For close to four decades, many nursing scholars have called for the profession to develop a cadre of politically active nurses... There is consensus among nursing scholars, particularly those active in policy, politics, and nursing practice, that nurses need to be politically active (Avolio, 2014; Juma, Edwards, & Spitzer, 2014; Kelly, 2007; Montalvo & Byrne, 2016; O’Rourke, Crawford, Morris, & Pulcini, 2017; Primomo & Bjorling, 2013; Vandenhouten, Malakar, Kubsch, Block, & Gallagher-Lepak, 2011). For close to four decades, many nursing scholars have called for the profession to develop a cadre of politically active nurses in order to compete for scarce resources (Cramer, 2002). Scholars have presented various reasons as to why the call for nurses to be politically active is ethical and the right thing to do.

Kelly (2007) posits that nurses must become political activists to safeguard the profession from unhealthy policies, which can be channeled through politics and changes in public policy. Health reform has become largely polarized along political and partisan lines (Keepnews, 2012). Hence, for nurses to influence such reforms, they must be both politically involved and politically skillful. In many countries, nurses constitute the largest workforce in the healthcare sector (Juma et al., 2014; Shariff, 2014). As the largest group of healthcare providers, nurses are in a unique and very powerful position to serve as advocates for patients, communities, and the nursing profession, by leveraging their numbers to exert influence on healthcare policies (Avolio, 2014; Vandenhouten et al., 2011).

Nurses must be seen and heard in health policy debates. Among all healthcare professionals, nurses are the ones closest to clients and consumers of healthcare (Juma et al., 2014). As such, they are witnesses to inadequacies and inequalities within the healthcare delivery system and have first-hand knowledge that can lend expertise to discussions on health policies. Nurses must be seen and heard in health policy debates. Nurses have the requisite education, experience, and legacy that will enable them to lead the world in addressing the social determinants of health, factors that have a dramatic impact on the health of populations (Lathrop, 2013).

Whitehead (2010) argues that influencing health policy through political involvement amounts to population-level health promotion. In spite of these calls for nurses to be politically active, studies continue to report low levels of political participation among nurses (Ahoya, Abhichartibuttra, & Wichaikhum, 2016; Avolio, 2014; O’Rourke et al., 2017; Vandenhouten et al., 2011).

The Study

Studies exploring the political behavior of nurses in Ghana are virtually non-existent. Studies exploring the political behavior of nurses in Ghana are virtually non-existent. This article reports findings from a survey of registered nurses in three hospitals and two nursing training schools in Tamale, Ghana. The study aim was to determine the extent to which nurses in Ghana engage in political activities and to identify the demographic characteristics influencing nurses' political participation.

Political participation was defined as nurses’ involvement in activities considered to be political in nature (Vandenhouten et al., 2011). These activities included voting; campaigning; attending rallies; volunteering; contacting elected officials; working with others on local problems or issues; and being a member of nursing or non-nursing organizations that take stands on political issues.

Methods

This descriptive, cross-sectional study design included a survey of nurses. This section will describe the study setting; population and sample; data collection instrument and procedure; data management and analysis; and ethical considerations.

Setting
The study was conducted in Tamale, which is officially called Tamale Metropolitan area and is the capital town of the Northern Region of Ghana. Tamale is Ghana’s fourth largest city with a population of 360,579 people (World Population Review, 2019); it is the fastest-growing city in West Africa (Abaneh, 2019). The town is located 600 kilometers north of Accra, the capital of Ghana.

Most residents of Tamale are Muslims, as reflected by the multitude of mosques in Tamale, and most notably, the Central Mosque. Tamale is located in the Northern region of Ghana, in the Kingdom of Dagbong. More than 80% of the inhabitants are Dagdombas. Other large groups of people living here include the Dagarbas, Mamprusis, and Akans. Due to its central location, Tamale serves as a hub for all administrative and commercial activities in the Northern region. It also is the political, economic and financial capital of the Northern region. Additionally, the city is host to three major hospitals and two educational facilities from which the study participants were drawn.

The city is characterized by high levels of political activities...The city is characterized by high levels of political activities, including television and radio discussions, rallies, mounting of billboards and party flags, and street carnivals, especially during electioneering campaigns. This generally high level of political participation among residents of Tamale makes it an ideal setting to study political behavior among a group of people. The two leading political parties in Ghana—the National Democratic Congress (NDC) and The New Patriotic Party (NPP) both have a strong presence in the metropolis, although the NDC candidates have been winning all recent elections in this city.

Population and Sample
The study population included nurses working in three hospitals and two nursing training schools. The sample size was 272 nurses, calculated using the Yamane formula (Yamane, 1967). The proportional stratified random sampling method was used to determine the number of nurses from each facility. This approach was necessary to ensure a fair distribution of participants across the different study sites. All registered nurses working in the selected facilities were included in the study population. However, nurses who were on leave, or who had retired by the time the data were collected, were excluded from the final sample.

Data Collection Instrument
The instrument for data collection included two main sections, one designed to capture data on the demographic characteristics of participants and one designed to assess their level of political participation. The demographic section contained questions about participant age, gender, professional rank, academic qualification, and area of nursing practice (whether clinical or education). The section on political participation contained an adapted version of the Political Astuteness Inventory (PAI) developed by P. E. Clark (2008) and used with permission. The PAI is a 40-item questionnaire with each affirmative response valued at one point. Five questions on the inventory did not apply to the political context in Ghana and these were removed from the instrument. Examples of questions that were removed include: I know the names of my state senators in Washington, DC; I know the name of the state senator from my district; and I support my state professional organization’s political arm.

The adapted version of the PAI used in this study included 35 questions, with a range of scores from 0 – 35. The Cronbach's alpha for this adapted version was 0.82. Examples of questions asked on the PAI include, “I am registered to vote,” “I belong to a professional nurses’ organization,” and “I have provided testimony at a public hearing on an issue related to health." The summation and levels of the PAI used in this study included: (a) totally politically unaware (0-8 points); (b) slightly aware of the implications of political activity for nursing (9-17 points); (c) shows a beginning political awareness (18-26 points); and (d) politically astute and an asset to the profession (27-35 points).

Data Collection Procedure
After institutional approval, data collection was completed over a period of three weeks, from March 27 to April 14, 2017. The questionnaires, along with a cover letter to introduce the study purpose and the rights of participants, were personally distributed by the researcher and two volunteers. We requested that participants read the consent form, and sign if they agreed to take part in the study. A period of one week was allowed for consenting participants to complete the survey. The researcher then collected the completed surveys, which generally had been left with the charge nurse. Nurses who were unable to complete surveys by the time of this first collection were given another week to complete the survey. During the third week, the remaining questionnaires were collected.

Data Management and Analysis
During the data collection process, questionnaires were kept in separate envelopes marked with the facility name to track the rate of retrieval from each facility. Questionnaires were marked as entered to avoid duplicate entries. After data from each questionnaire had been entered, questionnaires were bagged in an envelope, labeled as completed and locked in a cabinet. At the end of each day, data were saved on an external drive and on Microsoft OneDrive online.

Data analysis was performed using the Statistical Package for Social Sciences (SPSS), version 21 (IBM, 2015). Background characteristics of participants were described using frequencies, percentages, and means. Descriptive statistics were used to show the level of nurse participation in politics and to describe common practices engaged in by nurses as a form of political participation. Independent samples t-test was used to test the association between gender, area of practice, and political participation. The one-way ANOVA was conducted to determine the association between age, academic qualification, and political participation.

Ethical Considerations
The study was conducted in five different institutions, specifically two district hospitals, one teaching hospital, and two nursing training schools. Ethical clearance was obtained from the Institutional Review Board of the University of Cape Coast before the study commenced. Clearance was also obtained from the Institutional Review Board of Tamale Teaching Hospital, allowing the study to be conducted in this hospital. In the case of the two district hospitals, we sought permission from the Northern Regional Health Directorate to carry out the study in those facilities, since they did not have institutional review boards. Additionally, the two training schools did not have institutional review boards, but their academic boards reviewed the proposal and gave verbal approval to conduct the study.

Findings

This section will describe the characteristics of the respondents, report nurses' levels of political participation and present the political practices of the nurses. It will conclude by addressing the relationships between political participation of nurses and their demographic characteristics.

Background Characteristics of Respondents
Only a minute percentage were in the highest category of political participation. Out of the initial sample of 272 registered nurses to whom the questionnaires were administered, 225 participants completed the survey (retrieval rate of 82.7%). The characteristics of this sample are presented in Table 1. Most participants were in their 30s (Mean age = 30.84, Median = 30.00). Males were slightly greater in number than females. The majority of participants (63.6%) were in the junior ranks, holding ranks of Staff Nurse or Senior Staff Nurse. A related finding was observed in participants' academic qualifications, with 56.9% having a diploma in nursing as their highest academic qualification. These findings reflect the general characteristics of the target population and the nursing population in Ghana as a whole, where the majority of nurses have a diploma as their highest qualification, and only a few nurses have master’s degrees or doctoral degrees.

Table 1. Background Characteristics of Respondents

Nurses’ level of political participation was measured using the Political Astuteness Inventory. Statistics describing the categories of nurses’ levels of political astuteness are presented in Table 2. The majority of respondents (64.4%) were in the category of slightly aware of the implications of political activity for nursing. Only a minute percentage (0.4%) were in the highest category of political participation.

Table 2. Level of Nurses’ Political Participation

Political Practices of Nurses
Nurses were generally not likely to actively support a candidate for elections.
As a way of exploring additional dimensions of nurses’ level of political participation, practices that nurses usually engage in as forms of political activity were analyzed. The result of this analysis is presented in Table 3. The most common political practices reported by participants were: registering to vote (95.1%), voting in the last general election (77.3%), and voting in the last two elections (80%). The majority of respondents (91.1%) were registered members of the Ghana Registered Nurses and Midwives Association (GRNMA), but only a few took part in meetings and programs of the association. Nurses were generally not likely to actively support a candidate for elections.

Table 3. Political Practices of Nurses

Note: The values in this table represent multiple responses from participants.

Relationship Between Political Participation and Demographic Characteristics
Data were analyzed for significant differences in the level of political participation of participants based on selected demographic variables. The independent samples t-test was conducted to determine differences in the level of political participation based on gender and practice area, while the one-way ANOVA was used to determine differences in political participation based on age and academic qualification. The results of the independent t-test showed that the mean score on political participation for males was statistically significantly higher (15.81) compared to females (14.20), (t (223) = 2.525, p = .012). However, there was no statistically significant difference in the mean scores of political participation between nurse educators and clinical nurses (p = .140). The results of these tests are presented in Table 4.

Table 4. Independent Samples T-test for Gender, Practice Area, and Political Participation

Results of the one-way ANOVA showed no statistically significant differences in the mean scores on political participation among the participants based on age (p = .101), or academic qualification (p = .486). Detailed results are presented in Table 5.

Table 5. One-way ANOVA – Age, Academic Qualification, and Political Participation

 
Discussion

...only a small number of the nurses were found to be politically astute. One key objective of this study was to determine the extent to which nurses in Ghana are involved in political activities. Concerning this objective, there were mixed findings from this study in that, although nurses agreed that politics should be of concern to nurses, only a small number of the nurses were found to be politically astute. When nurses were asked how important it is for nurses to know about political issues, 80% said it was very important. In what looked like a reverse of this question, nurses were asked to state their agreement or disagreement with the statement: “Politics is not the concern of nurses.” In their responses, 79% either disagreed or strongly disagreed with this statement, again saying that politics is a concern of nurses. These findings are similar to those of Avolio (2014) who studied the beliefs and practices of registered nurses in Canada with regards to political advocacy, and reported that 78% of nurses surveyed either agreed or strongly agreed that it is important for nurses to be politically active, and 76% of respondents agreed or strongly agreed that politics is a concern of nurses.

The large majority of the participants were either totally politically unaware or only slightly aware of the implications of politics for nursing. In spite of the overwhelming agreement that it is important for nurses to know about politics, and that politics should be a matter of concern to nurses, only 0.4% of the respondents were found to be concerned and knew much about political issues. The large majority of the participants (76%) were either totally politically unaware or only slightly aware of the implications of politics for nursing. In other words, they were in the category of low and very low levels of political participation. Similarly, Avolio (2014) noted that although nurses agreed that it was important to be politically active, only 30% of respondents reported that they were motivated to become involved in politics. This finding also supports the assertion of Boswell, Cannon, and Miller (2005) who described nurses’ apathy towards political participation as a pandemic.

However, when we compare these findings to the findings that were obtained from an analysis of common political practices of nurses, there was a difference. For instance, in terms of voting, 95% were registered voters, 77.3% had voted in the last general election, and 80% had voted in the last two elections. These percentages are generally higher than the average voter turnout in national elections in Ghana, which is estimated at 71.35% (International Foundation for Electoral Systems, 2019). Previous studies about nurse participation in political activities have also reported high voter turn-outs among the nursing population (Ahoya, Abhichartibuttra, & Wichaikhum, 2016; Avolio, 2014). In a study about the political participation of registered nurses in the US, Vandenhouten et al. (2011) reported that 95% of the participants were registered to vote, 83% had voted in all or most of the presidential elections, and more than half (62%) had voted in all or most state elections since they were old enough to vote. All of these findings clearly indicate that nurses are generally very interested in voting as a political activity. The fact that nurses generally do register to vote, and do vote in many elections, suggests that nurses may not be generally apathetic towards politics as has been suggested, but rather may limit the extent of their participation.

All of these findings clearly indicate that nurses are generally very interested in voting as a political activity. This limited participation is seen more clearly when nurses were asked about how much money they were able to contribute to political parties, candidates or nursing organizations for political purposes. Over 88% of respondents indicated they did not contribute any money at all towards political causes. Additionally, participants were asked whether they have ever actively supported a candidate for election as an Assemblyman or a Member of Parliament (e.g., by campaigning or wearing party souvenirs). In the case of an Assemblyman, 85.3% said no; and 82.2% said no for that of a Member of Parliament.

This situation is not peculiar to Ghana. In a study about political efficacy and political participation among nurses in Kenya, Ahoya et al. (2016) noted that nurses were generally unable to make financial contributions to political organizations as a result of low-income earnings. In a study conducted in the United States regarding political participation of registered nurses, only 23% of participants reported making monetary contributions to political candidates (Vandenhouten et al., 2011). Another study in the United States assessing the political efficacy of nurse practitioners reported that the participants generally had limited political participation (O’Rourke et al., 2017). Consistent with the present study, Avolio (2014), in a study of Canadian nurses, reported that only 11.4% of nurses in her study had ever written a letter about health or a nursing issue for publication in a newspaper. All these findings suggest that even though nurses may register to vote, and vote for a particular candidate in an election, they may not participate in other activities to support the candidate or political party. Unfortunately, with such limited participation, they lack leverage with which to lobby for elected officials to take certain decisions in favor of the profession.

A similar trend of passive participation was observed among participants in terms of organizational participation... A similar trend of passive participation was observed among participants in terms of organizational participation, that is nurses’ level of engagement within nursing organizations. Cramer (2002) noted a decline in the membership of the American Nurses Association from as high as 55% of all employed registered nurses in 1948 to only 8% in 2002. Only 30% and 45% of participants in studies by Vandenhouten et al. (2011) and Avolio (2014) respectively were registered members of a professional nursing organization. These earlier findings are in sharp contrast to the present study where 91.1% of the participants were registered members of the Ghana Registered Nurses and Midwives Association (GRNMA). This is probably because gaining membership of the GRNMA is a very passive endeavor. Even without completing a membership application form, nurses are automatically drafted into the association once the government posts them to start working. However, despite this high membership in GRNMA, only a few of them showed an active interest in the activities of that association. For instance, only 5.8% reported that they attended the most recent district meeting of GRNMA, and only 16% indicated that they attended the last regional symposium organized by GRNMA in their region. Again, nurses’ tendency to be passive in political participation is evident here.

...gaining membership of the GRNMA is a very passive endeavor... nurses are automatically drafted into the association once the government posts them to start working. From the foregoing discussion, we may conclude that nurses can be classified as voting specialists, based on the empirical typology of different modes of participation developed by Verba and Nie in 1972 (Whiteley & Seyd, 2002). Based on this typology, the authors classified citizens into six different groups on the basis of the types of political activities they undertook. These groups include (a) the inactive, who do virtually nothing or very little, (b) the voting specialist, who vote regularly but do nothing else, (c) the parochial participant, who contact officials in relation to specific problems but are otherwise inactive, (d) the communalist, who intermittently engage in political action on broad social issues but are not highly involved, (e) the campaigner, who are highly involved in campaigns of various kinds, and finally (f) the complete activist, who participate in all kinds of activities. Since Ghanaian nurses are generally more interested in just voting, and also since they register with professional nursing organizations but do not actively participate in the activities of these organizations, it may be appropriate to say that these nurses fall within the category of voting specialists.

Conclusion

...nurses are not generally apathetic towards political activities, yet they are limited in the extent to which they participate. This study has demonstrated that, while nurses may not get involved in political activities that require greater effort and sacrifice (known as high-intensity participation), they are highly involved when it comes to low-intensity forms of political participation such as registering to vote and voting in elections. It can, therefore, be concluded that nurses are not generally apathetic towards political activities, yet they are limited in the extent to which they participate. This limited participation does not augur well for the nursing profession because, as noted earlier, limited participation in political activities fails to give nurses the needed leverage to lobby for better policies and programs for the profession.

For nurses to advocate effectively for the profession and their clients, to be able to address the social determinants of health and to influence policy formulation at all levels, they must be active in the political process beyond voting. It is essential that they write more articles about nursing and health issues, become more active in the activities of their professional organizations, contribute financially to political initiatives and activities, and become more conversant with their elected officials. Future research in this area needs to focus on strategies that enhance the political efficacy and participation of nurses, so as to enhance their role to strengthen healthcare and the health of the patients they serve.

Author Declaration: The authors declare that there is no conflict of interest with respect to the research, authorship, and/or publication of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors

Afizu Alhassan, MN, BSN, RN
Email: hafizbinhassan@outlook.com

Mr. Afizu Alhassan holds a Master of Nursing Degree from the University of Cape Coast in Ghana and a Bachelor of Science in Nursing from the University for Development Studies, also in Ghana. He served as the national president of the Ghana Nurse and Midwife Trainees Association during his student days at the Nurses’ Training College, Tamale. He worked as a clinical nurse for four years at the Tamale Teaching Hospital before beginning his teaching career, which has included teaching at the Nursing and Midwifery Training College, Kpembe, for four years, and also at the Midwifery Training College, Gushegu. During his time at the Tamale Teaching Hospital, he was deputy secretary for the local chapter of the Ghana Registered Nurses and Midwives Association. He is currently a Senior Nursing Tutor with the Ghana Ministry of Health and the General Secretary of Nurse Educators’ Group, Ghana. These previous nursing leadership positions have motivated him to study the political behavior of nurses.

Akwasi Kumi-Kyereme, PhD, MPhil, B.A
Email: akkyereme@ucc.edu.gh

Professor Akwasi Kumi-Kyereme is an Associate Professor at the University of Cape Coast, Ghana. He has held key positions in the university including Head, Department of Population and Health (2010 – 2014) and Vice Dean, Faculty of Social Sciences (2014 – 2018). He has also served on numerous university boards and committees. He is the current Convocation Representative (Professorial) on the University of Cape Coast Council and a member of a number of professional associations. Professor Akwasi Kumi-Kyereme has been involved in various research projects and has published extensively in his major areas of research interest, namely sexual and reproductive health; social dimensions of health (including HIV, AIDS, and Tuberculosis); and healthcare financing. He has supervised numerous research projects at the undergraduate, post-graduate, and doctoral levels, and provided supervisory guidance for the study reported in this article, from the conceptual stages to its very final stages.

Michael Wombeogo, PhD, DLITT ET PHIL; MA, HPE; MA, DS; MSc, PH; BA, Nur & Psy; SRN
Email: mwombeogo@gmail.com

Dr. Wombeogo is a professional nurse, pediatric nurse specialist, public health scientist Senior Lecturer at the University for Development Studies (UDS) and Head of the Department of Public Health at the School of Allied Health Sciences. He is a Fellow of both the West African College of Nurses and the Ghana College of Nurses and Midwives and a Member of the Sigma Theta Tau International. He serves as a faculty member of the Department of Paediatric Nursing Division of the Ghana College of Nurses and Midwives and a member of a select committee on the Accelerated Fellowship programme of the Ghana College of Nurses and Midwives. Dr. Wombeogo lectures in various nursing and health-related courses, at the Schools of Allied Health Sciences and Medicine and Health Sciences, of UDS. He has mentored and supervised students in nursing and in the health and has published many articles and authored four books. He is a health development consultant who has had significant experience in health and sustainable livelihoods surveys and programming, at Ghana's regional and national levels.

Abdul-Ganiyu Fuseini, MPhil, BSN, RN
Email: fuseiniabdulganiyu@gmail.com

Mr. Fuseini Abdul Ganiyuis is a Registered Nurse with a Master of Philosophy in Nursing Degree from the University of Ghana and a Bachelor of Science in Nursing degree from the University for Development Studies, Ghana. He serves as an Assistant Lecturer at the Department of Nursing, School of Allied Health, University for Development Studies, where he also doubles as the examination officer for the department. Before this position, he taught at the Nursing and Midwifery Training College, Kpembe, for five years, and worked as a clinical nurse for five years at the Tamale Teaching Hospital. His duties at the University for Development Studies include coordinating and supervising student research.