Nursing stakeholder identification guidelines for human resources for health and health workforce development: A scoping review.

AIM: To investigate the existence of guidelines on the identification of nursing stakeholders as part of planning for human resources for health processes.
BACKGROUND: Effective involvement of nursing stakeholders in planning and implementing human resources for health policies is strongly advocated by leading global bodies. Systematic identification of nursing stakeholders at an early stage is fundamentally important. Guidelines to support appropriate identification and inclusion of nursing stakeholders could support the active involvement of nurses and midwives in human resources for health planning processes at all levels.
METHODS: We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We conducted a widely inclusive search for all types of records, including searches of bibliographic databases (PubMed, CINAHL, Scopus and Web of Science) and manual searches of selected websites and internet archives to identify grey literature, published in English since 2009. Search terms related to guidelines, stakeholder engagement and the health workforce.
RESULTS: Of the 1058 potentially relevant sources identified, two studies met inclusion criteria. Both were guidelines produced by global bodies more than 12 years ago. Cochrane guidance on reporting 'near-empty' reviews was followed, and eight additional sources meeting most of the inclusion criteria were identified and critiqued.
CONCLUSIONS: Guidelines regarding the process of nursing stakeholder identification specific to human resources for health planning processes are scarce and require updating. Critique of recent practices suggests considerable methodological variety and sub-optimal identification of nursing stakeholders. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nursing stakeholder engagement is an essential component of human resources for health planning processes, and the gap in literature points to a need for up-to-date guidance to ensure nurses' active involvement.

INTRODUCTION

Effective stakeholder engagement is a central challenge for human resources for health (HRH). The field of HRH seeks to optimise the health workforce, defined by the World Health Organization (WHO) as “all people engaged in actions whose primary intent is to enhance health” (WHO, 2006, p. 1). Well‐functioning systems for HRH require engaged participation from multiple sectors that directly affect health workforce capacity (Dussault & Dubois, 2003; Nyoni & Gedik, 2012). The Kampala Declaration and Agenda for Global Action (AGA; WHO), 2008) regarded effective stakeholder engagement as essential to achieving a renewed primary health care approach, providing an equitable continuum of quality healthcare to the whole of society, delivered as close as possible to people's everyday environments (WHO & UNICEF, 2018). The AGA attached high priority to establishing coherent national and global leadership for health workforce solutions capable of comprehensively addressing the wide range of factors that shape the health workforce (Resolution AGA1).

Effective mobilisation of stakeholders—defined as the individuals, organisations or communities directly interested in an initiative or policy endeavour (Deverka et al., 2012)—is critical to the successful development and implementation of HRH policies. In a report for the World Bank, Dussault and Dubois (2003) proposed that a wide range of factors (and therefore stakeholders) that shape the health workforce can be categorised into six functional domains. These span activities such as the negotiation and definition of working conditions, regulating standards of practice, training health workers, resourcing, service delivery and service use (Dussault & Dubois, 2003).

Assessments of HRH unit capacity in the WHO African Region have highlighted the challenges of achieving the necessary collaboration and across these domains (Nyoni & Gedik, 2012). Difficulties mobilising and coordinating multiple and diverse stakeholders have been found to contribute to the fragmentation of efforts and a lack of policy coherence (Nyoni & Gedik, 2012).

Effective involvement of nursing stakeholders in planning and implementing HRH policies is strongly advocated by global bodies, including the WHO and the International Council of Nurses (Shamian, 2015; Thorne, 2018; Tomblin‐Murphy & Rose, 2016; WHO, 2016). Resolution 59.27 of the World Health Assembly, for Strengthening Nursing and Midwifery, urges Members States to actively involve nurses and midwives in HRH planning processes at all levels, in ways that achieve genuine influence (WHO, 2006).

High‐level global HRH initiatives often treat the nursing workforce as a single homogeneous entity, but there is emerging interest in the development of key nursing specialisations (North et al., 2019). For example, prior research by the Harry Crossley Children's Nursing Development Unit (South Africa), which works to build the children's nursing workforce in southern and east Africa (Ruthe & North, 2020), encountered a need for a guideline to support systematic and comprehensive stakeholder identification to facilitate integrated specialist children's nursing workforce development.

There is widely accepted and authoritative advice on stakeholder engagement in general (Reed et al., 2009; Varvasovszky & Brugha, 2000), and it consistently recommends a multi‐stage approach. Stakeholder identification forms the first stage of this process and involves the identification of groups and individuals (stakeholders) relevant to the policy issue of focus. Subsequent stages of the process may involve determining stakeholder positions (e.g. support/opposition) regarding the issue, and determining the power of stakeholders relative to one another. Collectively, these activities are often referred to as stakeholder analysis (Gilson et al., 2012).

In a recent systematic scoping review of health innovations encompassing, but not limited to HRH, Franco‐Trigo et al. (2020) note that systematic identification of stakeholders is a crucial stage that is fundamentally important to the success of the wider project or process. The inclusion or exclusion of stakeholders at this initial stage may have far‐reaching consequences.

Guidelines have been described as “a convenient way of packaging and presenting evidence and recommendations to healthcare decision makers” (Treweek et al., 2013, p. 2). General characteristics of guidelines include statements of expected practice; benchmarks or standards, comparison and potential improvement of practices; or the presentation of structured recommendations about how to undertake particular tasks (Kredo et al. 2016).

Despite the critical importance of nursing stakeholder identification for HRH planning, we were aware of only one guideline focussing specifically on stakeholder identification for HRH planning (Global Health Workforce Alliance, 2009), and the extent to which this guideline explicitly considered nursing stakeholders was not immediately clear. A preliminary search for existing systematic reviews on the topic revealed no published reviews.

Aim

The aim of this review was to investigate the existence of guidelines on the identification of nursing stakeholders as part of planning for HRH processes. The questions guiding the review were:

What are the existing guidelines regarding the process of nursing stakeholder identification specific to HRH?

What methods of stakeholder identification do these guidelines recommend?

To what extent are nursing stakeholders explicitly considered in existing guidelines, and how does this relate to the functional domains of HRH?

METHODS

A protocol was developed following the methodology for scoping reviews published by the Joanna Briggs Institute (JBI) (Peters et al., 2020), reviewed by a specialist librarian using the PRESS tool (McGowan et al., 2016), and registered with the Open Science Framework (North et al., 2020).

A scoping review approach was selected for two main reasons. First, it is particularly suited to exploratory research questions (Peters et al., 2020) where literature is thought to be scarce or diverse (Arksey & O'Malley, 2005; Colquhoun et al., 2014). Second, consultation with stakeholders familiar with the body of knowledge relevant to the review question is recommended for scoping reviews to identify additional sources not identified through the initial search strategy (Levac et al., 2010). Scoping reviews can be conducted iteratively, enabling the incorporation of information obtained via stakeholder consultation (Levac et al., 2010), consistent with stakeholder‐engaged research principles. Because it was anticipated that guidance specific to nursing stakeholder identification would be very scarce, the focus of the review was not restricted to nursing, but was instead widely inclusive, covering all sectors of the professional HRH workforce.

Eligibility criteria

The population–concept–context (P‐C‐C) mnemonic was used to define key inclusion criteria, and definitions of all terms were specified (Supplementary Appendix S2). Included documents represented guidelines in English about how to conduct the process of stakeholder identification. No restrictions were placed on publication status because of the desirability of identifying relevant items from a diverse range of information sources.

Documents were excluded if they did not represent a guideline or were not specifically focused on HRH and health workforce development.

Information sources and search strategy

A structured search was made of bibliographic databases relevant to health sciences, social sciences and nursing (PubMed, CINAHL, Scopus and Web of Science). The search strategy was developed with assistance from specialist librarians and is available as a supplementary file (see Supplementary Appendix S3). A date range of 1 January 2009 to 31 December 2019 was selected to cover a ten‐year period commencing shortly after the publication of The Kampala Declaration and AGA (WHO, 2008), which was seen as a key driver for activity related to stakeholder engagement in HRH. The most recent bibliographic database search was executed on 23 February 2020.

Supplementary searches were conducted through four routes, between January 2020 and June 2021. Email consultation was carried out with seven individuals in senior global health and nursing leadership roles or with technical expertise in relation to global and Africa‐wide nursing workforce development. Both citation searching and reference list checking of included items were performed. Finally, manual searches of selected websites were undertaken to identify grey literature (see Supplementary Appendix S3). No date range was applied to supplementary searches, to maximise the identification of potentially relevant items.

Selection of sources of evidence

Search results were imported into EndNote X8 for de‐duplication and then exported to Rayyan QCRI (Ouzzani et al. 2016) for screening.

Two researchers worked independently to examine all sources and record their recommendations. Sources were screened for eligibility for inclusion according to the P‐C‐C criteria (Supplementary Appendix S2), and then an independent full‐text examination of identified sources was performed. A third reviewer scrutinised decisions and was available to resolve disputes.

Data charting and synthesis of results

Data charting recorded information about sources according to article characteristics (e.g. country of publication and year of publication), methods used to identify stakeholders and recommended stakeholder categories. Sources were appraised for evidence of the explicit identification of nursing stakeholders, and where relevant the identification of nursing stakeholders according to HRH functional domain was recorded. Data were extracted by both researchers working independently to chart the data. The results were discussed at two stages, first by the two researchers involved in data extraction and second with the third researcher who had not been involved in data extraction, before the synthesis of results.

RESULTS

The search identified 1058 records after de‐duplication (Figure 1). Of these, 1055 were excluded as they did not meet P‐C‐C criteria; therefore, the expectation that the search would identify a high proportion of irrelevant records was accurate. The remaining three records were screened using the full text for eligibility, and two were found to be eligible for inclusion. Manual searching of the reference lists and citation searching in Google Scholar for the included items did not identify any additional relevant items. This is, therefore, a ‘near‐empty’ review (Yaffe et al., 2012). We followed recommendations by the Cochrane Collaboration (Yaffe et al., 2012) and Lang et al. (2007) for reporting empty and near‐empty reviews, which suggest that reviewers may usefully offer some of the insights and new knowledge generated through the review of abstracts and articles, even where eligibility criteria were not met in full. We describe these sources as ‘additional sources’ in the remainder of this paper, to transparently distinguish them from the included sources.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA‐ScR) diagram

Characteristics of included sources

Both the included records are guidance documents published in Europe in 2009 by global non‐governmental organisations (Global Health Workforce Alliance, 2009; International Council of Nurses 2009) and characteristics are summarised in Table 1.

TABLE 1

Record characteristics of included sources (n = 2)

						Identification of nursing stakeholders according to HRH functional domain
Author, year; country. Title.	Document type	Aims and purpose	Methods used to identify stakeholders (indicating primary 1 or secondary 2 sources where relevant)	Recommended stakeholder categories	Extent and level of identification of nursing stakeholders (indicating supra‐national, national, regional, local where relevant)	Working conditions	Professional regulation	Education	Health services	Users	Resourcing
Global Health Workforce Alliance, 2009; Switzerland. Human resources for health: country coordination and facilitation principles and process (CCF).	Guideline	To guide the development of HRH plans, with the intention of improving stakeholder participation and coordination.	Provides a list of suggested stakeholders to include in country‐level HRH committees. Stakeholder analysis to be done to ensure all constituencies are represented adequately. No methods are specified for further local implementation of stakeholder identification.	Government, multilateral agencies, the private sector, bilateral agencies, civil society, academia, professional associations, regulatory bodies, labour movements, networks and foundations. Examples of institutions or departments are provided under each category, together with suggested functions and responsibilities in relation to HRH. All are national or supra‐national.	National. Very limited mention of nursing. Nurses are included as example of an institution in the categories of professional associations and regulatory bodies (p. 21).	X	X
International Council of Nurses, 2009; Switzerland. Guidelines on planning human resources for nursing.	Guideline	To assist national nursing associations (NNAs) and nurse leaders in contributing to HRH planning for nursing.	Suggests potential roles for NNAs in relation to HRH: lobbying; defining scope of practice; situational and needs analyses; data collection and verification; and formulating, implementing and evaluating strategic plans. No methods are specified for nursing stakeholder identification.	Presents a conceptual framework for effective nursing HRH management with six categories: policy and planning; education, training and development; deployment and utilisation; regulation; and evidence for decision making.	National. Nurses are the main focus of this document. Other stakeholder groups are referred to briefly, in connection with the need for collaboration and coordination.	X	X	X	X		X

Primary: suggestions obtained from stakeholders themselves.

Secondary: suggestions obtained from secondary sources. e.g. documents, reports or consultation with individuals who are not themselves stakeholders.

Synthesis of results

Existing guidelines regarding the process of nursing stakeholder identification specific to HRH planning processes

The WHO/Global Health Workforce Alliance developed and published the Country Coordination and Facilitation Framework (CCFF) in 2009 to guide the development of HRH plans, with the intention of improving stakeholder participation and coordination. The International Council of Nurses published guidelines on planning human resources for nursing in the same year, to support nursing involvement in HRH.

Recommended methods of stakeholder identification

The CCFF approach involves establishing and supporting the governance structures needed for inter‐sectoral collaboration and coordination, aiming to achieve planning, implementation and monitoring of HRH through one unified HRH plan. It is recommended that the plan must reflect training, retention, performance, remuneration, equitable distribution, responsiveness and migration of the workforce, consistent with the overall national health strategy. The methods used to devise the list of suggested stakeholders are not reported. It is recommended that a stakeholder analysis should be conducted to ensure adequate representation of all constituencies on the country's HRH committee (GHWA 2009). No recommendations are made concerning methods for the implementation of local stakeholder identification.

The ICN guidelines focus on assessing and strengthening nursing stakeholders’ capacity to engage with HRH planning processes. Nursing stakeholders are identified according to their contributions to various categories of activity, defined according to a conceptual framework for HRH. No methods are specified for nursing stakeholder identification at the local level.

Recommended stakeholder categories

The CCFF presents a recommended list of stakeholder categories aligned with these functions. The included stakeholders are all national or supra‐national. Major categories include government, multilateral agencies, the private sector, bilateral agencies, civil society, academia, professional associations, regulatory bodies, labour movements, networks and foundations. Examples of institutions or departments are provided under each category, together with suggested functions and responsibilities in relation to HRH.

Consideration of nursing stakeholders

The CCFF broadly focuses on all sectors of the professional HRH workforce. Consideration of nurses as stakeholders within the CCFF is limited. In contrast, the ICN guideline focuses exclusively on nursing stakeholders and refers only briefly to other stakeholder groups, in connection with the need for collaboration and coordination. No recommendations are made regarding the integration of nursing and non‐nursing stakeholder groups.

Identification of nursing stakeholders according to the HRH functional domain

The CCFF includes nurses alongside doctors and pharmacists as an example of an institution in the categories of professional associations and regulatory bodies. The ICN guideline identifies nursing stakeholders in connection with five of the six functional domains, omitting only the ‘service user’ domain.

Additional sources not meeting the inclusion criteria

Recommendations regarding the process of nursing stakeholder identification specific to HRH planning processes

We identified eight additional sources providing information relevant to the review questions; however, they did not meet the definition of a guideline (Akwanalo et al., 2019; Coetzee, 2014; Department of Health (England), 2005; Hyder et al., 2010; Namazzi et al., 2013; Oluoch et al., 2018; Witter et al., 2012) or were not specific to health professionals (Cometto et al., 2018). All the additional sources offer detailed recommendations regarding the process of stakeholder identification specific to HRH and health workforce development. The sources reported on work undertaken in a total of 12 countries, published between 2005 and 2019, and the characteristics are summarised in Table 2.

TABLE 2

Record characteristics of additional sources (n = 8)

					Identification of nursing stakeholders according to HRH functional domain
Author, year; setting (country)	Aims and purpose	Methods used to identify stakeholders (indicating primary or secondary sources where relevant)	Recommended stakeholder categories	Extent and level of identification of nursing stakeholders (indicating supra‐national, national, regional, local where relevant)	Working conditions	Professional regulation	Education	Health services	Users	Resourcing
Akwanalo et al., 2019. Kenya	Identification and engagement of key stakeholders involved in referral of patients as part of approach to strengthening specialist health systems in Kenya.	Participatory research methodology using International Association of Public Participation (IAP2) framework. Primary: Snowball technique.	Ministry of Health; the Academic Model Providing Access to Healthcare (AMPATH); health care providers affiliated to the MoH and AMPATH; health professionals; communities and their leadership; patients.	Nurses not identified as stakeholders.
Coetzee, 2014. South Africa	Strengthening paediatric nurse training in South Africa by convening stakeholder colloquium.	Participatory workshop using World Café methods. Primary: Consensus methods, graphic harvest to create stakeholder grid.	Schools of nursing; departments of health; health care facilities; clinicians; regulatory.	National, regional, local. Almost all stakeholders were nursing stakeholders or connected to HRH for nursing.		X	X	X		X
Cometto et al., 2018. Global	To guide primary health care and health systems strengthening, focusing on Community Health Worker (CHW) programmes.	Presents a health system approach to identify relevant policy and system enablers and associated stakeholders relevant to CHW initiatives.	Selection, education and certification of CHWs; management and supervision of CHWs; integration and support of CHWs by health system and communities.	Nurses not identified as stakeholders.
Department of Health (England), 2005. United Kingdom	To address specialist service staffing in the English National Health Service (NHS).	Mandates the formation and specifies the composition of Care Group Workforce Teams (CGWTs) as expert working groups, interacting with other formal NHS structures.	Complex matrix of health workforce stakeholders comprising ±30 individuals, plus cross‐membership with other relevant bodies. Full membership of the Children's CGWT can be viewed here.	National, regional, local. Nursing stakeholders identified as representatives of clinical specialisms and service delivery.				X
Hyder et al., 2010. USA, UK, Bangladesh, China, India, Nigeria, Uganda	To review methodological issues in conducting stakeholder analyses in low‐ and middle‐income countries, related to health systems strengthening research.	Qualitative stakeholder analysis. Identification of stakeholders according to 11 pre‐defined categories. Primary: Snowball technique.	Beneficiaries, with a focus on neglected groups; central government agencies, e.g. ministries of finance, planning, civil service; ministry of health and key parts of the ministry; local governments; financiers; civil society organisations; health governing boards; provider organisations; professional organisations and health workers; unions; and suppliers.	Nurses not identified as stakeholders.
Namazzi et al., 2013. Uganda	To guide CHW strengthening programmes.	Primary: Brainstorming among research team members, and subsequent snowballing.	National level: MoH, Member of Parliament, development partners, religious bureaus. District level: District leadership, district health team. Health sub‐district: Health providers, public providers, private providers. Village: Households, women, men, community leaders, opinion leaders, transport drivers.	Nurses not identified as stakeholders.
Oluoch et al., 2018. Kenya	Identification of key neonatal nursing policy development and implementation stakeholders.	Secondary: Documentary review Primary: Snowballing, through consultation with stakeholders identified via documentary review.	(i) statutory policy making/strategic endorsement, (ii) technical advice, (iii) evidence generation and (iv) consultative.	National. The Office of the Chief Nursing Officer in the Ministry of Health; Nursing Council of Kenya; Kenya National Nurses Association; Nurse Training Institutions.	X	X	X	X
ReBuild Consortium, 2012. Sierra Leone	Stakeholder mapping of key actors influencing policy and practices in HRH.	Primary: Brainstorming workshop using structured questions.	Ministry of Health Services, other ministries and public bodies; political bodies: regulatory bodies; training institutions; donors; NGOs, and the private sector.	National. Nurses and Midwives Board.		X

The additional sources presented a variety of methods for stakeholder identification, with many eliciting information through a combination of primary sources (e.g. suggestions obtained from stakeholders themselves) and secondary sources (e.g. suggestions obtained from secondary sources, e.g. documents, reports or consultation with individuals who are not themselves stakeholders). Two of the additional sources cite pre‐existing methodologies as the basis for their approach. Both used participatory design. Coetzee (2014) describes the application of the World Café method to facilitate a stakeholder identification exercise. Akwanalo et al. (2019) describe the use of participatory research methodology using the International Association of Public Participation (IAP2) framework. None refer to either the CCFF or the ICN guidelines.

Recommended stakeholder categories were charted (see Table 2). Three of the additional sources describe using pre‐defined stakeholder categories to guide stakeholder identification (Cometto et al., 2018; Department of Health (England), 2005; Hyder et al., 2010). The remaining additional sources allocated stakeholders to categories that were devised after initial stakeholder identification, as part of a subsequent analysis of power and influence dynamics.

The extent to which nursing stakeholders were considered, and thus identified as stakeholders, varied between no consideration (n = 4), very limited consideration (n = 1: nursing stakeholders identified in relation to one category only) and more extensive (n = 3: two or more categories) (see Table 2), with no discernible consistency of approach.

The five sources that used participatory and consultative methods resulted in the identification of nine nursing stakeholders (Akwanalo et al. 2019; Coetzee, 2014; Namazzi et al., 2013; Oluoch et al., 2018; Witter et al., 2012). The three sources which used pre‐defined stakeholder categories resulted in the identification of only one nursing stakeholder in total (Cometto et al. 2018; Department of Health (England), 2005; GHWA, 2009; Hyder et al., 2010). There was, however, considerable variation in outcomes between additional sources—using apparently similar methods—with the use of consultative approaches resulting in the identification of four (Oluoch et al., 2018), one (Witter et al., 2012) and no nursing stakeholders (Namazzi et al., 2013). We did not discern any consistency between methods and outcomes related to the identification of nursing stakeholders according to the HRH functional domain.

Very few of the additional sources were explicit about which HRH functional domain stakeholders these were related to. Where nursing stakeholders were identified, but the HRH functional domain was not explicit, we recorded them according to the categories suggested by Dussault and Dubois (2003). Nursing stakeholders were identified in relation to functional leadership of professional regulation (Coetzee, 2014; Oluoch et al., 2018; Witter et al., 2012), education (Coetzee, 2014; Oluoch et al., 2018), health services (Coetzee, 2014; Department of Health (England), 2005; Oluoch et al., 2018), working conditions (Oluoch et al., 2018) and resourcing (Coetzee, 2014).

DISCUSSION

Summary of evidence

We undertook this review to investigate the existence of guidelines on the identification of nursing stakeholders as part of planning for HRH processes. This scoping review had one main finding: Guidelines regarding the process of nursing stakeholder identification specific to HRH are sparse and not very current. In addition, we observed that the documented descriptions of the process of stakeholder identification specific to HRH and health workforce development in the additional courses that we critiqued demonstrate the considerable methodological variety and often lack the detail needed for local replication or implementation.

Our initial speculation about a scarcity of formal guidelines regarding the process of identifying nursing stakeholders specific to HRH and health workforce development was supported by the findings of this near‐empty review. Both included items were published more than 10 years ago, in the period immediately after The Kampala Declaration (WHO, 2008). Whilst effective stakeholder engagement was identified as an important area at that time, understanding of the inherent challenges has developed considerably in the succeeding years (Nyoni & Gedik, 2012). Multi‐level stakeholder integration, collaboration and coordination are increasingly emphasised as central challenges in HRH activity (Afriyie et al., 2019; Van Ryneveld et al., 2020). The sources we identified offer little detailed guidance specifically intended to integrate nursing stakeholders with the existing national HRH planning process.

Where nursing stakeholders were referred to, such as the Chief Nursing Officer, or the Nurses’ Council, we noted a lack of detail regarding the specific HRH leadership functions these stakeholders were being asked to represent. This lack of specificity in engaging nursing stakeholders has been observed in relation to all forms of health policy making, not only HRH (Tomblin‐Murphy, 2016) and may reflect simplistic perceptions of ‘nursing’. Nursing leaders have previously highlighted the need to achieve functionally specific nursing leadership engagement, spanning the ‘three pillars’ of regulation, professional practice and socio‐economic welfare (Tomblin‐Murphy & Rose, 2016). The ICN guideline advises that complex HRH processes cannot be the sole responsibility of one nurse or one nursing organisation (International Council of Nurses, 2009). More recently, the WHO's State of the World's Nursing report (2020) also cautions against generic views of nursing leadership, describing the Government Chief Nursing Officer role as an essential nursing leadership position, but not one that should be expected to embody or represent all nursing leadership and governance functions alone (WHO, 2020).

Two of the additional sources that we critiqued (Oluoch et al., 2018; Witter et al., 2012) classified nursing stakeholders as high in interest, but relatively lacking in influence related to HRH, compared with technical partners, donors and advisers. This is consistent with the conclusions of the UK All‐Party Parliamentary Group (APPG) on Global Health's ‘Triple Impact’ report (2016). The APPG concluded that nurses’ importance within the policy‐making process (including planning for HRH) is frequently undervalued, with nursing stakeholders often confined to implementation stages and excluded from policy design and planning. The APPG speculated that nurses’ exclusion from policy making may be due to the perceived lower status of nurses and nursing within the political and organisational cultures of healthcare (APPG on Global Health 2016).

We discerned little detail in the recommendations or reporting about how nursing stakeholders should be identified. Rationales for the method of stakeholder identification used were scant and were often stated in the form of a purpose statement or goal rather than a justification of the processes followed. None of the sources critiqued were solely concerned with stakeholder identification. All of them were concerned with stakeholder identification as one part of a wider project or endeavour. These observations correspond with the findings of a more broadly focused systematic scoping review by Franco‐Trigo et al. (2020), which found that despite stakeholder identification being crucial in effective engagement, this is often overlooked in policy development processes, with more priority given to mapping stakeholder attitudes or dynamics. The consequences of not investing sufficient attention to stakeholder identification appear likely, on the basis of our review, to compound the under‐representation of nursing leaders as part of planning for HRH processes.

We did not discern any consistency between methods and outcomes related to the identification of nursing stakeholders according to the HRH functional domain. The range of methods was narrow, and we are aware of a greater variety in methods applied more recently to engaging stakeholders beyond the scope of this review (Akwanalo et al., 2019; Bird et al., 2021; Greenhalgh et al., 2019; Tesfazghi et al., 2016), all with potential applicability. Although consultative methods might have been expected to result in the identification of more nursing stakeholders than the use of pre‐defined categories—which do not include nursing leadership functions—our review of the literature does not support this conclusion. The consultative methods described by the additional sources resulted in the identification of four (Oluoch et al., 2018), one (Witter et al., 2012) and no nursing stakeholders (Namazzi et al., 2013). The lack of detail regarding what questions were asked and of whom in these consultations is a barrier to further analysis. The use of documentary analysis to identify stakeholders, reported by one of the additional sources we critiqued (Oluoch et al. 2018), has also been applied within health services research (Dizon et al. 2016) and health policy development not specific to HRH (Tesfazghi et al. 2016). We note that in all the reports we critiqued, documentary analysis was always used alongside other consultative methods, e.g. snowballing. It is, however, likely that an initial under‐representation of nursing stakeholders as authors of peer‐reviewed publications would be compounded through subsequent selection bias associated with snowball sampling.

We did not identify a guideline or a detailed process providing guidance likely to result in the systematic identification of nursing stakeholders involved in planning for HRH. Nor were we able to conclude outcomes associated with different methods for stakeholder identification, given the lack of detail and transparency in reporting. Future studies that report on HRH stakeholder mapping could usefully apply the Reporting Items for Stakeholder Analysis tool (Franco‐Trigo et al., 2020) intended to improve the quality and transparency of stakeholder analysis through consistent reporting. Our review suggests that there is a need for updated guidance to support the systematic identification of nursing stakeholders involved in planning for HRH and facilitate the integration of nursing stakeholders with HRH planning processes at every level.

Strengths and limitations

To our knowledge, this is the first attempt to investigate the existence of guidelines on the identification of stakeholders as part of planning for HRH processes, and the first to explore the extent to which existing guidelines explicitly consider nursing stakeholders. Despite the results constituting a near‐empty review, we consider the comprehensive search strategy to be a major strength of this study, comprising rigorously designed and executed bibliographic database searches in combination with expert consultation and searches of grey literature internet archives. It is, however, very possible that we missed relevant sources, mainly because of the difficulty of constructing search terms due to a lack of controlled vocabulary on this topic. Having determined that our initial results represented a near‐empty review, with just two included sources both published 12 years previously, we decided to summarise pertinent information gleaned from additional sources that did not meet the inclusion criteria. This strategy contains a few limitations, though we present this information transparently to enable readers to draw their own conclusions. Guidance on empty and near‐empty reviews (Lang et al., 2007; Yaffe et al., 2012) recommends that researchers reflect on whether the search strategy was excessively exclusive. We consider that the search strategy was appropriately focused and that the scarcity of included items is likely to be a reasonably accurate representation of the state of the field at this point.

It was challenging to define search terms that were sensitive to the central concept of HRH, and the input of specialist librarians was invaluable in devising a strategy. Terms in wide usage in the literature including ‘human resources for health’ are not part of the controlled vocabulary for indexing and a variety of keywords are in use (manpower, labour, human resources etc), many of which are not specific to the health workforce. The term ‘health workforce’ was introduced only as a Medical Subject Headings (MeSH) term in 2019. A further challenge was the ubiquity of the terms ‘stakeholders’ and ‘guideline’, often in combination, which were noted to occur in almost every abstract screened. These challenges were mitigated as far as possible by diligent planning and piloting of the search strategy for bibliographic databases, with close collaboration between the researchers and a specialist librarian. We support the recommendation of Franco‐Trigo et al. (2020) regarding the creation of new MeSH terms for ‘stakeholder’ ‘stakeholder analysis’ and ‘stakeholder mapping’ to support the identification of literature in this field.

CONCLUSIONS

Despite recognition of the centrality of the nursing contribution to planning for HRH, our review found little explicit consideration of nursing stakeholders within existing guidelines or reports regarding the process of stakeholder identification specific to HRH. The sparse literature identified suggests a topic where there has been little scholarly activity to date. Repeating this review at a later date would enable the evaluation of progress within this field. Methods of stakeholder identification currently appear highly variable, and the relationship between methods and outcomes in relation to the identification of nursing stakeholders is opaque. We conclude that the goal of identifying and engaging functionally specific nursing leadership for HRH risks being missed because of inadequate attention to the crucial stage of stakeholder identification within HRH planning processes, compounded by simplistic perceptions of nursing leadership. This situation could be improved through the development of up‐to‐date guidance to support the systematic identification of nursing stakeholders involved in planning for HRH, related to specific functional domains. Importantly, guidance should support the integration of nursing and non‐nursing stakeholders as part of an integrated approach to HRH planning.

Implications for nursing practice and policy

Nursing leaders have knowledge and insights that are central to HRH and the achievement of universal health care. However, the systematic identification of nursing stakeholders as part of HRH planning processes appears to have received little attention in recent years. There are a variety of approaches to stakeholder identification currently in use within HRH. Our critique of accounts of stakeholder engagement in HRH suggests that the identification of nursing stakeholders may often be ‘hit or miss’, with inconsistent recognition of specific nursing leadership responsibilities related to HRH functions.

Lessons learned

Areas for further development include strengthening the design and reporting of methods for stakeholder identification in this field and updating guidance to support the systematic identification of nursing stakeholders involved in planning for HRH, spanning all relevant HRH functions.

ETHICS STATEMENT

This study was approved by the Human Research Ethics Committee (HREC) of the University of Cape Town. HREC Ref: 022/2020.

FUNDING INFORMATION

No funding was received in respect of this review.

AUTHOR CONTRIBUTIONS

Study design: NN; data collection: NN, PB; data analysis: NN, PB, MC; study supervision: PB, MC; manuscript writing: NN; critical revisions for important intellectual content: PB, MC.

CONFLICTS OF INTEREST

The authors declare that they have no conflict of interest.

Appendix S1: Inclusion criteria and definitions

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Appendix S2: Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) Checklist

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Appendix S3: SEARCH STRATEGY

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