Role of Advocacy and Professional

Role of Advocacy and Professional Nursing

Patient advocacy has been a concept in nursing since Florence Nightingale. Although it is an accepted component of the profession of nursing, the concept of advocacy's ambiguous nature has resulted in a variety of definitions causing confusion. Despite the confusion, the catalyst for advocacy is the same -- protecting patients against risks of vulnerabilities. There are specialized instances when advocacy goes even one step further, such as with victim care. However, to facilitate advocacy, nurses need to be empowered. Without empowerment, nurses often turn to informal power structures to perform patient advocacy. Although advocacy is an important part of the nursing profession, until the concept is clearly defined, there will continue to be confusion regarding the role of advocacy in professional nursing, especially for students just entering the profession.

The Role of Advocacy and Professional Nursing

Introduction:

Patient advocacy has been a concept in nursing since Florence Nightingale. Although it is an accepted component of the profession of nursing, the concept of advocacy's ambiguous nature has resulted in a variety of definitions causing confusion. Despite the confusion, the catalyst for advocacy is the same -- protecting patients against risks of vulnerabilities. There are specialized instances when advocacy goes even one step further, such as with victim care. However, to facilitate advocacy, nurses need to be empowered. Without empowerment, nurses often turn to informal power structures to perform patient advocacy. Although advocacy is an important part of the nursing profession, until the concept is clearly defined, there will continue to be confusion regarding the role of advocacy in professional nursing, especially for students just entering the profession.

Overview of the Concept of Patient Advocacy

The concept of patient advocacy has been a much discussed topic in nursing literature, for several decades. However, as Negarandeh et al. (2008) note, ambiguities remain regarding the definitions of patient advocacy in professional nursing. The nature of the nurse-patient relationship is often described as 'advocacy'. Many nurses assume that there is an ethical obligation to advocate on behalf of their patients. Negarandeh et al. further detail how nurses often "describe their judgments and action on behalf of a patient as 'being a patient advocate'" (p. 457). For this reason, it's not surprising that many see patient advocacy as an inherent component of professional nursing.

Despite the fact that advocacy is often perceived to be a key role in nursing, diverse definitions of the concept exist. This causes confusion about the role of an advocate, which then leads to difficulties in putting advocacy into practice (Negarandeh et al., 2008). Early philosophical models of patient advocacy centered on the patient's right to self-determination. It was surmised that the nurses role was to assist the patient with exercising this right. A primary duty was to help patients decide a course of action. Later, more pragmatic models were developed. These theorized that advocacy pivoted on the patient's right to self-determination as well, but that the patient must make an informed decision. Therefore, the role of advocacy in professional nursing was to inform the patient and to not only support the patient's decisions, but also their right to make these decisions. Negarandeh et. al cite Mallik and Chafey as describing advocacy as being triadic in nature. Not only does advocacy involve the relationship between the patient and nurses, but also the relationship between nurses, patients and others in the environment. Patient advocacy, therefore, sees the nurse actively involved in the representation of the patients to others. No matter what the differences are in the conceptual definition, however, the primary condition that requires the need for advocacy remains the same.

The vulnerability of patients is the core condition that mandates advocacy action, for nursing professionals. Negarandeh et al. (2008) separates this vulnerability into two categories of risk -- personal and institutional. Personal vulnerability risk results due to the patient's illness, while institutional vulnerability risk results do the processes inherent to the institutional health care system. Most patients demonstrate some level of vulnerability due to their: illness, culture, economic status, educational background, personality, or previous experience with health care. In addition, certain medical conditions including mental illness, unconsciousness, or cancer can compromise a patient's ability to self-determine their health care, allowing them to protect their own best interests. Patients may fell powerless, due to having a limited knowledge about health care, or due to neglect from the health care system, increasing their vulnerability. Piper (2008) cites several World Health Organization reports which note that patients often are unable to take control of their own health care when in a hospital. Even a health care professional's attitude towards a patient can increase vulnerability. Attitudes such as the dehumanizing, disregarding, punitive, controlling, and judgmental practices of biomedicine are of particular concern.

Restructuring of hospitals, as well as the implementation of cost cutting and care management policies and procedures, have negatively affected the healthcare industry's ability to assure safe and quality patient care. Cost saving programs, and reactions by healthcare organizations to the lower funding, caused a great deal of concern amongst the nursing profession. Of particular concern is patient safety. It is feared that decreasing nursing skill mix as well as decreasing numbers of registered nurses that could provide direct patient care as and provide supervision of support staff, could lead to a reduced number of opportunities for the patient to receive appropriate interventions and assessments that are important to facilitating their recovery. There has been a paradigm shift in the healthcare environment, from patient-focused to cost-focused (Rowell, 2003). For this reason, the role of advocates for professional nurses is evermore important.

Person-Centered Care: Comprehensive Patient Advocacy for Victims:

Lawson (2008) discusses the common occurrence of the use of the term 'victim-centered' when it comes to care for those who were the victim of a crime. However, despite the best intentions of the use of terms such as victim-centered care, it is truly person-centered care that nurses must focus on, not only to give the highest level of care possible, but also to ensure they are fulfilling their duties as patient advocate, to the best of their abilities. Giving the patient a label of 'victim' reduces the patient to a singular dimension instead of recognizing them as the unique individual that they are. Lawson recommends simply focusing on the practice of nursing. In addition to the role of the nurse as patient advocate, patients who have been victimized also often require the services of a victim advocate. Obtaining these additional advocacy services for the patient are part of the role of advocacy in nursing, in these situations.

Empowerment as a Means of Promoting Advocacy in the Role of Professional Nursing:

Although most nursing professionals have some understanding regarding the role of advocacy in their profession, the success of their advocacy for their patients is often challenging. McCarthy and Freeman (2008) surmise that empowerment is a powerful tool for facilitating nursing's role in influencing patient safety, care quality, and equitable access to health care. The seminal report, Keeping Patients Safe: Transforming the Work Environment of Nurses, released by the Institute of Medicine (IOM) in 2004, McCarthy and Freeman note, was key in igniting public concern for this topic. The IOM report "identified nursing's failure to effectively shape the health care system and to advocate successfully for healthier communities, individuals, and for nurses themselves" (p. 68). To fully take advantage of this tool, however, empowerment first must be clearly understood, which isn't as easy as it sounds.

The concept of empowerment is both abstract and ambiguous, according to McCarthy and Freeman (2008). Part of this ambiguity comes from its application to a variety of different disciplines, each imbuing the concept with different meaning that varied dependent on the perspective and the context. The researchers analyzed the characteristics, attributes and application of empowerment to nursing to clarify the meaning, along with its potential to influence nursing roles.

Three classifications of empowerment were discovered in McCarthy and Freeman's (2008) study -- community advocacy, patient care, and empowerment of the nurses themselves. In light of the 2004 IOM report, it's clear that empowerment of nurses is critical. Interestingly, this process is not dependent on management, instead it's a mutual process of learning, along with nurses becoming both politically and collectively active, while also accepting their autonomous roles in these instances and their responsibilities. Advocacy, according to the authors, goes beyond the individual patient and includes the larger social, political and economic environment. Only when considering this larger scope can nurses fully embrace their role as advocates for their patients, families, communities, and themselves. To facilitate this process, empowerment is the key.

The Informal Power of Nurses and Their Role of Advocacy:

Paynton (2009) surmised that nurses were already empowered to facilitate their role as advocates, via informal power. The communicative techniques nurses utilize to advocate appropriate patient care, Paynton insists, has gone largely unexamined. Where a significant amount of formal healthcare power resides in organized health care systems, clinical administration, and physicians, interestingly, nurses in the study demonstrated "they communicatively exercised informal power strategies in the performance of their role as patient advocates" (p. 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.