From Bedside to Policy Table: Examining the Importance of Nurses’ Participation in Health Policy Development

Introduction

Nurses constitute the largest professional group within the global health workforce and serve as the backbone of healthcare systems worldwide.¹ According to the WHO, nurses account for nearly 60% of health professionals globally and play a critical role in delivering quality care, promoting health, preventing disease, and strengthening healthcare systems.² Their close and continuous engagement with patients, families, communities, and frontline healthcare services gives them unique insights into the daily functioning of health systems and the lived experiences of healthcare users.

Health policy plays a central role in shaping healthcare delivery, resource allocation, workforce planning, and access to quality services.³ The WHO defines health policy as the decisions, plans, and actions undertaken to achieve specific healthcare goals within a society.⁴ Nurses are uniquely positioned to contribute to these processes because of their direct understanding of patient needs, service delivery challenges, and system-level gaps in healthcare. Their involvement in policy discussions can help ensure that policies are practical, patient-centered, and responsive to realities experienced within healthcare settings.⁵

Despite their essential contributions to healthcare delivery, nurses remain underrepresented in health policy formulation and decision-making across many healthcare systems.⁶ In many settings, nurses are more commonly involved in implementing policies rather than participating in their development.^4,7 Existing evidence suggests that power imbalances within healthcare systems, limited leadership opportunities, inadequate policy training, and professional hierarchies continue to restrict nurses’ involvement in governance and policymaking.⁵ This challenge is particularly significant in LMICs, where nurses often provide the majority of primary healthcare services but remain minimally represented within strategic decision-making structures.⁶

The limited participation of nurses in health policy development has important implications for healthcare systems. Policies developed without adequate frontline nursing perspectives may fail to fully address challenges related to patient safety, workforce management, healthcare accessibility, and quality of care. Studies have shown that involving nurses in policy discussions contributes to more effective health policies, improved patient outcomes, and stronger healthcare delivery systems.^4–7 Nurses’ participation in policy development is therefore not only a matter of professional recognition, but also an important component of building responsive, equitable, and sustainable healthcare systems.

Despite growing recognition of the importance of nursing leadership in healthcare systems, nurses remain underrepresented in global health policy development and governance processes, particularly in LMICs.⁸ Existing literature has largely focused on nurses’ clinical and service delivery roles. At the same time, comparatively less attention has been given to the structural, educational, and professional barriers limiting their active participation in policy formulation and decision-making. Consequently, frontline nursing perspectives remain insufficiently integrated into health policy discussions, potentially limiting the responsiveness and effectiveness of healthcare policies.⁹

This perspective article examines the importance of nurses’ participation in health policy development and implementation by synthesizing global evidence and selected examples from LMICs. The paper explores the barriers, enabling factors, and structural challenges influencing nurses’ engagement in policy processes while highlighting the critical role of nursing leadership, advocacy, and frontline perspectives in strengthening health governance. By bringing together evidence from diverse healthcare settings, the article contributes to ongoing discussions on nursing leadership and health systems strengthening. It proposes practical strategies to enhance nurses’ participation in policy formulation and decision-making.

Current Situation

Globally, nurses are increasingly recognized as essential contributors to health policy, leadership, and health system strengthening. Beyond their traditional role in direct patient care, nurses bring practical knowledge of how health systems function at the frontline.¹⁰ Their daily interactions with patients, families, and communities position them to identify service delivery gaps, workforce challenges, patient safety concerns, and barriers to access that may not always be visible at higher levels of decision-making.^11–13

The World Health Organization (WHO) and the International Council of Nurses have emphasized that nurses should be actively involved not only in service delivery but also in leadership, governance, workforce planning, regulation, education, and policy development.^2,14 The WHO Global Strategic Directions for Nursing and Midwifery 2021–2025 identifies nursing leadership as a key priority for advancing universal health coverage and improving population health outcomes.¹⁵

Despite this growing recognition, nurses remain underrepresented in formal health policy forums and decision-making structures. In many healthcare systems, nurses are more commonly involved in implementing policies than in shaping them. This means that nurses are often expected to translate health policies into practice without having had meaningful input into their design. Such exclusion can weaken the relevance and feasibility of health policies because important frontline realities, including staffing shortages, workload pressures, resource limitations, workflow challenges, and patient safety concerns, may not be adequately considered during policy formulation.^6,8

Evidence from different countries demonstrates that this gap is not confined to a single setting. In Ghana, Acheampong et al found that nurses and midwives were often excluded from national policy development, review, and reform processes, despite their central role in healthcare delivery. Their study showed that limited recognition of nursing expertise, weak representation in decision-making platforms, and professional hierarchies restricted nurses’ participation in policy processes.¹⁶ Similarly, in Thailand, Kunaviktikul et al (2010) reported that nurses had limited knowledge and involvement in health policy development, suggesting that meaningful participation requires both opportunity and preparation. These findings show that nurses’ limited involvement in policy is influenced not only by individual capacity but also by broader institutional and structural factors.¹⁷

This situation is particularly serious in LMICs, where nurses often provide a large proportion of essential health services. In many settings, including sub-Saharan Africa, nurses are central to primary healthcare, maternal and child health, infectious disease¹⁸ prevention and management, chronic disease care, health education, and community-based services. Their experience gives them valuable insight into what works in practice and where health systems need improvement. However, their formal influence in policy and governance often remains limited compared with their contribution to service delivery. This creates a gap between the realities of healthcare practice and the decisions made within policy spaces.

In Rwanda, published evidence specifically examining nurses’ direct involvement in health policy development remains limited. Therefore, Rwanda should be understood within the broader low- and middle-income country context rather than presented as a setting with extensive country-specific evidence. However, Rwanda’s current health policy environment offers important opportunities to strengthen nursing leadership and policy engagement. The Health Sector ca V 2024/25–2028/29 emphasizes health workforce development, quality of care, primary healthcare, governance, and progress toward universal health coverage.¹⁸ These national priorities create potential entry points for nurses to contribute more actively to technical working groups, district health planning, hospital leadership, quality improvement initiatives, and national policy discussions.

Rwanda also has professional and regulatory structures that can support stronger nursing engagement. The Rwanda Nursing and Midwifery Council provides an important platform for professional regulation, standards, accountability, and leadership development within nursing and midwifery practice. Such structures can help increase nurses’ visibility and strengthen their role in shaping policies that affect healthcare delivery. However, the presence of regulatory and policy frameworks alone does not guarantee meaningful participation. Nurses still need policy literacy, leadership preparation, mentorship, institutional support, and formal opportunities to participate in decision-making processes.

Overall, the current situation shows a clear gap between the recognized importance of nurses and their actual influence in health policy development. Although nurses remain central to healthcare delivery, they are still insufficiently represented in policy formulation and governance. Addressing this gap requires a shift from viewing nurses mainly as policy implementers to recognizing them as essential contributors to policy design, implementation, and evaluation. Strengthening nurses’ participation in health policy development is therefore both a professional priority and a health system necessity.

Why Nurse Participation in Health Policy Development Matters

Nurses spent around 37% of their time with patients.¹⁹ Their participation in health policy development matters because they understand their needs; their foundational training, combined with daily clinical experience, equips them to accurately identify system gaps and patient needs, providing essential insights for developing effective health policies.⁴ When nurses participate in policy discussions, they contribute practical frontline insights that support the development of policies that accurately reflect the needs and realities of healthcare settings and the communities they serve.⁶

Nurses’ perspectives help ensure that policies are realistic, patient-centered, and grounded in both clinical practice and the functioning of the health system, enhancing the feasibility and effectiveness of policy implementation. Nurses play a central role in advancing healthcare quality and ensuring patient safety. As the largest group within the health workforce and the primary point of contact for patients, they possess unique perspectives shaped by their ongoing, direct interactions with patients. This frontline experience provides valuable insight into workload pressures, patient flow, resource limitations, and broader system challenges, making their voices indispensable in quality improvement and policy discussions.²⁰ When policymakers incorporate nurses’ firsthand knowledge into decision-making, they are better equipped to craft practical and effective policies that address real-world challenges and ultimately enhance care quality, safety, and health outcomes across entire populations.⁴

Nurses also play a significant role in improving the quality and safety of healthcare. Because they work directly with patients, they understand issues such as workload, patient flow, equipment shortages, and service delivery challenges. Having nurses involved in policy development helps leaders design policies that address frontline challenges and improve the quality of care and patient safety.¹⁶ Their participation can shape stronger national programs in areas such as maternal health, chronic disease care, infection prevention, and community outreach.

Additionally, involving nurses in policy decisions strengthens the overall healthcare system. Nurses make up the largest part of the health workforce, so their leadership and knowledge are essential to developing sustainable and effective health strategies. When nurses are involved in designing health policies, they bring clinical experience, knowledge of community realities, and understanding of patient needs. This helps create policies that are more effective, fair, and better suited to public health priorities.

Barriers to Effective Participation

Despite their critical role, nurses frequently encounter multiple barriers that hinder their involvement in health policy development. Many nurses face personal challenges that make it hard for them to engage in health policy. Some individuals do not fully understand how policies are created or how to analyze them, a condition known as limited policy literacy. Others have no formal training in health policy, so they may not know how to contribute evidence or recommendations.¹³ Leadership skills are also necessary. Nurses who have not been trained to lead or speak up in meetings may feel unprepared to share their ideas.

At the same time, low confidence can prevent even experienced nurses from participating in policy discussions, especially when senior officials dominate the conversation. Workload and time constraints due to clinical duties further hinder engagement, particularly in resource-limited or rural settings where nurse-to-patient ratios are high.⁸ Socio-cultural barriers, including gender norms and professional stereotypes, further restrict nurses’ public and political engagement, particularly in contexts where nursing is predominantly female.¹⁴

Facilitators and Enablers of Nurse Participation

Conversely, empirical literature also identifies factors that enable or facilitate nurses’ participation in health policy development. Individual enablers include advanced education, specialized policy training, leadership skills, research competence, and prior advocacy experience. Organizational facilitators include supportive leadership, formal mechanisms for nursing inclusion in policy-making bodies, protected time for policy engagement, and access to mentorship and professional development opportunities. System-level enablers encompass strong professional nursing associations that coordinate advocacy, inclusive health governance frameworks, and national policies that recognize and incorporate nurse input in decision-making processes.¹⁵ Participation in professional networks, interprofessional coalitions, and international partnerships provides additional avenues for influence, resources, and visibility, particularly in LMIC and rural contexts. Studies suggest that a combination of these facilitators, especially when tailored to local contexts, enhances nurses’ confidence, competence, and opportunities to participate effectively in policy processes.⁶

Discussion

This perspective article highlights the critical importance of involving nurses in health policy development and decision-making processes. As the largest group within the global health workforce, nurses possess firsthand knowledge of patient needs, healthcare delivery challenges, and system-level gaps that can significantly inform policy formulation and implementation. Despite this strategic position, evidence synthesized in this paper demonstrates that nurses remain underrepresented in policy discussions and governance structures across many healthcare systems, particularly in LMICs.

The findings discussed in this article suggest that interconnected structural, professional, and educational barriers influence limited nurse participation in policymaking. Hierarchical healthcare systems, limited policy training, inadequate leadership development opportunities, and restricted representation in decision-making platforms continue to constrain nurses’ engagement in health governance. These barriers not only affect professional visibility but may also limit the development of policies that adequately reflect frontline healthcare realities and patient-centered priorities.

The literature further indicates that strengthening nurses’ participation in policy processes can contribute to more responsive, equitable, and effective healthcare systems. Nurses’ close engagement with patients and communities places them in a unique position to identify service delivery gaps, workforce challenges, and emerging healthcare needs. Integrating these perspectives into health policy discussions may improve healthcare quality, patient safety, workforce planning, and implementation feasibility, particularly in resource-limited settings where nurses constitute the majority of the healthcare workforce.

This paper also highlights the importance of investing in nursing leadership and policy capacity-building. Evidence from various healthcare settings demonstrates that mentorship programs, policy education, leadership training, and formal inclusion of nurses in advisory and governance structures can strengthen nurses’ confidence and ability to participate effectively in policymaking processes. Strengthening professional nursing associations and creating structured opportunities for policy engagement may further enhance nursing influence within healthcare systems.

Although this article does not present original empirical findings, it contributes to ongoing discussions on nursing leadership and health governance by synthesizing existing evidence and highlighting practical strategies for improving nurse participation in health policy development. Future research should explore context-specific approaches for strengthening nursing engagement in policy processes and evaluate the impact of increased nursing representation on healthcare outcomes and health system performance.

The Way Forward: A Call to Action

Strengthening nurse participation in health policy development requires a multifaceted and intentional approach. Empirical evidence highlights several interventions implemented globally to enhance nurses’ involvement in policy development. Capacity-building programs, including workshops, short courses, policy fellowships, and mentorship programs, improve nurses’ policy knowledge, advocacy skills, and self-efficacy,³ Institutional interventions such as formal inclusion of nurses on hospital boards, technical working groups, and national advisory committees ensure sustained opportunities for participation and recognition of nursing expertise,⁸ Furthermore, establishing Chief Nursing Officer (CNO) roles within ministries of health, as recommended by WHO, is critical because the countries that have implemented this model report better nursing input into national health strategies, workforce planning, and regulatory frameworks. Strengthening nursing associations to enable collective advocacy, leadership programs that develop political skills, and the creation of structured career pathways for policy engagement have been associated with increased nurse influence in health policy.¹⁶

Conclusion

Nurse participation in health policy development extends beyond professional recognition and remains essential for building responsive, equitable, and sustainable healthcare systems. Nurses’ close engagement with patients, families, and communities provides valuable frontline perspectives that can strengthen the design, implementation, and service delivery of health policy. As healthcare systems continue to face challenges such as workforce shortages, growing disease burdens, and persistent health inequities, strengthening nurses’ involvement in policymaking has become increasingly important.

However, meaningful participation of nurses in health governance requires more than advocacy alone. Resource limitations, heavy clinical workloads, limited leadership opportunities, and institutional barriers continue to affect nurses’ active engagement in policy processes, particularly in LMICs. Addressing these challenges will require realistic and context-specific strategies that strengthen nursing leadership and create supportive governance structures.

In Rwanda, there is an opportunity to strengthen nurses’ participation in health policy by increasing leadership training, integrating policy education into nursing curricula, and increasing nurses’ representation in technical working groups and national health decision-making platforms. Existing national frameworks, including the Rwanda Health Sector Strategic Plan and initiatives of the Rwanda Nursing and Midwifery Council, may provide important pathways for advancing nursing leadership and policy engagement.

This perspective article is limited by its reliance on existing literature and the absence of original empirical data. Nevertheless, it contributes to ongoing discussions on nursing leadership and health governance by synthesizing current evidence and highlighting practical considerations for strengthening nurses’ participation in health policy development and decision-making processes.