Analysis of a nursing workforce policy on the career ladder and pay structure of public sector nurses in the Maldives: a qualitative study

Abstract

Background

International organizations have encouraged countries to adopt policies that ensure adequate pay and career development opportunities for professional advancement and job satisfaction, thereby contributing to organizational effectiveness. The Job Family Standard for Nursing (2018) is a workforce policy on the career ladder and pay structure that aims to improve the career advancement and pay progression of public sector nurses in the Maldives. This study explores the context, process, actors, and content of the policy with regard to the career ladder and pay structure in the Maldives.

Methods

A qualitative descriptive design was used to collect and analyze data from individuals involved in policymaking. Semi-structured interviews with 26 participants and a document review were used for data collection, and a thematic analysis was conducted. The results were reported via the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist and categorized into four major components: context, process, actors, and workforce policy content. The findings indicate that contextual factors, such as the modernization of public administration, political changes, challenges in health system development, and engagement and communication with different actors, influence the process of policy formulation and implementation. Actors such as government elites significantly influence policy content and implementation.

Conclusions

The findings provide evidence of how contextual factors and the role of actors influence the policy development process so that the content of policies can be finalized and implemented. It is crucial to undertake comprehensive policy analysis to identify contextual factors, engagement and communication with different actors, and these actors’ power and influence in shaping policy content and implementation. Nurse leaders and managers should proactively engage relevant actors to contribute to the development of effective policies for nurses’ retention and organizational effectiveness.

Trial registration

Not applicable to the study.

Background

During deliberations at the World Health Assembly in 2021, concerns were expressed regarding the detrimental impact of the coronavirus disease 2019 (COVID-19) pandemic on nurses and midwives, particularly with regard to remuneration policies and sustainable financial and nonfinancial incentive packages [1]. Nurses in other nations would have been impacted similarly to their peers in the Maldives. For example, India, a middle-income country like the Maldives, faces comparable challenges concerning a lack of policies that provide adequate remuneration and opportunities for career advancement [2]. The International Council of Nurses’ (ICN) report “Recovery to Rebuild” is indicative of the necessary changes to policy and practice. Changes to practice involve the need to invest in workforce sustainability. Effective and coordinated policy responses at the national and global levels can enhance the recovery and rebuilding of health systems globally following a pandemic [3]. Therefore, there is a need for national-level planning to invest in nurse retention by implementing strategies such as offering fair pay structures, creating well-structured career pathways, and implementing policies to enhance career advancement [4].

Adequate pay and career opportunities are elements of a decent work environment and are closely related to health care workers’ legal and civil rights [5]. The International Labor Organization (ILO) called for regulatory frameworks for the health workforce to address clear career progression and incentive schemes [6]. In the global context, the National Health Services (NHS) Agenda for Change is a pay policy for nursing and pay system progression that was introduced in the United Kingdom in 2004 to improve the retention, recruitment, and productivity of the NHS workforce [7].

A substantial body of research has emphasized the importance of a career ladder, the presence of career paths with professional advancement, nurses’ job satisfaction, the intention to leave, and decreased turnover [8, 9]. Similarly, previous studies have shown that “pay” is a crucial factor that impacts job satisfaction, motivation, positive work attitudes, retention, and the intention to leave [10, 11]. A study of the nursing workforce in India reported on processes related to career advancement. These processes are highly disorganized and irregular, and varying salary structures for nurses across the country impede the advancement of the nursing profession [12]. A study of Maldivian nurses also reported that low pay and few opportunities for career advancement contribute to high turnover rates [13].

Nursing workforce policy context in the Maldives

The Maldives is an archipelago in the Indian Ocean with 1192 coral islands, of which 188 are officially inhabited islands grouped into 20 administrative atolls. The health care delivery system in the Maldives is organized into a four-tier system where tertiary hospitals provide services at the highest level. Across the Maldives, there are 5 regional hospitals and 20 atoll hospitals that have limited health care facilities. The lowest level consists of island health care centers that provide primary care [14]. The tier system is within the public health care sector, even though a few private hospitals provide specialized care, and many smaller private clinics provide limited health care services. The Maldivian nursing system comprises several types of nurses that must be registered and licensed by the Maldives Nursing and Midwifery Council (MNMC) depending on the level of nursing education and corresponding nursing registration and licenses to practice [15].

Although several workforce policies have been implemented within the context of nursing in the Maldives [14], no uniform framework was developed for the career ladder and pay structure until 2018, when the Maldives’ Civil Service Commission (CSC) implemented a national policy for the nursing workforce. This national policy, known as the Job Family Standards for Nursing 2018, harmonized the career ladder and pay structure only for nurses employed in the public health care sector in the country [16].

Policies related to nursing exist in a competitive arena of power, funding, and agendas developed through consultation and negotiation and influenced by policymakers within the social and clinical culture [17]. In Bangladesh, to incorporate nurses’ voices in decision-making, the government implemented a policy for education, career, and governance to improve nurses’ position in the public service sector by designing an independent directorate general post. New policies often entail new apprehensions related to new positions [18]. A policy analysis framework is critical for examining and understanding past lessons and providing evidence for future policy development [19]. However, few studies have examined the factors that affect the formulation and implementation of nursing policy. The health policy triangle (HPT) model proposed by Walt and Gilson [20] has been widely applied because it offers a systematic analysis of the complex relationships in health-related policies [21]. The HPT model advocates for analytical attention to four interrelated aspects: context, process, actors, and content [22]. Context refers to political, economic, social, national, and international systemic factors that may influence policy formulation and implementation. Process refers to the way policies are initiated, developed, negotiated, implemented, monitored, and evaluated. Actors refer to the individuals, organizations, and government institutions that influence policies. Finally, content refers to the substantive details of a policy and includes the constituents it affects. According to the HPT model, policy analysis provides valuable evidence of how context influences the policymaking process, its outcomes, and the significant actors who exert their power and influence to support policy decisions. The Longest model for public policymaking is a comprehensive framework in which processes involve three interconnected phases of policy formulation, implementation, and modification [23]. In this study, we use a hybrid conceptual framework developed by researchers that comprises the HPT and Longest models for public policymaking and analyze the four dimensions of the Job Family Standards for Nursing (2018).

Study aim

This study aimed to explore and analyze the context, process, actors, and content of the Family Standards for Nursing (2018) policy and data collected from individuals involved in policy-making. The policy focused on the nursing career ladder and pay structure and was designed to address career advancement and pay progression.

Methods

Research design

A qualitative descriptive design was employed to achieve the aim outlined above. This design allows for better understanding of a phenomenon [24] by considering the voices of individuals involved in policy development while closely analyzing the data. Unlike quantitative methods that seek to neutralize the position of the researcher, qualitative methods, such as interpretive description (ID), deliberately capitalize on the researcher as an instrument in the research process. Qualitative researchers such as Thorne [25] (2016, p. 70) acknowledge that researchers are valuable instruments and that their “technical knowledge, research backgrounds and personal experiences are major sources of insight” (p. 339 [26]). The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used as a guide to ensure detailed reporting.

Participants and setting

This study was conducted in a public-sector healthcare setting in the Maldives. The sample comprised 26 participants who contributed to various stages of the policy formulation and implementation process. The sample was drawn from two groups.

• The first group comprised national-level participants, including high-level policymakers or officials who were involved in different stages of policymaking, and stakeholders from institutions such as the President’s Office (PO), the Ministry of Health (MoH), the Ministry of Finance (MoF), the CSC, and the MNMC.

• The second group comprised technical-level participants, including technical-level policy implementors or stakeholders from the MoH, MoF, and CSC, healthcare facilities, nursing managers, and individuals from the Maldivian Nurses Association (MNA), who contributed to policy formulation and implementation.

Purposive and snowball sampling were used to identify possible participants, who were subsequently asked whether they were willing to participate in this study. Participants who agreed were provided with detailed information about the study via email. In addition, 52 documents comprising related laws, regulations, guidelines, reports, memoranda, and letters were reviewed as part of the data collection process.

Ethical considerations

Ethical approval was obtained from the research ethics committee, Faculty of Nursing, Chiang Mai University (Approval no: 112/2022). Given that the study was conducted in the Maldives, the Maldives National Health Research Council did not object to the research. Informed consent to participate was obtained from all participants after they received information about the study’s aim and objectives. It was also emphasized that participation in the study was voluntary and that an individual could refrain from participating in the study at any time without any negative consequences. All participants were informed about their rights and that their decisions would be respected. No unforeseen harm arose for any of the study participants.

Data collection

Data were collected from January 2023 to March 2023 by a researcher trained in conducting qualitative interviews. The interviews were conducted at a venue that was convenient for the participants. Strict confidentiality was ensured, and all interviews were conducted in English. Two semi-structured expert-validated interview guides (Supplementary File 1) developed by the authors included questions derived from the conceptual framework of the study on the basis of four dimensions of the HPT model [21] and three phases of the Longest model of public policymaking [23]. These dimensions were used to gather information from the two groups of national- and technical-level participants. The interview guide was pilot tested prior to data collection. The researcher collected data until data saturation was reached. Each interview lasted approximately one hour and was audio-recorded with the participant’s permission before being transcribed verbatim. Additionally, 52 documents comprising laws, regulations, and reports were reviewed. The major documents examined were the Civil Services Act, National Pay Act, Health Professionals Act, civil service regulations, National Pay Commission (NPC) regulations, Maldives Health Master Plans, and National Health Workforce strategic plans to support data triangulation.

Data analysis

All recorded interviews were transcribed verbatim by the first author. The qualitative data were organized and managed via the computer-assisted program ATLAS.ti version 23.2.1 (4325), where all the transcribed interviews were uploaded for coding and categorization and subthemes and themes were derived. The first author performed the initial coding, which was subsequently verified by the rest of the research team. The researchers analyzed the dataset via Braun & Clarke’s six-step thematic analysis, a flexible method that enables systematic examination of qualitative data in the following order: (1) familiarization by reading and rereading the data; (2) development of codes; (3) development of themes; (4) review and revising of themes; (5) defining and naming themes; and (6) writing the analysis report [27]. The reviewed documents were analyzed along with the interview content to triangulate the data. The themes were supported by direct verbatim quotes and excerpts from the interviews and documents.

Rigor

In a qualitative study, rigor and trustworthiness are vital for methodological accuracy and soundness [24]. Processes to enhance trustworthiness, as recommended by Lincoln and Guba, that were used in this study included member checking, data and method triangulation, and peer debriefing [28]. Member checking or respondent validation was performed by approaching some participants (n = 10) with the results of the analysis and interpretation of the findings. This enabled confirmation that the data represented the participants’ realities. Rigorous peer debriefing was conducted with qualitative experts to assess the qualitative data and establish the credibility of the findings. Data triangulation was performed to compare the interview findings with the documents that were reviewed during data collection.

Results

The qualitative findings included an analysis of the participants’ perceptions of the Job Family Standards for Nursing (2018) policy. The data were triangulated with the findings from the reviewed documents. The themes were constructed around the four dimensions of the HPT [19] model and three phases of the Longest model for public policymaking [23]. Table 1 presents the ten themes identified and categorized under the four dimensions of context, process, actors, and content.

Table 1 Dimensions and themes

Context

Analysis of the contextual factors that influenced the formulation and implementation of the Job Family Standards for Nursing (2018) policy revealed three major themes: (1) the modernization of public administrative services; (2) the changing political scenario; and (3) challenges in health system development.

Modernization of public administrative services

The first theme refers to the reforms and significant changes to the Maldivian government due to the need for modernization within the recruitment and employment of personnel in the public service, including the nursing workforce. For decades, all government employees, including public health professionals, were directly managed (appointed and dismissed) by the office of the country’s president. In 2007, the lack of rules for recruitment, promotions, and transfers was addressed. Each profession requires a separate career ladder system, a feature that was previously lacking. One participant stated,

We have been in a traditional job structure, a one-basket structure, for a very long time. Maybe 30 years or more. Likely from the beginning of nursing. (Technical-level participant 4)

Under the legal framework of the Maldives Services Act (2007), a CSC report outlines the creation of the Maldivian Civil Service. This report defines the responsibilities of personnel and showcases the authority of civil services separate from presidential power:

With the establishment of the CSC, all employees’ human resource management functions were transferred from the Public Service Division of the President’s Office to the Civil Service Commission under the Civil Service Act. (Document 3)

Similarly, with the enactment of the Civil Service Regulation in 2014, the CSC was mandated to formulate career ladders and pay structure frameworks for all public sector professions, including the nursing profession. Article 62 of the Maldives Civil Services Act states,

Job classification states the classification of Maldives Civil Service employees’ positions (career ladder/path)…. Common principles shall be applied equally and fairly in employing personnel and determining the salary and benefits for positions (career ladder/pay in the same classification). (Document 1)

The CSC initiated the development of an equitable system in which employees are promoted commensurate with and reflective of the productive output of their services. Nurses represent a large group of civil service employees and were a focus for the development of a modern career pathway that is consistent with aspirations for quality health services:

When we were formed by the Civil Service Act, the first thing the Civil Service Commission did was to create standards for modern career paths for all the occupations within the civil service, including nurses. (Technical-level participant 13)

However, with the formation of the NPC during the ratification of the National Pay Act in 2016, a shift from the CSC to the NPC was mandated. The aim was to determine, consolidate, and renew the policies and principles for the career ladders, salaries and benefits given to individuals in the public service sector.

Changing political scenario

The second theme, the changing political scenario, refers to the political transitions that occurred in the Maldives and influenced the formulation and implementation of the career ladder and pay structure policy. In 2008, the first multiparty system democratic election was held; since that time, nurses have had increased expectations for a new career ladder and pay structure. However, as stressed by two participants, no such reform occurred until 2018:

Especially since that was an election year…. I would not say only in the Maldives but anywhere else in world, politics and the economy must have had a lot of influence for a new career ladder and pay structure to be implemented. (National-level participant 4)

The major factor was that it was 2018, and there was so much pressure because of the delay in providing professional job categories as well as pressure from the government owing to the delay in implementing job structures. (Technical-level participant 7)

Challenges in health system development

The third theme, challenges in health system development, also influenced policy formulation. For example, recruitment difficulties in response to the expanding healthcare services resulted in the development of a policy aimed at retaining the healthcare workforce given the difficulty of hiring qualified local nurses, particularly on the regional and outer islands. As one participant stated,

There were challenges at that time because the salary structure in the career path could have been better. In particular, locally trained nurses are less attracted to the salary and the other benefits the civil services offer. (Technical-level participant 14)

The Maldives Health Master Plan 2016–2025 emphasized that strengthening the nursing workforce with a reward system and incentives is crucial for the expansion of the health sector:

To strengthen the health workforce (including nurses) that supports equitable distribution of an appropriate skill mix to provide quality health services, there is a greater need to market the health sector as attractive by providing incentives and opportunities for career advancement to motivate employees to advocate a reward system to enhance workforce productivity and the retention of qualified staff. (Document 16)

Process

Analysis of the policy process revealed three themes: (1) policy formulation, (2) policy implementation, and (3) policy modification

Policy formulation

The first theme, policy formulation, represents the commencement of policy development, which involved setting an agenda for career ladder and pay structure standards. The lack of modern career pathways was identified by several studies that assessed the Maldives’ civil service system. These studies emphasized the lack of separate career ladder systems or pathways that allow for career advancement for professionals, including nurses. The solution was the creation of the Job Family Standards policy, which is a workforce policy on the career ladder and pay structure of nurses. The negotiations conducted to formulate the policy represented a significant paradigm shift. Initially, the CSC took the lead in 2013 by organizing discussions and negotiations among stakeholders to create a career ladder and pay structure. One participant stated,

The initial discussion engaged the stakeholders…. They are the Nursing Council, representatives from the Ministry of Health, and nurses from Indhira Gandhi Memorial (IGMH), which is the biggest tertiary hospital in the Maldives. (National-level participant 7)

Thus, the policy was derived from stakeholders’ input, market analysis reference documents, and ILO documents. However, some senior nurses on the stakeholder committees felt that they could not influence the policy formulation and that their input was not considered. This was a concern for one of the participants:

However, the endorsed and implemented structure did not wholly include our suggestions. (Technical-level participant 7)

Although CSC members endorsed the initial Job Family Standards for Nursing policy in March 2015, the implementation process could not be initiated owing to financial barriers. Consequently, the implementation of the policy was hindered given the budgetary constraints and the high cost to the state’s budget. One participant stated,

It was the final endorsed structure (career ladder and pay structure of the policy), but there was a considerable delay because the government could not provide the budget for implementation. There was a significant effect on the government budget. (National-level participant 7)

Policy implementation

The second theme, policy implementation, was initiated by the MoH and included continuous negotiations related to the pay structure budget with decision-makers, including the CSC, MoF, PO, and NPC. However, no specific negotiation plan was established, particularly with respect to the budget. In early 2018, according to the participants, stakeholders engaged in ongoing dialogue to discuss compromises for the final version of the policy. One participant stated,

Negotiations were carried out with stakeholders. One of the delays in implementing the new policy was due to the many negotiations among the stakeholders. (National-level participant 10)

Finally, in 2018, with budget approval from the NPC and MoF, the PO instructed the CSC to implement the Job Family Standards for Nursing (2018) policy. The MoH was mandated to implement the policy across all public healthcare institutions, and the policy was fully executed across the Maldives for all public-sector nurses. Figure 1 presents the timeline of the activities that occurred during the policy formulation and implementation phases.

Fig. 1

Timeline of policy formulation and implementation phases

The CSC found implementation of the new policy on the career ladder and pay structure was demanding. The implementation of the policy was sudden news for nurses. One participant stated,

I think that process did not go very smoothly. It was somehow rushed… The proper communication channels must not have occurred or were not discussed, so they were forced to implement this… we did not have much time to discuss it with the nursing workforce. (Technical-level participant 1)

Policy modification

The third theme, policy modification, refers to revisions to the policy after implementation. The first revision involved the appointment of ward managers, which was not part of the Job Family Standard for Nursing (2018) policy when it was implemented in 2018. The amended document stated,

Ward managers are recruited with the requirement of clinical nurses and given a functional title as identified in the organizational charts of the healthcare institutions. (Document 2)

The policy amended the requirement for recruiting ward managers, a functional title on the career ladder for the clinical nurses who are appointed as in-charges of the wards in the hospitals. The second revision changed the tenure duration for the ward managers from two to four years.

The need to regularly revise health workforce policies, including those for nursing, was highlighted by one participant,

It is important to regularly review nursing workforce policies every 5 years so that we can better address the workforce in a rapidly evolving and developing system. (National-level participant 4)

Actors

Two main themes emerged from the analysis of the actor component: (1) the roles and influence of governing elites and (2) the roles and influence of nongoverning elites. The first theme refers to the different groups of actors who were top-level government policymakers or experts with the power to influence policy formulation and implementation.

The roles and influence of governing elites

CSC members were among the governing elites entrusted with developing a cadre for specific professions as per the Civil Services Act. In 2013, when the CSC initiated the policy formulation process, a consultative process was conducted with the MNMC and senior nurses from the main tertiary hospital (IGMH) to help develop the policy. The first version of the workforce policy was endorsed by CSC members in March 2015. One of the experts involved in policy formulation stated,

I took the draft policy to the nurses and held a meeting at IGMH, the largest hospital for nurses. I got their comments, brought some revisions based on their suggestion, got the draft approved by the nursing council, and then shared with the Civil Service Commission. (National-level participant 3)

Although the MoF had the power to allocate the budget, it did not approve the policy because of the increased salaries. The CSC attempted to intervene through parliament to speed the approval process; however, it was unsuccessful in influencing policy implementation in 2015. One participant mentioned,

We have been discussing this since March 2015 to implement the policy. We had a series of meetings with the Finance Ministry. We had written to the People’s Majlis (Maldivian parliament) regarding this because the Commission is legally mandated to implement such things to draft. (National-level participant 7)

However, CSC members worked actively in coordination with the MoH to negotiate and secure the budget required to implement the workforce policy on the career ladder and pay structure from the MoF. It was finally approved in 2018, just before the presidential election.

The roles and influence of nongoverning elites

The second theme, nongoverning elites, refers to professional or technical experts in professional nursing, human resources, management, and finance during policy formulation and implementation. These actors included members of the MNA and a few senior registered nurses who voiced their demands for the formulation and implementation of a nursing workforce policy on the career ladder and pay structure. Some of these actors met several times with MoH and PO officials regarding requests to increase nurses’ salaries, as reflected in the following quotes:

As the president of the Nurses Association, I met with the Minister of Health regarding the implementation of a career ladder. (National-level participant 11)

We also went to meet the President’s Office, but that was regarding the desire to increase the salary structure of the nurses. (Technical-level Informant 1)

Content

Analysis of the content dimension revealed two major themes: (1) elements of the policy and (2) promotional pathways for career and pay progression.

Elements of the policy

The first theme reflected elements of content in the Job Family Standard for Nursing (2018). In this theme, nursing positions were categorized into levels of nursing personnel required by public sector healthcare organizations. The required educational qualifications and experience for nurses, the corresponding pay structure band for each category, and the level of nurses were outlined. The career ladder and salaries were readily seen as beneficial for those with longevity in nursing services, with a 30–40% increase in salary. For example, it was evident for nurses with ten years of experience. One participant stated,

Overall, I think the structure (career ladder) is okay; it is good…. So I think that work or the groundwork/foundation of what was most beneficial for the nursing service or to the nurses is written (in the policy). (National-level participant 1)

Table 2 presents details of the career ladder pathway identified in the Job Family Standard for Nursing (2018). The career ladder pathway was broadly classified into three professional groups: director group positions, general nursing positions, and specialized nursing positions. Each group was subsequently classified according to job title.

Table 2 Three main group classifications with job titles in the job family standard (2018) policy

Promotional pathways for career and pay progression

The second theme, promotional pathways for career and pay progression, indicated that the main objectives of the policy were to provide career ladders and pay promotional pathways for professional advancement and pay progression. Career promotions were based on educational qualifications. For example, the requirements to move from the senior registered nurse title to the clinical nurse title and the requirements for a nurse to obtain a master’s degree in nursing are stated in the Job Family Standard for Nursing (2018) policy (Table 3).

Table 3 Job title and basic educational requirements

Appraisal was based on annual performance and resulted in salary increments. However, concerns were raised that the appraisal system was not sufficiently robust to measure performance accurately. One participant stated,

We need to see whether performance appraisal is done correctly, which is an issue in the system of how we practice… rather than a salary (pay) structure issue. (Technical-level participant 11)

Discussion

The findings indicated that the Civil Service Act mandated the drafting of a job structure for all professionals through the Job Family Standard for Nursing policy. In accordance with the global human resource for health (HRH) strategy, countries should adopt policy options in which the MoH, CSC, and employers provide financial strategies for adequate wages and ensure career development opportunities [28]. Prominent contextual factors emphasized changes in the Maldives arising from public administrative reform, particular political scenarios during the 2018 election, and challenges in health sector development. Various social, political, and economic forces and national events, such as elections, reveal highly complex and evolving contexts that affect policy development [29].

The formulation and implementation of the Job Family Standard for Nursing (2018) policy occurred in three phases: formulation, implementation, and modification. This pattern is consistent with the public policymaking process outlined by the Longest model for health policymaking [23]. Evidence of agenda setting, such as the reform process required to create a modern career path for all professionals, including nurses, was found in the formulation phase.

The analysis of the process indicated that policy formulation was a complex coordinated effort in which the influence and power of several government institutions affected the content and implementation of the policy. A similar policy analysis of Zambia’s community health strategy revealed the complexity of the policy process manifested through multiple partners that contested the development process and the adoption and rejection of the policy within two years [30].

According to the Longest model, the final stage of policy development is the modification phase, which involves an intricate process of revision and adjustment to accommodate fluctuating circumstances [23]. The Job Family Standards for Nursing (2018) policy also underwent modifications. A revised version of the policy was published with amendments.

The findings of this study show that CSC members, the MoH, and the MoF played active roles in the policy formulation phase. Political actors such as the Minister of Finance, who had the power, did not exercise the authority of the position to provide adequate support to approve the initial policy. The proposed changes in pay structure significantly impacted the government’s budget. However, CSC members worked actively in coordination with the MoH to negotiate and secure the budget from the MoF for implementation in 2018, just before the presidential election. The political actors used their positional influence and control over the national budget to pursue their interests, which were showcased during election campaigns [31].

Additionally, pressure from the MNA and senior nurses, who demanded a salary increase from the government, was evident. Although professional nursing bodies and individual senior nurses attempted to influence the formulation and implementation of the policy, they felt that their comments and suggestions were not incorporated. They reported perception of limited involvement in the policy development process. International evidence supports their arguments. Nurses are often excluded from policy development or planning or are given ad hoc responsibilities in policy formulation [32]. Reasons for exclusion include a lack of knowledge and skills in substantive policy areas, a lack of education on policy and political content, inferiority to other health professionals, credibility in policy environments, and a negative public image [33, 34].

This study identified career ladder structures, specialization pathways, experience requirements, promotion pathways, and pay structures for various categories and levels of nurses. Research reports that identify the levels of nurses in an organization on the basis of their educational qualifications, work experience, and work duration allow them to perform in a manner consistent with their competencies [34]. Similarly, the formulation of an evidence-informed career pathway for registered, specialized, and advanced practice nurses that involves titles, the scope of roles, educational requirements, and evaluation processes, has led to increased awareness and acknowledgment of the traditional and new roles of registered nurses within healthcare environments [35]. The results of this study indicate the need to generate knowledge from policy analysis in different countries to enable actors’ participation in the development and implementation of future policies for the nursing workforce related to the career ladder and pay structure in the public sector.

Limitations

This study had several limitations. First, because the data were collected from participants who had been involved in policy development over an extended period, the retrospective approach may have led to recall bias as the participants struggled to accurately remember details or processes from years earlier. For more robust and insightful data, the researcher ensured the inclusion of participants who were still involved in policy development at the time of data collection. Senior officials and technical staff of the MOH and CSC and nursing managers were included. Second, the relatively small sample of 26 participants may not fully capture the diversity of perspectives within the nursing workforce or among policymakers. However, this study used purposive and snowball sampling, which are standard qualitative techniques, to collect data from the participants and triangulate these data with material from policy-supporting documents. Furthermore, reviews of the literature were performed. Third, this study analyzed workforce policy for nurses who worked in the public-sector healthcare setting. Therefore, the findings may not be completely applicable to the private sector or other healthcare settings.

Implications

This study provides valuable evidence-based findings for policymakers, nursing administrators, and researchers on four components—the context, process, actors, and content of the policy—that may be pertinent to similar settings in other countries. The implications for nursing policy suggest that future policymakers should be mindful of contextual factors such as administrative reforms and political shifts. Additionally, the process of formulating and implementing workforce policy for pay structures impacts budgets. Therefore, an appropriate plan for dialogues and negotiations is required to finalize and implement an evidence-based policy.

Furthermore, understanding various actors’ roles and influences in shaping policies is crucial. It is vital to ensure that actors and stakeholders, including those directly involved and affected, are engaged in developing nursing workforce policies for the career ladder and pay structure. Nurses’ participation is essential to design impactful policies pertaining to their employment and practice. In particular, the participation of senior nurses who have knowledge and expertise on what constitutes a comprehensive policy on the career ladder and pay structure is necessary. Thus, nurses must be educated in policy studies and empowered, and opportunities must be created for them to contribute to the policy formulation phase.

Conclusions

The results provide a comprehensive understanding of the Job Family Standards for Nursing (2018) policy process across four dimensions: context, process, actors, and content. The results indicate that contextual factors are essential. While the formulation and implementation process took several years owing to negotiations, the policy led to an increase in nurses’ pay and established a career ladder that provided career advancement opportunities. A comprehensive policy analysis is crucial for identifying contextual factors and the process of engagement and communication with different actors as well as their power and influence in shaping policy content and implementation. Furthermore, nurse leaders and managers should proactively engage with relevant actors to contribute to effective nursing policies. The findings may be applicable to other public sector nursing policies on career ladders and pay structures. However, additional examination of similar contexts in different countries is needed.