Department of Nursing Administration, the Republic of Kenya
Received date: October 21, 2016; Accepted date: November 12, 2016; Published date: November 19, 2016
Citation: Ahoya CK (2016) Political Efficacy and Political Participation among Nurses in Tertiary Hospitals, the Republic of Kenya. J Comm Pub Health Nurs 2:142. doi:10.4172/2471-9846.1000142
Copyright: © 2016 Ahoya CK. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Nurses are health professionals with first-hand knowledge and expertise to influence health policy. This correlational descriptive study aimed to determine political efficacy, political participation and the relationship between political efficacy and political participation among nurses at the tertiary level hospitals, the Republic of Kenya. The sample consisted of 347 nurses from two tertiary level hospitals, selected using the stratified random sampling method. Research instruments were the Demographic data form, the Political Efficacy (PE) Scale, and the Political Participation (PP) Scale. The Cronbach’s alpha coefficient of both the PE and PP Scales were 0.82. Data was analyzed using descriptive statistics and Spearman’s Rank Correlation Coefficient.
The results revealed that the overall scores for PE and PP were at moderate levels. There was a statistically significant positive correlation between PP and PE. The study results can be used by nurse administrators to develop strategies to improve nurse’s political efficacy and political participation.
Political efficacy; Political participation; Nurse; Tertiary hospitals
In any democratic system, nurses as citizens have the right to express their views and attitudes towards almost everything happening in the public domain or concerning health care and the profession at large . Furthermore, public policy reforms require nurses to have the capacity to voice their health problems to policy makers as well as generate alternatives to existing policies in healthcare . Additionally, in times of rapid change and fundamental restructuring of the health care system, nurses’ professional contribution at the policy table can be recognized if they participate more in political activities . Political participation is therefore important for nurses at all levels of healthcare.
Political participation refers to actions-formal or informal, mainstream or unconventional, collective or individual-that seek to influence (either directly or indirectly) on what the government does. Political activities include 1) voting, 2) protesting, 3) campaigning, 4) volunteering for a local government board, 5) contributing money to a candidate, 6) engaging in community work, 7) initiating contact with government officials, and 8) membership in an organization . According to Moran , political participation activities are grouped into two main dimensions: voting and non-voting activities. Nurse’s participation in the political process that impacts practice regulations is crucial if nurses are to guide their professional evolution and make significant strides in directing the structure and operation of the health care system . However, study findings in Canada by Avolio  found that the majority of nurses agreed that health policy issues should be of concern to nurses and that it is their duty to be politically active. Despite these findings, nurses were only moderately active. Furthermore, a study by Chan and Cheng  revealed that Hong Kong nurses had low levels of political participation. These studies indicate the need for nurses to participate more in politics.
One of the factors that affect political participation is political efficacy; the belief that an individual’s political action can influence the political process . Political efficacy contains two separate components: (1) internal political efficacy (IPE), that refers to the individual’s belief about their ability to understand and to make a difference in political matters, and (2) external political efficacy (EPE), that refers to the individual’s belief that decision makers will listen to citizens’ opinions that the political system is responsive [10,11]. According to Levy , IPE is further divided into two dimensions; IPE/knowledge and IPE/skills. IPE/knowledge refers to an individual’s self-efficacy for understanding and knowing facts, concepts, and theories relevant to politics, whereas IPE/skills refer to a person’s selfefficacy for competently performing politically relevant tasks, such as public speaking and constructing reasoned arguments. Additionally, EPE is also divided into two dimensions: EPE/local, which refers to an individual’s belief that he/she can influence community or local governmental institutions while EPE/distal, refers to one’s external political efficacy at the state and national level.
A study in the USA by McDaniels  showed that the feeling of political efficacy was a powerful determinant of political participation among 56 nurses that were sampled. A high positive correlation was found between political efficacy and political participation (r=0.79; p<0.01). Additionally, Vandenhouten et al.  found a high significant correlation between political efficacy and political participation (r=0.59; p<0.01), in a study on the political participation of 468 registered nurses in the USA.
|Political Efficacy||Actual range||Mean||Standard Deviation||Level|
|Overall Political Efficacy||15-90||61.57||12.79||Moderate|
Table 1: Mean, Standard deviation and the level of overall and each dimensions of political efficacy as perceived by the subjects (n=347), EPE=External Political Efficacy, IPE=Internal Political Efficacy.
|Political Participation||Actual range||Mean||SD||Level|
|Overall Political Participation||18-72||46.28||10.22||Moderate|
Table 2: Mean, Standard deviation and the level of overall and each dimensions of political participation as perceived by the subjects (n=347).
Table 3: Relationship between political efficacy and political participation of the subjects (n=347).
The health care system in the Republic of Kenya is based on a fourtier system: community, primary care, county referral and national referral . There are two national referral hospitals in Kenya, which serve to provide tertiary care to all Kenyans as well as those from across its borders. These tertiary hospitals encounter nursing shortages, in that, while a basic certified nurse is supposed to be assigned to not more than six patients at a time, nurses in these hospitals are responsible for up to eight times that number, and sometimes must care for three or more patients sharing a single bed . Apart from patient care, nurses at these tertiary hospitals engage in teaching and mentoring students while on placement. The current shortage of nurses as well as increased workload, results in nurses’ lack of adequate time and interest in public policy activities that are of concern to their profession .
Although nurses in Kenya have some level of participation in political activities, more engagement is required. For instance, nurses have participated in the public protest against certain policies such as the decentralization of healthcare services and the free maternal care, which were perceived to be the cause of 1) poor remuneration, 2) lack of recognition, 3) poor working conditions and selective promotions among other core issues related to their workplace activities . Nurses through their vibrant organizations , will seldom hold back from participating in countrywide strikes and demonstrations geared towards seeking government response to their impending demands. However, there were frequent waves of unsuccessful strikes and boycotts by nurses through their organizations KNUN and NNAK. The challenges encouraged nurses to enhance their participation efforts in the political arena.
From the review of previous literature, two studies were found investigating nurses involvement in health policy issues. In the study on the extent of East African (Kenya, Uganda and Tanzania) nurses’ participation in health policy development by Shariff , 78 nurse leaders were purposively selected for inclusion. Findings indicated that the nurse leaders’ perceived involvement in the policy arena as limited. In the other study on Kenyan nurses’ participation in national policy development by Juma et al. , findings revealed that the reason why there’s low participation of Kenyan nurses in policy development is that the policymaking process primarily followed a top-down approach, which denied nurses at the lower levels opportunities for direct involvement in national policy decisions.
In summary, previous studies indicated that nurses have minimal opportunities to participate in health policy activities. Moreover, from the review of previous studies in Kenya, on political participation, the subjects were nurse leaders. Additionally, a majority of previous studies indicating the relationship between political efficacy and political participation were conducted in developed democracies/countries [13,21-23]. These studies show that little is known about political participation among nurses in Kenya. In this regard, the researcher found it necessary to revisit and determine the levels of nurse’s political efficacy and political participation as well as explore the relationship between political efficacy and political participation among nurses in tertiary hospitals, the Republic of Kenya.
The study aimed to determine the levels of political efficacy and political participation. Additionally, the study explored the relationship between political efficacy and political participation among nurses in tertiary hospitals, the Republic of Kenya.
This study was based on the concept of political efficacy by Levy  and concept of political participation from the review of literature. Political efficacy is the feeling that an individual’s political action can influence the political process. The concept of political efficacy has four domains: external political efficacy/distal, external political efficacy/ local, internal political efficacy/skills, internal political efficacy/ knowledge . Political participation refers to any activity, formal or informal, mainstream or unconventional, collective or individual that seeks to influence either directly or indirectly on what the government does. Activities of political participation include (1) voting, and (2) Non-voting activities [4,5]. Evidence from the reviewed literature indicates that political efficacies are fostered in individuals who participated in politics; hence the need to explore the relationship between political efficacy and political participation among nurses in this study.
Population and sampling
This descriptive correlational study was designed to study a population of 2600 nurses who worked in the two national tertiary level hospitals in Kenya [24,25]. The sample size was 347 nurses, calculated based on the Yamane  formula. In consideration of loss of subjects, 20% of samples were added so that 416 questionnaires were distributed to collect data. Proportional stratified random sampling method was used to determine the number of nurses from each tertiary hospital units. Nurses who had worked at the hospitals for three years or more were included in the study. However, nurses who were away on sick leave or study leave during data collection were excluded from the final study.
Instruments used in this study included the following: 1) the Demographic Data Form, which was developed by the researcher and comprised the age, gender, marital status, level of education, salary per month, working experience in years, membership in organizations, the job titles as well as the unit in which the nurse worked. 2) The Political Efficacy Scale adopted from Levy  which measured political efficacy as a four dimensional concept, with a total of 15 items that were measured on a six-point likert-type scale of 1 (strongly disagree) to 6 (strongly agree). The possible score for the instrument ranged from a minimum of 15 to a maximum of 90, and the scores were interpreted into three levels (low=15.00-40.99; moderate=41.00-66.99; high=67.00-90.00). 3) The Political Participation Scale modified from Moran , which measured political participation as a two dimensional concept had 19 items of which the first item was dichotomous and was not included in the final scoring of the scale. The other 18 items were measured on a four-point likert-type scale of increasing frequency from 1 (Never) to 4 (frequently). The possible scores ranged from a minimum of 18 to a maximum of 72 (low=18-36.99; moderate=37.00-55.99; high=56.00-72.00). Content validity index of the Political Participation Scale was 0.92. The reliabilities of both scales (PE and PP scales) on Chronbach’s alpha were found to be 0.82.
Data collection was carried out using a self-administered questionnaire. The assigned coordinators distributed and collected the research package that contained an information sheet, consent form and the questionnaire, with an envelope. The research package was submitted to the participants. The subjects responded to the questionnaires within two weeks and returned it sealed in the envelopes provided, to the coordinator. Out of the 416 questionnaires submitted, 347 were returned and checked for completeness. An 80% response rate was achieved for data analysis.
Protection of human rights
The study was approved by the Research Ethics Review Committee of the Faculty of Nursing, Chiang Mai University, in Thailand (No. 003/2016). Permission and approvals to collect data from the two tertiary level hospitals was obtained from the respective Ethics and Research committees (KNH-P68/02/2016; MTRH-0001590). Subjects were informed of the purpose of the study and method of data collection; voluntary participation was assured through signing the consent form, as well as free choice to withdraw from the study at any time without having any effect on their performance evaluation or lose benefits entitled to them. Anonymity and confidentiality of all the information was maintained by using numerical codes in the questionnaires instead of using subjects’ names.
Data analysis was done after data collection, using a computer program. The statistical significance alpha (α) value was 0.05. Descriptive statistics were used to analyze demographic characteristics as well as the levels of political efficacy and political participation. The relationship between the overall scores for political efficacy and political participation among nurses was analyzed using Spearman Rho correlation since the data was not normally distributed. The magnitude of the correlation coefficient and direction of the relationship were interpreted according to Burns and Grove .
Demographic characteristics of the subjects
Among the 347 nurses that participated in the study, 75.50% of the subjects were females while 78.39% were married. Over half (66.28%) of the nurses were in the age group of not more than 40 years old, with 60.52% of the respondents being diploma holders. Furthermore, 94.24% were members of some organization, while 56.77% of the nurses were nursing officers (general staff nurses). 83.29% of the nurses earned less than or equal to Kshs. 150,000 (less than or equal to 1,500 USD)
The overall as well as the levels of each dimension of political efficacy were at moderate level (Table 1).
The results for the overall political participation as well as the levels of each dimensions were at moderate level (Table 2).
Relationship between PE and PP
There was a statistically significant moderate positive correlation between political efficacy and political participation (Table 3).
This study found that the overall score for political efficacy as perceived by nurses in the tertiary hospitals was at moderate level (=61.57; SD=12.79). This finding is consistent with previous study by Salvado  in which nurses generally rated themselves in the moderate range in terms of political efficacy (median score=40 on a scale of 0-80). The possible explanations for the moderate level of political efficacy among nurses in these tertiary hospitals can be linked to factors such as age and work experience. In this study, 66.28% of the nurses were in the young age group of less than 40 years old, while 56.77% of the nurses were merely nurse officers (general staff nurses); the minimum entry level at the workplace. In Kenya, this young age group (less than 40 years old) nurses were not in the influential positions of management, since they are perceived to be less equipped with the experience to handle policy issues within their facilities. This finding is consistent with previous studies which indicated that the older people will be more involved in politics than the young . Additionally, the findings indicated that 75.50% of the nurses were females; which meant that they seldom participate in politics due to their reluctance to exhibit the masculine trait typically associated with politics as identified in previous studies by Boswell et al. . In this regard age, minimum work experience as well as gender issue, contributed to nurses’ moderate levels of political efficacy.
The four dimensions of political efficacy were also at the moderate level. In this study, results for the internal political efficacy/knowledge which relates to an individual’s self-efficacy for understanding and knowing facts, concepts and theories relevant to politics was at moderate level. Possible explanation would be that some nurses had little knowledge about politics. The study findings showed that 39.48% of the nurses graduated from bachelor, masters, and doctoral degrees. These category of nurses had a chance to attend, voice their concerns and discuss policy issues during the managerial meetings, thereby granting them first-hand knowledge and skills related to politics. However, 60.52% of the respondents were at the diploma level of education which meant that they were least exposed to adequate knowledge to articulate issues in the political field. This is because the diploma program focuses on nursing care practice with little or no exposure on key management skills necessary in influencing policy.
Results for the internal political efficacy/skill which relates to a person’s self-efficacy for competently performing politically relevant tasks such as public speaking and constructing reasoned arguments were at moderate level. However, the score was moderately high. The explanation would be that nurses had an opportunity to learn and discuss about political activities in their organizations. In this study 94.24% of the nurses were members of some organization which conducted many political activities such as organizing for strikes, demonstrations and protests against the government. An example of the professional nursing organization is the Kenya National Union of Nurses, which mobilizes nurses to attend court or legal proceedings that pertain to nurses grievances with a view to improve the working conditions for nurses . Membership in nursing organizations, gives nurses a competitive edge to get involved by coming together to voice their concerns as a group , engage in constructive legal battles to gain an upper hand on certain policy issues of concern, express their dissatisfaction during the demonstrations and collectively boycott duty, until their demands are adhered to [32,33]. It is in this regard that nurses believed that they had adequate internal political efficacy/skills to construct good arguments about political issues. This finding is supported by Morrell  who claimed that discussing political issues with peers has a positive effect on individual’s political efficacy.
Study findings for the external political efficacy/distal which relates to an individual’s belief that they can influence political activities at the state and national levels were at the moderate level. The study also revealed that the external political efficacy/local which relates to an individual’s belief that they can influence community or local governmental institutions was at a moderate level. Possible explanations would be that there were many political activities nurses got involved in at the national level, such as voting into office the national officials for the organizations and attending legal proceedings at the national labor courts for a collective bargaining agreement with the government. In this regard, nurses believed that they could influence political activities at the national level. At the local level, nurses had some interest in the local politics that seemed much easier and less intimidating for them to participate. However, nurses found that only a few issues were taken into consideration by the National and County governments, hence the frequent waves of unsuccessful strikes. Ultimately, this contributed to the moderate levels of EPE/ distal and EPE/local.
The study found that political participation as perceived by the nurses in the tertiary level hospitals was at moderate level (=46.28; SD=10.22). This findings are consistent with a previous study by Avolio  among 201 Canadian nurses, in which nurses were only moderately active and just 30% of the respondents stated that they were motivated to become more involved.
The study found a moderate level of the voting dimension. The possible explanation would be that nurses as citizens of the country, have an individual responsibility of voting into office the government officials to run key issues at the ministries of health and other allied ministries of concern to health care, as the study findings showed that 82.42% of the nurses voted in the presidential elections in 2013. As Muchui  and Nation Media Group  found that nurses believed that through voting in a new government administration, certain policy issues of concern to their profession could be amended in their favor.
The study also found a moderate level of the non-voting dimension. The explanation could be that nurses’ have an interest in the sociopolitical issues that can only be changed through engaging in politics, such as pay increase, promotions, shortage of staff and recognition among other grievances at their workplaces. These socio-political interests motivate the nurses to pile pressure on the government to respond to their agenda through many activities; for example, nurses organize protests and demonstrations, boycott duty and campaign for or against certain political leaders to spearhead the realization of their impending demands. Moreover, in this study, 94.24% of the respondents were members of some professional nursing organization, which gave them a competitive edge in voicing their concerns to influence what the government will do with regards to attending to their demands, as a study by Vandenhouten et al.  reported that sources of encouragement to engage in political activities included nursing organizations (27%) and voluntary organizations (22%).
However, both voting and non-voting activities require having a sufficient amount of time to participate as claimed by Verba et al.  that people with more free time would be more politically active than those with less free time. In this regard, some of the nurses cannot leave their duties to vote since they have the responsibility for 24 hours caring of patients. Moreover, in this study, 83.29% of the nurses earned less than or equal to Kshs. 150,000 (approximately 1500 USD) which made them less capable of contributing monetarily in support of the political activities in their organizations. This is consistent with Vandenhouten et al.  who indicated that 9 out of 10 (92%) of the respondents perceived an inability to contribute monetarily to political candidates, parties or courses, as well as to nursing organizations for political purposes.
The relationship between political efficacy and political participation
The study found a statistically significant moderate positive correlation between political efficacy and political participation (r=0.31; p<0.01). In this view, the more politically efficacious an individual is, the more they will participate in other political activities (voting or non-voting) that have an influence on what the government does. Similar results were obtained in previous studies by Jun et al. , among 286 nurses in North Korea, who found that political efficacy had a moderate positive correlation with political participation (r=0.32; p<0.001); Vandenhouten et al.  found a strong significant correlation between political efficacy and political participation (r=0.59; p<0.01); McDaniels , in a study on the political participation of 56 registered nurses, showed that the feelings of political efficacy were a powerful determinant of political participation among nurses and there was a high positive correlation between political efficacy and political participation (r=0.797, p<0.01).
Possible explanation for the statistically significant moderate positive correlation could be that, political efficacy which refers to individual’s belief that they can understand and influence political issues, builds people’s confidence to participate in the political arena. According to Bandura’s  theory, self-efficacy refers to whether people believe that they have the skills to influence the political system. This study found that 43.22% of the nurses were in the higher rank of senior nurses, clinical educators and nurse managers, which gave them the chance and confidence to articulate issues related to policy. Furthermore, 39.48% of the nurses were bachelors, master’s or doctoral degree holders; 24.50% had a work experience of more than or equal to 15 years, which meant that they were experienced enough to engage in policy issues at their facilities. This is consistent with study findings by Caprara et al.  who inferred that, active participation requires citizens to believe in their own ability to influence the course of politics, in other words, to feel politically efficacious.
Furthermore, previous studies indicated that political efficacy, the belief that individuals’ action can influence governmental processes, increases when individuals have opportunities to; discuss public issues, participate in small-scale democratic processes, and develop connections with others who are politically engaged . In this study, 94.24% of the respondents belonged to some professional nursing organizations which gave them a platform to develop connections with others as well as participate more in political as well as the organizational activities such as contributing money, voting and participate in protests and demonstrations. In this regard, nurses perceived having some level of political efficacy that enabled them participate in political activities, hence the statistically significant positive correlation between political efficacy and political participation.
Since the study was conducted in two national tertiary level hospitals, the findings cannot be generalized to the whole population of nurses countrywide.
The study findings revealed that, the overall level of political efficacy as well as political participation as perceived by nurses were at a moderate level. Additionally, a statistically significant moderate correlation between political efficacy and political participation was found in this study. The findings of this study can provide valuable information to academic administrators on the need to introduce within the curriculum to equip nurses with knowledge and skills necessary for effective participation in the political field. Nurse leaders in professional nursing organizations can initiate fellowship as well as internship programs for nurses to learn and experience first-hand opportunity of participating in political activities geared towards changing policy in health care. Nurse administrators can help develop nurse’s participation in politics by encouraging them to become members of both institutional as well as national nursing organizations that take stands for nurses in the political arena.
Based on the study findings, the researcher proposes the need to conduct the same study at different levels of health care institutions (secondary and primary levels) among nurses in the Republic of Kenya. Moreover, conducting a predictive study on the factors related to political participation among nurses in tertiary care hospitals would be imperative.
A sincere appreciation is extended to the Thailand International Cooperation Agency (TICA) for the research grant and scholarship, Chiang Mai University, as well as faculty members who assisted in making my research dream as well as completion of the master’s degree, a reality.
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