key: cord-0774983-f0qoyv5o authors: Çatıker, Aslıhan title: Political power and awareness of nursing during the COVID‐19 pandemic from the views of senior nursing students date: 2021-09-26 journal: World Med Health Policy DOI: 10.1002/wmh3.475 sha: df57006b0e040e1846a360c0756058d8b637e366 doc_id: 774983 cord_uid: f0qoyv5o Studying the impact of the COVID‐19 pandemic on the current nursing workforce and the training of future nurses is important. This study aimed to assess the views of senior nursing students pursuing health policy courses on the effects of the COVID‐19 pandemic on the political power and awareness of nursing profession. Document analysis method, one of the qualitative enhancement patterns, was employed in this study. This study was conducted in a nursing school with a sample comprising 34 nursing students. The data were collected from online homework documents and evaluated with thematic analysis. Students on the effects of the COVID‐19 pandemic on the nursing profession were categorized into three main themes and nine subthemes. Students reported that although the visibility of nursing increased during the COVID‐19 pandemic, the problems of this profession did not change. The results showed that depoliticization was an important obstacle in the fight against these problems and students stated that the struggle could be realized together with a unified and strong political voice. Students suggested being organized in the struggle against problems, addressing unions and associations, and political awareness and political participation as a remedy. Studying the impact of the COVID-19 pandemic on the current nursing workforce and the training of future nurses is important. This study aimed to assess the views of senior nursing students pursuing health policy courses on the effects of the COVID-19 pandemic on the political power and awareness of nursing profession. Document analysis method, one of the qualitative enhancement patterns, was employed in this study. This study was conducted in a nursing school with a sample comprising 34 nursing students. The data were collected from online homework documents and evaluated with thematic analysis. Students on the effects of the COVID-19 pandemic on the nursing profession were categorized into three main themes and nine subthemes. Students reported that although the visibility of nursing increased during the COVID-19 pandemic, the problems of this profession did not change. The results showed that depoliticization was an important obstacle in the fight against these problems and students stated that the struggle could be realized together with a unified and strong political voice. Students suggested being organized in the struggle against problems, addressing unions and associations, and political awareness and political participation as a remedy. The world is facing one of the biggest public health crises in a long time, the COVID-19 pandemic. Nurses are one of the professionals who are most affected by this crisis and have to do their jobs at a great risk (Morin & Baptiste, 2020) . Because the COVID-19 pandemic has put forth unprecedented challenges for health systems, the condition and status of the professionals within this system has become more visible. Particularly, the experiences of nurses were suddenly on the agenda of the public, and it was reported that there was an almost threefold increase in media coverage about nursing during the pandemic. At such times, nurses are sometimes described as heroes in the face of adversity because of their courage, devotion, endurance, and perseverance. Sometimes, nurses have been included in militarist discourses such as "fighting on the front lines" and "dying in service" (Bennett et al., 2020; Cervera-Gasch et al., 2020; Morin & Baptiste, 2020) . However, when evaluated in detail, it is seen that there has been no change in the working life of nurses, and it is the public perception that has changed. Especially schools that carry out training for nurses; it had to be innovative, flexible, quick. On the other hand, educators had to move face-to-face classes to online environments. This has caused them to face new challenges such as delivering clinical experiences and student assessment processes (Dewart et al., 2020; Morin, 2020) in Turkey, nursing education has been severely affected during the pandemic. Immediately after the cases began to appear in Turkey, higher education institutions (based on Higher Education Authority's decision) switched from classical learning to distance learning. During this period, nursing education was also conducted through distance learning activities (CoHE, 2020) . Nursing students and nurses feel excluded, believe they are not part of the health policy development process, and are not important enough to make a difference. However, in studies conducted on nursing students, most of the nursing students stated that they were willing to volunteer for work in the event of a pandemic. In this respect, COVID-19 should be considered not only as a new epidemic but also a turning point in the training of future health professionals (Cervera-Gasch et al., 2020; Temple, 2020; Yonge et al., 2010) . Consistent with these results, the awareness of nursing students should be increased and made more effective and strengthened, particularly during their education. Only if this is done can the voice of nursing be heard in political discussions involving care. Information on nursing students' views on the situation of nurses during the COVID-19 pandemic is limited. However, it is important to consider the opinions of students who will provide health services in the future. Based on this perspective, the aim of this study was to assess the views of senior nursing students pursuing health policy courses on the effects of the COVID-19 pandemic on the political power and awareness of nursing profession. • What are the opinions of nursing students pursuing a health policy course on the impact of the COVID-19 pandemic on the nursing profession? • What are the views of nursing students pursuing health policy course about nurses' political power, political awareness, and participation in political actions? • What are the views of nursing students pursuing health policy course on ways to increase nurses' political power? Document analysis method, one of the qualitative research designs, was employed in this study. This study was based on the guidelines proposed by the COREQ checklist. Purposeful sampling method was used to determine the participants. In this study, nursing students who took an elective health policies course in the 2019-2020 academic year were included in the study to ensure that observations and opinions about health policies were stated from a broad perspective (N = 36). Two students did not submit their homework in the study. All the online homework of the students who accepted to participate in the study were included in the study (N = 34). Participants were students from various regions of Turkey. All the students participating in the study have taken the elective "Health Policies" course. Within the scope of the course, the students took theoretical lessons 2 h a week for 6 weeks before the COVID-19 restrictions were imposed and then online for 8 weeks. The topics covered in the course are general concepts (policy, health policies, law, regulations, etc.), the importance of health policies in nursing, international decisions and organizations that direct health and nursing, health policies and nursing in Turkey, and legal regulations related to nursing. The data collected in this study includes online homework documents prepared by nursing students within the scope of the health policies course regarding the reflection of the COVID-19 pandemic on health policies and the nursing profession. This form comprises three questions prepared on the basis of theoretical knowledge during formal education and online courses within the pandemic restriction period and the observations on nurses and health policies during the pandemic. In these questions, the students were asked to evaluate nurses' current state of political power, political awareness, and political action, and the effects of the pandemic on nursing and health policies. The data were collected between June 13 and July 01. The data were obtained through the distance learning module of the university. Thematic analysis of the data was done according to the six steps indicated by Braun and Clarke (Braun & Clarke, 2006) , and these data analysis steps are summarized in the flow chart ( Figure 1 ). In qualitative research, it is stated that the background and position of the researcher will affect the subject they chose to research, its purpose, and its approach to the subject in line with this purpose (Malterud, 2001) . The researcher has completed her doctorate in public health nursing (PhD) and has worked on health policies in different branches of the national trade union and Turkish Nurses Association since she started working. In addition, the researcher has scientific research on health policies and qualitative research. Credibility in the study was achieved by an expert review method. The online homework form was finalized by submitting to expert opinion before sending it to the students. In the data analysis, the themes created by the researcher were finalized by taking expert opinions from two independent researchers with qualitative research education and experience. To achieve acceptability, grades related to student statements were taken from homework as raw data and participant statements were directly included in the research report. The sample, participants and setting were explained in detail in the study. In addition, student statements were included on a voluntary basis. It is thought that the findings obtained from the study are of a quality that can be used on similar participants and environments and that transferability is ensured in this respect. In the study, it is thought that transferability is provided by using direct student assignments as raw data and the findings including the participants' own expressions. The ages of the students investigated in the study ranged from 21 to 33 years, with an average of 22.5 years. In total, 26 participants were women, eight were men, and one was working as a nurse. As a result of the analysis, three main themes and nine subthemes emerged. These themes were visibility, depoliticization, and political voice. The themes and subthemes obtained in the study are presented in Figure 2 . Students provided numerous views on the impact of the COVID-19 pandemic on nurse labor and nurses' political power. Most students stated that during the pandemic, nurses had to struggle with many problems and were seriously challenged. The views of the students were considered visibility issues and associated with the subthemes of being a loser, changelessness, and attrition. POLITICAL POWER AND AWARENESS OF NURSING | 5 Being a loser Some students stated that nurses did not get what they deserve during the COVID-19 pandemic. Moreover, students reported that nurses experienced many losses in their personal and working life. …. During the pandemic, it was revealed that nursing was not only about measuring blood pressure and taking blood, and people realized that it was an important profession. I think the effect on political power was not as expected. It seems that after all that intensive work, staying away from their family and loved ones, nurses did not get the reward they deserved for their labor and the respect for the profession was not there. In addition, I think that the nurses are unable to make their voices heard and claim their rights on this issue (P1, Woman). Although I think that the pandemic drew, albeit slightly, attention to the distress and problems of nurses, we still see that efforts are ignored (P15, Male). The pandemic has had an impact on the visibility of nursing labor, but I don't think this effect is fully realized. I think the pandemic has little effect on political power. It is a step that nurses try to make their voices heard and defend their rights during this process and appear on news channels. However, although the increased need for nurses during the pandemic allowed people to realize F I G U R E 2 Themes and subthemes emerging from the documents 6 | ÇATIKER the importance of our profession, it was not enough to improve our rights (P18, Woman). The importance of the nursing profession is too great to be limited only by pandemics. Unfortunately, I do not think it holds the value it deserves in the society (P32, Woman). Some students reported during the interviews that although the COVID-19 pandemic made nurses visible in many ways, in reality, nothing is changing about nursing. This (pandemic), maybe in 6 months or 1 year, will definitely end. How persistent, how effective, and how comprehensive will be the solutions to our problems? For example, will there be a bonus or early retirement due to the attrition or exhaustion we faced after this period is over? Or let's expect much simpler things, will healthcare professionals be able to use public transport for free? Forget all that, will the perception in people's minds when a nurse tells them about his/her profession that "oh nurses, they insert serums, draw blood, and make 4000 TL as salary" be destroyed? Forget about the prevention of violence against healthcare workers, will there be appropriate punishment?" (P6, Male). …. Nurses were not given their due regarding the difference in performance compensation with other professionals and they were not satisfied with this situation. I do not think we were able to adequately express the dissatisfaction in this matter. These wage differences, which have been ongoing for years, will continue as long as we are not politically effective" (P8, Male). Some students emphasized that nurses experienced loss of rights and security, deteriorated working conditions, and exhaustion during the pandemic. While the pandemic threatened the world, our colleagues were the most severely affected occupational group. The only thing that changed was that our colleagues were exhausted and worn down even more (P22, Woman). However, in the face of newly emerging issues, problems such as not being able to provide enough equipment, not conducting regular diagnostic tests, long working hours, fatigue, inability to provide transportation and accommodation facilities, caused nurses to wear out even more during this period. I think that they do not get enough wages in return for this labor and exhaustion (P24, Woman). POLITICAL POWER AND AWARENESS OF NURSING | 7 Theme 2. Depoliticization While reporting their views on nursing during the COVID-19 pandemic, the students especially expressed their opinions on political power, political awareness, and participation of nurses in political decisions and stated that depoliticization was an important determinant. Students addressed depoliticization within the framework of powerlessness, political ignorance, and being a woman. It was observed that the students considered powerlessness as one of the most important reasons of depoliticization. Nurses are the largest group among healthcare professionals. They spend a long time with the individuals they care for, but they feel powerless (P4, Woman). I think the nurses do not find themselves politically powerful. If they found themselves strong enough, they could have forced bureaucrats or administrators to take more deterrent measures against violence against health workers (P7, Male). If it were an organization with a really solid foundation and if they were able to hold power as well as other organizations, nurses could have a say in health policies, at least as much as physicians. Although nurses are in a position where they can easily attain such power, I think that the thought 'it was like this, thus will it be' prevents this (P8, Male). Most students reported that they regarded political ignorance as an important problem. Students stated that this ignorance distanced nurses from politics and prevented them from being politically powerful. In order for nurses to find themselves politically powerful, they must have full self-confidence, and solid and internalized policy knowledge. However, because nurses are politically ignorant, they are not politically powerful either. Political awareness is required to take political action. To provide political awareness, it is necessary to have knowledge regarding politics (P3, Woman). Nurses do not find themselves politically powerful nor are they aware of whether they are actually powerful. They do not question and are not aware of their duties and responsibilities (P2, Woman). Students stated being a woman as one of the main reasons for being depoliticized. When we look at who has been pursuing the nursing profession from past to present, we see that women considered this profession. Of course, nurses don't have enough interest in politics due to the addition of the patriarchal society perspective on women to the negative image of nursing. (P1, Woman) …. I think one of the main reasons is that the nursing profession is still seen as a women profession. I think the voices of women are suppressed in a patriarchal society. I think there will be developments that will make a difference in terms of both activism and politics over time as male nurses enter the profession and organization. (P8, Male) Students stated that the problems faced by the nurses could be solved with a stronger political voice and they associated political voice with the subthemes of education, organization, and political participation. Some students emphasized that a good education on this subject is necessary for political voice. One should not retreat to his own shell rather find solutions to the problems … I think this will be done with good education and skills (P2, Woman). Another way is to increase political activity. … I think nurses need to know about politics to increase awareness (P16, Woman). We should follow the ever-changing and developing information and technology by giving importance to our education and try to make our voices heard by increasing efficiency (P10, Woman). Almost all the students stated that nurses must act together and organize better. Most students referred to nursing associations and unions. Political power in nursing is about the unification of nurses, that is, turning thousands of voices into a single voice. The easiest way to do this is to gather nurses under one roof, that is, one voice telling about their problems… Nurses need to be organized. This organization should not be specific to nurses in a certain place or city, but should include all the nurses in Turkey (P1, Woman). Nurses can become members of associations that will embrace all members of the profession in a holistic manner as well as unions of their choosing. In addition, chambers and unions are platforms where professional organization will be provided in the most impartial and holistic way (P9, Male). If nurses become more conscious about organizing and if they are in solidarity, I think that enough political power will be obtained by nurses. I think that this organization can be realized at the university education level through Turkish Nurses Association Student Commission (TNASC) at the beginning of our professional careers (P25, Male). I think the most essential thing for them to increase their strength is to act together rather than compete with each other. With a professional association, they can be heard and position themselves. If we, as nurses, can act together on what is important for nursing, our voices will be heard. Otherwise, we will let other people's decisions govern us (P31, Woman). Some of the students mentioned the importance and necessity of political participation for political voice. By saying "I also have a right, a responsibility," with the political participation of nurses, by voting, by claiming their rights, nurses need develop their own position, institutions, and profession into a better and stronger place (P2, Woman). …. Then, by planning what can be done toward the goal, taking action (political action) and becoming able to influence other people toward their goals, political power is gained (P3, Woman). It will be in the interest of everyone involved that nurses' political awareness, political participation, and actions are at the highest level to both improve professional conditions and attain maximum efficiency in health services (P7, Male). The COVID-19 pandemic continues to be a global concern wherein the nurse labor force, its value, and the problems faced by nurses are becoming visible. In the present study, the opinions of nursing students regarding the effects of the COVID-19 pandemic on the nursing profession were examined. Although students stated that the pandemic made nursing more visible, they also stated that in many respects, nurses suffered losses, nothing changed for the profession, particularly in terms of working life, and the nurses were seriously worn out owing to hard work. Similarly, it has been reported in the literature that the current public has more idea about nursing, but nothing has changed in the lives of nurses, and it is the public perception that changes (Morin & Baptiste, 2020; Thomas et al., 2020) . However, some students in the present study described nursing as a profession that loses/does not get the value it deserves, although they work at least as much as other health-care professionals. The students' observation that although their visibility has increased, nurses are not getting what they deserve can negatively affect the value they attribute to the profession and reinforce their thoughts that this profession will never achieve its desired place. This can lead students to be depolitical and avoid facing political issues when they enter the profession. Whereas, nurses' insight, values and policy knowledge are extremely important to public health and well-being. Nurses can be involved in political agenda-setting and policy making, and can encourage political activation by guiding colleagues and students (Wilson et al., 2020) . Policy is an important tool that affects nurses and health care, and nurses must understand policies to be politically effective. Nurses must have knowledge of health policies to gain a voice in health care and provide health care services to the community. In addition, nurses should be aware of the fact that any change in health policies affects nursing (Cohen & Milone-Nuzzo, 2001; Groenwald & Eldridge, 2020) . If a real difference is to be made in terms of health policy, it is necessary to empower, support, and encourage nurses. It is particularly important to help nurses understand the importance of health policy and the policy development process and include them in the policy development process (AbuAlRub & Abdulnabi, 2020). In the present study, it was observed that students regarded nurses as depoliticized and associated this stance with powerlessness, political ignorance, and being a woman. Students often reported that nurses were politically weak and that nurses considered themselves to be weak. However, power and influence are very important in policy and policy development and the ability of one person to influence others and influence requires power (Groenwald & Eldridge, 2020) . Therefore, it is important that nursing students understand the importance of power in nursing to have power and to empower their environment. The students attributed their political powerlessness and lack of political awareness to political ignorance. Thus, it has been reported that lack of knowledge is the basis of nurses' lack of participation in policy (Cohen & Milone-Nuzzo, 2001) . Nurses should have the necessary knowledge, skills, and attitude to participate in decision-making processes and policy making; this will further motivate them to be involved in politics (Turale & Kunaviktikul, 2019) . Although policy has its own complex structure, it is important for nurses to know that policy is an important implementation tool. Because nurses have knowledge of policy and can build relationships, they can be involved in the development and implementation of successful policies related to nursing and influence policies (F. Hughes, 2005) . One of the most important obstacles to political participation is the perception that women have a lower status in society (Temple, 2020) . In a patriarchal society, it is noted that policymakers, decision makers, and political figures are mostly men, and women are responsible for traditional roles such as conducting domestic work and caring for the child or elderly, although they are part of working life. Some students in the present study stated that the patriarchal society prevents nurses, who are mostly women, from participating in politics. In a study, it was found that men's participation in politics was higher than women, and it was determined that women nurses participated in politics passively, such as voting instead of actively participating (Alhassan et al., 2019) . Accordingly, the patriarchal social structure may prevent women nurses from being a part of policymaking and may cause them to avoid situations that require being on the front stage. Although nursing is seen as a women profession in Turkey, males have also begun to use the title of nurse owing to a law amended in 2007 (Kaya et al., 2011) . However, this may bring some problems with it, such as male nurses starting to take more managerial positions. The fact that men occupy managerial positions more than women among health-care workers has been explained by gender identities and power relations in management boards. Accordingly, women nurses face problems of decreasing or neutralizing their numbers as a result of gender-based power relations, especially in the stages of influencing and contributing to health policy (A. Hughes, 2010) . One of the students stated that the participation of male nurses in the profession would contribute politically to the profession; this view is compatible with the patriarchal social structure and may stem discrimination based on gender in the future. In the present study, students emphasized on education, organization, and political participation as a way for nurses gaining a powerful political voice. Similarly, it has been stated in the literature that nursing education is very important and necessary for health policies. The lack of information that underlies the nurses' lack of involvement in policy may be owing to the gap in education related to this issue. However, with the inclusion of the health policies course in the nursing education curriculum, students can gain the necessary knowledge and behaviors that will affect health policies (Cohen & Milone-Nuzzo, 2001 ). In addition, it is reported that the health policies course is important in terms of establishing the advocacy role in nursing. Furthermore, it is important to discuss political success stories in the field of nursing to make students believe in the transformative effect of policy. Therefore, it is necessary to include a health policy course in nursing education (de Cordova et al., 2019; Oestberg, 2012; Staebler et al., 2017) . Despite this necessity, previous studies have stated that nursing students' political awareness is low, they have limited abilities to participate in health policy activities, they are politically inexperienced and their active participation rates in policy issues are very low (Byrd et al., 2012; de Cordova et al., 2019; Staebler et al., 2017) . However, in a study conducted with undergraduate, graduate, and doctoral students in the United States, it was determined that nursing students have the values and experience required for participation in making health policies. Improving the competence of students and shaping students on this topic is important for countries to transform their health policies (Thomas et al., 2020) . Nurses should have sufficient knowledge, skills, and attitude to be involved in decision-making authorities and to be involved in policy making; this will further motivate them to get involved in politics (Turale & Kunaviktikul, 2019) . Nurses must be organized to be united, in solidarity, and strong. Although the ratio of nurses in the public sector who are union members is high in Turkey, this contribution is unfortunately limited to membership size (Aydoğan, 2007) . However, if all coalitions that report that the problems are bigger and accept various health-care professionals other than nurses as members can adopt a common strategy, their chances of political success are very high (Groenwald & Eldridge, 2020) . Although there are many professional associations in Turkey for different specialties, it is reported that membership rates in professional associations are low among nurses in Turkey, and most members only pay the membership fees and do not assume active duty (Altuntaş & Yetginler, 2020) . In fact, such organizations play an important role in filling the gaps and empowering nurses to become more involved in political processes (Groenwald & Eldridge, 2020) . Studies have shown that the perceived level of political activity and participation in health policy is low among nurses and only moderate involvement to participate in health policy making (AbuAlRub & Abdulnabi, 2020; Safari et al., 2020) . This passiveness of nurses is based on complex reasons such as the fact that they cannot freely express their thoughts, lack of time, political ignorance, disappointment in the work procedure, lack of external support, lack of access to key figures, diverging values or attitudes of policy makers, lack of financial support or other resources, etc. (Hughes, 2005; Safari et al., 2020) . In ensuring that nurses see the big picture and are ready for political participation; nursing education, educators, and professional organizations have an important place (Carnegie & Kiger, 2009; Cohen & Milone-Nuzzo, 2001) . It is reported that it would be appropriate to provide health policy education in nursing education not in a didactic way, but by using interactive techniques, and with an understanding that will improve the advocacy skills of students especially in health issues (Hallowell et al., 2020) . At this point, it is recommended to review existing curricula and emphasize health policies in all undergraduate education. In addition, it is stated that it is necessary to develop the health policy competencies of nursing students with the organization and financing of health services, payment systems, legal processes, policy development, and implementation (Benton et al., 2017) . Nurses knowledgeable about health policies will have the ability to shape health policies in the future. It is reported that the approaches adopted in nursing education will help the nursing students to be better prepared for this process and make them more ready to participate in policy (Ellenbecker et al., 2017; Thomas et al., 2020) . In the present study, students stated that although the pandemic increased the visibility of nurses, not much has changed for nurses, and the pandemic has increased the existing problems of nursing and nurses are exhausted. Students explained the obstacles to nurses' becoming stronger as depoliticization, political ignorance, the fact that nurses are mostly women, and the perception of low status toward women in patriarchal societies. The students explained that the way for nurses to be strong during and after the pandemic is through forming a single political voice, education, and organization. Thus, students suggested being organized in the struggle against problems, addressing unions and associations, and political awareness and political participation as a remedy, which is an important step in solving problems. The findings of this study contribute to future studies by revealing students' views on COVID-19 and nursing. Consistent with these results, it is recommended to include more political knowledge, solidarity, and organization issues in nursing education and curriculum so that nurses can respond stronger and in solidarity during possible future pandemics or health-related emergency situations. To develop nurses who are organized in working life, studies can be conducted to enable students to be organized during their nursing education. It is also believed that the results of the present study will bring a new perspective to the way health policies are handled in the nursing curriculum. Qualitative data are limited to students' views on their homework. I would like to thank public health nurses PhD. RN. Kamuran Özdil and PhD. RN. Gizem Deniz Bulucu Büyüksoy, who provided expert opinion during the creation of themes and sub-themes in the study, for their scientific contributions. This study was not supported by any financial institution. The author declare that there are no conflict of interests. Institutional permission was obtained from the school where the study was conducted (Decree no: 2020-01/04). Verbal and written consents (online form) were obtained by POLITICAL POWER AND AWARENESS OF NURSING | 13 informing the participants that the homework they prepared for the course would be examined within the scope of a research and that the obtained data would only be used for research purposes. The names of the participants were kept confidential and numbers were used instead of names in the excerpts. 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