Advocacy in nursing practice and patient care

¶ … Nurse as Patient Advocate

Persons who choose nursing as a profession do so because they have a deep sense that they want to help others. Most do not do it because of pay incentives. Those who choose nursing for that reason are soon disillusioned by the long hours, physical and mental fatigue that go along with it. People choose nursing because they have a need to help those in need. When they become nurses however, the role that they play is often defined by a large, bureaucratic system and they sometimes find that they must choose between their sense of doing what is right for the patient and conforming to the rules of the system.

Nurses traditionally served as helpers to the doctors, performing mundane tasks to free the doctor for other things.. Doctors make the decisions and give the orders. Nurses follow the orders that the doctor gives. Sometimes the orders that a doctor gives are in conflict with patient wishes. The nurse in this case is faced with a moral dilemma. Should she act on behalf of the patient, potentially putting her career in jeopardy, or should she just do as she is told and ignore the wants and wishes of the patient? This brings us to the primary issue at hand, "What is the role of the professional nurse in health care delivery?"

Jeanette Hewitt (2002) reviewed many articles published on the subject and came to the conclusion that the field of nursing is in general, made of a group of highly ethical people, who are charged with the care of those in need. Nurses are often powerless and must adhere to the rules under which they must operate. Sometimes a doctor may make a decision, that in the eyes of the nurse, is not in the best interest of the patient. However, under the present philosophy, is obligated to adhere to the doctor's orders. Often this emerges as a power struggle between the nursing staff and the physicians. According to Hewitt (2002), the doctors are not always the evil oppressors in this scenario and nurses do not always know all of the circumstances surrounding the case. In making decisions to go against doctor's orders, nurses must consider not only the potential consequences to their career, but also the dangers that they may be unintentionally imposing on the patient. The nurse has a responsibility to have a complete understanding of the laws and case before stepping outside of her prescribed role.

Jan Keffer (1996) also struggles with this issue of patient advocacy. She discusses an example where nurses were asked to convince mothers of newborns to room-in with their infants, not because it was better for the infants and mothers, but because it was a money-saving measure for the hospital. How can the nurse act in the best interest of the patient when she is powerless to go against the larger establishment?

Keffer discusses three levels of persuasion used to influence the patient's decision. Nurses are often asked to try to influence patients to make decisions that are in the best interest of the establishment. Persuasion is the gentler form of influence, where the person makes a good argument to support their side. Manipulation involves leaving out key information in order to influence the person's decision. This means that the person is making a decision based on mis-information or missing information. Coercion involves that threat of harm for failure to comply.

When a nurse decides to take a position as a patient advocate, many feel that he/she has and obligation to give the patient all of the facts in order to be fair to the patient. She must know the laws regarding informed consent and must adhere to these laws. Many people would not be adverse to using a little gentle persuasion now and then, as long as the patient has all of the facts and is making a decision of their own free will. Manipulation is where the area gets grey. Manipulation involves the omission of certain facts. There have been cases where these omissions could have a definite influence on the person's decision. It is an especially grey area when nurses are asked to withhold information about potential dangers of action or inaction. For most, the act of coercion poses a real ethical problem and many would not use this level of influence. Coercion takes away a person's free will and there are not many that would allow this practice.

Mary Brophy (2001) discusses the role of nurse advocacy in the neonatal unit. The doctors and nurses are acting in the best interest of the infant. However, they also must not forget the infant also has a family who also has an opinion as to what is best for the infant. This can get into a struggle as to who has the most rights, especially when the opinions differ widely..

In the days of Florence Nightingale, nurses were the subjects of the doctors. They treated a group of patients, whom, except for a few were an uneducated lot and placed their lives in the hands of the educated. The doctor, because of differences between the educational level of himself and that of his patient, often achieved a "God-like" status in the eyes of the patient. He knew what to do when they had nowhere to turn. The patient was a victim and at the mercy of the doctor. Patient rights were not an issue. The right to know was also not an issue, as most of the patients would not understand their condition anyway.

Now doctors and nurses are dealing with a more educated and informed society and the patient has definite opinions about their own care. In the early days of nursing, patients did not have a choice of doctors and were stuck with whoever was local. Now, with advances in communications and transportation, patients act more as consumers (Hewitt, 2002). As consumers they make buying choices as to whom to give their business to. They must be made to feel that they are in control to some degree. If they feel that information is being withheld or that the staff is not acting in their best interest, then they can choose another practitioner or hospital. This new-found knowledge is the basis for the dilemma that nurses face today, especially when acting in the role of patient advocate.

The changing role do of the nurse has been dictated by the changing role of the patient. Patients are becoming more service oriented and nurses' roles are changing as well. Nurses are no longer just following orders given by an omnipotent doctor, but are recognized as professionals in their own right. Their primary interest should always be in the best interest of the patient. The question is where to draw the line. Nurses now have more authority and are allowed to make many decisions that would have been off-limits in the past. Patients expect them to be knowledgeable and not dependent upon doctors for their every move.