The following is part of a research project I completed to answer the question of how we view Advocacy in nursing. This subject interests me because of the interpersonal relationships that affect our ability to be effective in our nursing roles. Advocacy has become a relevant issue when it comes to how we deal with our co-workers. In a profession that is predominanty female, it is certainly true that we women are hard on each other and are critical of each others abilities and motives. As a student, I’ve been warned that nurses eat their young. No worries, I replied… I’m not that young…LOL! Regardless I have experienced my share of bullying from instructors and co-workers during the five years I’ve taken to complete my Nursing degree and have seen the breakdown of communication that has led to many tears and leaving one’s job. Can we doubt the intentions of Nurses and Care Aides, that they (I mean we) have our patients best intentions at heart? That we have an innate compassion for others that often supercedes our own interests? And how long can we expect to sustain this compassion when met with such consternation amongst our peers?
It is for this reason that we need to define Advocacy… in modern terms and in a way that has meaning for us.
The term advocacy originated from the Latin Advocatus, `one who is summoned to give evidence’ (Gates 1995).
Dictionaries define an advocate as `one who pleads the cause of another’ (Oxford English Dictionary, 1989).
Advocacy as it was first understood was a legal term describing the activities and responsibility of a lawyer. It was later adopted as a concept in nursing:
Advocacy can be defined generally as “helping others to grow and self-actualize” (Marquis & Huston, 2012, p. 116). This can be by helping others to make decisions, by speaking for those who cannot speak for themselves and by protecting those who cannot protect themselves. It requires knowledge, confidence and skill and it considered a component of professional practice and is considered a leadership skill (Marquis & Huston, 2012)
Advocacy reflects the values of caring, autonomy, respect and empowerment and can be categorized as Patient, Professional, Subordinate and Whistleblower (Marquis & Huston, 2012).
Some additional definitions of Advocacy:
–An Ethic of Practice – “Patient advocacy is not merely the defence of infringements of patient rights. Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual.” (Gaylord & Grace, 2013)
–A Relational Narrative – “In practicing existential and human advocacy, or engaging in a relational narrative, nurses may assist persons who experience health inequalities to clarify their values, and, in becoming more fully their authentic selves, community members who ordinarily feel powerless in the public space may act with confidence in influencing the distribution of health-care resources” (Murphy & Aquino-Russell, 2008)
–A Collaborative, Team-Oriented, Multidisciplinary Approach to Care – “…nurse’s agency is expressed within the context of multidisciplinary team efforts to anticipate patient-related problems and address problems as they arise. Nurses act to influence the situation by understanding and giving voice to their own concerns as well as the concerns of the patient and the patient’s family, and by making these concerns heard in ways that result in action to address actual and potential problems” (Day, 2006)
How do we Advocate for our patients:
Disease results in a loss of independence, autonomy, loss of freedom and control. Nurses act as representatives of the patients’ voice who can help fulfill the patients unmet needs and decrease frustration and anxiety and help provide a sense of hope. Nurses, in various roles, can help allocate resources like social services, various therapies, Home Care, etc., which can facilitate transition from hospital to home, or help relieve financial stress for the patients.
The Canadian Nurses Association’s (CAN 2008) Code of Ethics for Registered Nurses lists ‘Promoting Justice’ (p. 17) as one of seven core values and responsibilities towards patients and provides recommendations to address social justice as a means of addressing the social determinants of health.
“Other public health social justice language included the terms disadvantaged (van den Bergh et al. 2009); disenfranchised and political rights (Peréz & Martinez 2008); financing of healthcare, prestige, deprivation, marginalization, equal opportunities, freedom to participate fully in one’s society and social structures (Braveman & Gruskin, 2003); and caring, dignity and collective health (Krieger & Birn 1998).”(From Buettner-Scmidt & Lobo, 2011)
The concept of social justice is reviewed by Buettner-Schmidt & Lobo, (2011) to yield the following concepts:
- Florence Nightingale and Lillian Wald actively addressed social injustices.
- The term social justice is used in documents guiding practice for nurses.
- Some nurses, specifically public health nurses, recognize their role in working towards social justice; however, there is no clear understanding of what social justice is.
- Social justice is defined as full participation in society and the balancing of benefits and burdens by all citizens, resulting in equitable living and a just ordering of society.
Attributes of social justice include:
(2) equity in the distribution of power, resources, and processes that affect the sufficiency of the social determinants of health;
(3) just institutions, systems, structures, policies, and processes;
(4) equity in human development, rights, and sustainability; and
(5) sufficiency of well-being.
“Consequences of social justice are peace, liberty, equity, the just ordering of society, sufficiency of social determinants of health, and health, safety and security for all of society’s members.”
From: Social Justice: A concept analysis. Buettner-Schmidt & Lobo, 2011. Journal of Advanced Nursing. Vol 68 (4).
How do we advocate for nursing as a profession?
Nurses participate as their own advocates by being leaders and advisors on boards and associations to offer their experience and expertise to the continually evolving culture of nursing practice. Jennifer Matthews, PhD RN writes in Role of Professional Organizations in Advocating for the Nursing Profession:
“…the professional associations, created by nurses for nurses to articulate nursing values, integrity, practice, and social policy, demonstrate advocacy and self-regulation” and that organizations and associations generate “energy, flow of ideas, and proactive work needed to maintain a healthy profession that advocates for the needs of its clients and nurses, and the trust of society.”
– Online Journal of Issues in Nursing (Vol 17, Jan 2012)
Nurses can play a more active role in shaping health policy but society’s expectations surrounding real vs. potential roles for nurse advocates remains unclear.
– The Road Less Traveled: Nursing Advocacy at the Policy Level (Spencely, et al in Policy, Politics & Nursing Practice, 13 (3) Aug 2012)
Buettner-Schmidt and Lobo (2011) discussed the potential role of:
- A synthesized definition of social justice for nursing assisting nursing to proactively use social justice throughout nursing research, education, practice and policy.
- Future development of a social justice framework and educational competencies by which all nurses can influence social justice globally is essential.
Nurses need to gain a clearer understanding of social justice, thereby allowing nursing to begin to reclaim its role in addressing global social injustices, with the ultimate goal of a just and fair society, reflected as peace, health and well-being for all.
What advocacy is NOT about in nursing
In a review by Hewitt (2002), literature exists that demonstrates the ongoing debate on the limitations of advocacy. These limitations are expressed in terms of how imbalances in power are viewed and redressed. The review describes the following themes:
- Perceived threat by nurses who ‘speak out’, especially against other healthcare professionals
- Culture of physician dominance over nurses
- Imposed advocacy on the patient vs being called to it?
- Nurses being out of touch with todays patient advocacy needs
- Advocacy as a separate phenomenon than ‘caring’
- Patients cannot choose their nurse nor their advocate
- Autocracy gets in the way
- Autonomy may be lacking
- Demands from many patients may create ethical dilemma/conflict
- Nurses advocate without knowledge or ‘practical aid’, leaving the nurse unprotected from conflict
- Lack of ‘whistleblower’ protection
Advocacy is described by various theories (ie. practical, vs. philosophical) which makes defining appropriate nursing advocacy roles and guidelines difficult. Independent advocacy is the practice of empowering and employing advocates who have no personal connection to the patient they are advocating for and who can serve as ‘champions of social justice’ (Hewitt, 2002).
This kind of advocacy is also described in the book From Silence to Voice (2000), which acts as a nurses’ manual (endorsed by the Canadian Nurses Association) for appropriate “nurse activism”. This resource answers question 4 below in chapters that address the “concepts of agency, presenting yourself as a nurse, and telling the world what you do”. It also looks at how nurses can interact effectively and appropriately with media and public relations professionals and how to promote nursing research and nursing for what it actually is and what it can realistically do.
How can Nurses better Advocate?
While no ‘how-to’ manual, or best practice guidelines could be found to answer this question, it is possible to glean an understanding of how to advocate by understanding the issues facing nurse advocates today.
Nursing: Profession in Peril (Emerson & Records, 2005), identifies the following issues facing Nurses and their ability to advocate:
The future of Advocacy in nursing is threatened by looming nursing crisis and its effect on nursing scholarship, research and leadership within the profession.
Nursing must expand in three essential areas of knowledge: generation, dissemination and application (Boyer 1990 and Langston et al. 1990).
Nursing research elevated the status of nursing as a distinct profession, separate yet integrated with other healthcare professionals.
The potential effect of nursing shortages translates to an increase in teaching and service workloads so that research into its own profession will fail to meet the academic needs of Universities and Nursing schools whose researchers are rapidly entering retirement.
The solutions offered center around valuing scholarship as part of the nursing profession.
- Students can be taught the value of the importance of nursing research and that students should “practice the scholarship of knowledge generation”
- Seasoned nurses must recall what they have taught others about self-care, reflection and rejuvenation so that they can be effective role models and mentors.
According to Ann Sheehan (DNP) in, The Value of Health Care Advocacy for Nurse Practitioners (2010):
- NP’s are in the unique position of being able to influence policy that effects their profession, yet few undertake the task.
- “Advocacy and health policy are a fundamental part of the mission of most professional nursing organizations”
- Affiliation and active participation in ‘organizations’ allows the freedom to explore advocacy roles with less risk and in areas outside but not independent of the nursing profession.
- NP’s must embody their personal commitment to advocacy – seeking opportunities to be leaders, role models and ideologists in advocacy initiatives and practices.
Susan Gordon and Bernice Buresh wrote about policy, politics and the agency of nurses in From Silence to Voice (2000) emphasising that nurses should challenge the paradigms that inhibit their professional progress, to embrace the values of caring for others but not at the sacrifice of themselves. They stress that the medico-centric view of nursing is a stereotype that “hobbles” nurses from reaching their full potential (p.43).
In, Realities of Canadian Nursing: Professional, Practice and Power Issues, (McIntyre & McDonald , 2010) reviewers looked at many issues facing nurses and Nurse Practitioners in healthcare today. In chapter 15 on Workplace Issues, they cite the report of Baumann and associates (2001) on the benefits of a healthy workplace stressing that all stakeholders in healthcare should work together in order to enhance the welfare of nurses and their patients.
Baumann, A., O’Brien-Pallas, L., & Armstrong-Strassen, M., et al. (2001). Commitment and care: The benefits of healthy workplaces for nurses, their patients and the system. A policy synthesis. Canadian Health Research Foundation. Ottawa: Government of Canada
Buresh, B., Gordon, S., (2000). From Silence to Voice: What nurses know and must communicate to the public. Canadian Nurses Association. Ottawa, Ontario.
Canadian Nurses Association (CNA) (2008) Code of Ethics for Registered Nurses. Author, Ottawa, ON.
Day, L., (2006). Advocacy, Agency and Collaboration. Am J Crit Care.Vol 15(4): 428-430.
Emerson, R., Records, K., (2005). Nursing in Peril. Journal of Prof Nurs. Vol 21(1): 9-15.
Gates B. (1995) Whose best interest? Nursing Times 91, 31–32.
Gaylord, N., Grace, P., (1995) Nursing advocacy: an ethic of practice. Nurs Ethics. Vol 2(1): 11-8.
Hewitt, J., (2002). A critical review of the arguments debating the role of the nurse advocate.Journal of Advanced Nursing. Vol. 37 (5): 439–445.
McIntyre, M., McDonald, C., (2010) Realities of Canadian Nursing: Professional, Practice, and Power Issues. Wolters Kluwer, New York, NY.
Murphy, N., Aquino-Russell, C., (2008). Nurses practice beyond simple advocacy to engage in relational narratives: Expanding opportunities for persons to influence the public space. The Open Nursing Journal. Vol 2, 40-47.
Oxford English Dictionary (1989) Oxford English Dictionary, 2nd ed. Prepared by Simpson, J.A., Weiner, E.S.L. Claredon Press, Oxford
Sheehan, A., (2010). The value of healthcare advocacy for nurse practitioners. Journal of Pediatric Health Care. Vol 24 (4): 280-282