133). This informal power is quite significant when it comes to patient decisions and as such doctors need to appreciate and understand this power nurses wield. Due to the unique information nurses have about patients, nurses have considerable decision-making responsibilities concerning patients. For this reason, many medical schools have implemented programs, in their curriculum, to teach medical student how important it is to listen to the advice of their nurses. Innovative universities like the University of Kentucky Medical Center actually encouraged their residents to develop a collaborative partnerships with the nurses with which they worked. Paynton (2009) notes that outcomes of patient care improve when collaboration increases and the role of nurses is valued. However, regretfully, this collaboration does not always take place.

Although there is a shift in trends towards more collaboration between doctors and nurses, giving nurses more formal power in advocating for patients, the narratives collected by Paynton (2009) revealed that nurses still must continue to use informal power strategies when working within formal constraints, in order to achieve desired patient outcomes. The medical profession is still perceived to have a monopoly regarding central patient care tasks, including diagnosis and therapeutic measures. Time and again, courts reiterate this formal power structure, calling medical and not nursing evidence to the stand (Goodman, 2003). Participants in Paynton's study expressed that they still felt obligated to follow the formal power structure of healthcare organizations and physicians, when it came to implementing patient care. The primary exception to this following of the formal power structure manifested itself when the nurses felt that the physicians' and/or healthcare organizations' decisions regarding patient care were inappropriate. When this occurred, the nurses surveyed employed significant informal power, as a means of advocating what they felt was appropriate patient care. All six of the nurses surveyed in Paynton's study felt that their role as patient advocate was most important duty.

Advocacy and Uncertainty in Nursing Students:

Although it's clear that nurses have a duty to act as a patient advocate, the conflicting power structures couple with the ambiguous nature of the definition of the concept of advocacy has often led to confusion regarding the role of advocacy and professional nursing, especially for nursing students. Keatley (2008) quotes a BSN student, "Sometimes patients are helpless or unsure in certain situations and I believe this is where we as nurses server as their advocates with our knowledge, close contact with their situations...

The team" (p 20). This student appears to have an understanding similar to the varied definitions discussed earlier. However, Keatley quotes another student describing advocacy by stating, "I try to show respect for others by understanding that people have a right to make their own decisions. My role (as) a nurse is to respect these choices and help them, when needed, to honor their decisions" (p. 20). This student demonstrates a different understanding of the components of the concept of advocacy. Until the nursing profession has a unified definition of advocacy there is likely to continuing uncertainty in nursing students, regarding the concept.
Conclusion:

Although patient advocacy is a critical role for professional nursing, there is still work to be done in defining the concept and facilitating nurses ability to be patient advocates. Patient advocacy has evolved to counter the personal and institutional vulnerabilities that patients face, which are often exacerbated by specialized patients, such as victims of crimes. To ensure nurses are able to be advocates, they must be empowered, yet often have to rely on an informal power structure to fulfill this important role. Yet, until the concept is clearly defined, the role of advocacy and professional nursing will continue to have elements of confusion.