led advocacy plan focused on drafting, introducing, and passing a bill banning use of medical supplies made with DEHP and related plasticizers in North Carolina (NC) health systems and engaging nurses and other stakeholders in advocating for this policy change to protect the health of patients, employees, and the planet.Advocacy PlanWe developed a health policy advocacy plan describing the issue; goal; interest groups; partners; scientific evidence; advocacy strategies; and expected outcomes. We engaged our project partners in implementing successful advocacy efforts. On March 31, 2025, NC House Bill 592, Toxic-Free Medical Devices Act of 2025, was introduced in the NC General Assembly. The Senate version was signed into law on July 3, 2025.DiscussionNurses are well-positioned to advocate for policies that protect health by addressing primary drivers of health, including environmental risk factors. Our nurse-led health policy advocacy plan and actions supported the development and passing of a bill that protects patients and health services workers from DEHP and other toxic plasticizers linked to numerous health problems.
This study aimed to examine the normative and policy frameworks influencing midwifery care delivery in Italy, generating insights to inform strategies for strengthening the recognition, role, and capacity of midwifery within the Italian health system. An interpretative approach, guided by Walt and Gilson's Policy Analysis Triangle, including actors, context, process, and content, was used to analyse 141 European, national, and regional documents related to Italian midwifery.The analysis shows that despite formal recognition as a profession, Italian midwives operate in a context that remains only partially professionalized, shaped by historical, social, and institutional influences. Three interrelated characteristics of the Italian maternity care landscape were identified: a persistent biomedical and risk-oriented paradigm, a technocratic approach to childbirth, and a hierarchical professional structure prioritizing obstetric-led models of care. These factors collectively constrain the recognition of diverse care models, limit midwives' autonomy and professional visibility, and shape the choices available to childbearing individuals.The study concludes that comprehensive, multilevel strategic interventions are essential to advance midwifery in Italy and ensure care provision aligns with international standards. By situating midwifery within the broader sociopolitical and regulatory ecosystem, the study offers insights into cultural and institutional determinants of care delivery and highlights areas for future research, advocacy, and professional development aimed at promoting high-quality, accessible, and person-centered midwifery services.
The Well-Being Insurance for Seniors to be at Home (WISH) Act proposes universal social insurance for long-term care through activities of daily living (ADL) assistance. While this legislation addresses basic personal care needs, it overlooks the clinical complexity of aging adults who require both ADL support and ongoing health monitoring. This policy analysis examines how strategic nursing integration can enhance WISH Act effectiveness by addressing the gap between ADL-focused services and the complex care needs of beneficiaries with multiple chronic conditions. Using Russell and Fawcett's Conceptual Model for Nursing and Health Policy, this qualitative analysis evaluated policy sources, components, and four outcome levels. The study analyzed legislative text, congressional reports, and peer-reviewed literature on long-term care policy, nursing coordination, and international social insurance models. Analysis reveals that 85% of WISH-eligible beneficiaries will have multiple chronic conditions requiring clinical oversight beyond basic ADL assistance. Personal care workers encounter medication management challenges in 78% of cases, while falls, declining functional abilities, pressure ulcers, and adverse medication events frequently result in unplanned hospitalizations when clinical changes go unrecognized during routine personal care. Strategic nursing integration targeting the 35% highest complexity cases could reduce emergency department visits by 32% and hospital readmissions by 25% while achieving cost neutrality through prevention-focused interventions. Strategic nursing involvement in complex case identification, care transitions, chronic disease monitoring, and family caregiver support could bridge the clinical complexity gap while complementing existing Medicare services. This targeted approach maintains the WISH Act's core ADL focus while ensuring comprehensive community-based care for aging populations with complex health needs.
Despite being a high-resource nation, the U.S. maternal mortality rate has been steadily rising since 1997 and disproportionately affects disenfranchised groups and communities. In 2024, the Massachusetts Maternal Mortality and Morbidity Review Committee released recommendations for remedial policy and practice changes based on a thorough review of 25 pregnancy-related in-state deaths, the majority of which were deemed preventable. The purpose of this paper is to use the conceptual model of nursing and health policy to analyze the committee's recommendations to determine their capacity to contribute to a comprehensive strategy against maternal mortality as well as their connection to perinatal nursing practices. The method involved classifying the report recommendations based on their strongest connection to specific levels of the conceptual model to highlight opportunities for nurses to engage with the policy recommendations. Results demonstrated that each of the recommendations aligned with one of the model's four levels (individual, community, geopolitical unit, global), demonstrating comprehensiveness and a focus on efficacy, quality, effectiveness, cost-effectiveness, accessibility, and social justice. Future action plans should consider the following recommendations absent from the report: (1) implementation of standardized obstetric protocols, (2) extension of duration/scope of postpartum care, (3) increasing access to screening and treatment for perinatal mental health conditions, midwifery care, community birth options, and telehealth, and (4) performing qualitative research to gain further insights from groups most affected by maternal mortality. This analysis shows that the report's recommendations are largely implementable through nursing practice and can serve as a model for all states.
