Learning Objectives
By the end of this section, you will be able to:
- Describe the role of nurses as advocates
- Recognize the importance of nursing advocacy
- Identify barriers to nursing advocacy
Publicly lending one’s voice and/or support to a cause, person, or policy is called advocacy. Florence Nightingale is the first nurse advocate we know of. Not only was she a fierce advocate for her patients, fighting hard to ensure cleanliness within hospitals, but she was also a tireless crusader for nurses themselves. She fought hard for respect and improvement of the nursing profession. Today, advocacy is a core component of professional nursing and a cornerstone of nursing practice.
Role of Nurses as Advocates
Nursing advocacy seems, on the surface, to be a simple concept: be vocal to support what is right. However, upon closer examination, it is a rather complex concept. Advocacy involves ensuring excellent care for patients and respect for their rights, as well as advocating for the nursing profession. Nurses advocate for what is ethically sound in their interactions with and provision of care to patients and their families. They also advocate for their patients with other healthcare providers and for all patients as well as the profession of nursing through activism and engagement at local, state, and national levels.
Advocacy for Patients
There are several different behaviors associated with patient advocacy (Figure 16.7). Nursing advocacy includes protecting patients from unintentional or intentional harm. Further, advocacy involves teaching patients and their families so they can understand their conditions and care for themselves. Simply caring and ensuring patients feel respected and as if they matter as a human, not only a sick body, is another way to show advocacy. Nurses are also well positioned to act as mediators to ensure that the patient’s wishes and needs are understood by all. Finally, nurses are excellent champions and advocate for their patients by speaking out against injustice (Abbasinia et al., 2019).
Link to Learning
A snapshot of nurses’ voices about the varied expressions of patient advocacy is presented in this brief video.
Promoting Self-Determination
The ways individuals control their lives and surroundings and express their autonomy is called self-determination. Increasing numbers of patients have complex chronic conditions, many with multiple comorbidities, which require sophisticated self-management on the patient’s part. Encouraging patients to be engaged and involved in their own care by implementing shared decision-making strategies and healthcare environments in which patients can ask questions, state their limitations, and feel safe and understood supports patient self-determination (Dineen-Griffin et al., 2019). Several strategies to help patients develop greater self-determination and management skills have proven effective with a variety of complex medical conditions, such as type 2 diabetes mellitus, asthma/COPD, and heart failure (Dineen-Griffin et al., 2019). Examples of effective strategies include the following:
- Educating patients regularly about their conditions, allowing patients to better manage their own health
- Improving patients’ ability to solve problems and make decisions regarding symptom changes
- Developing written action plans with patients including strategies for managing situations and exacerbations when they arise
- Encouraging active symptom awareness on the part of patients, such as maintaining blood pressure journals
Each of these strategies require patients to be engaged with healthcare providers on a one-to-one basis with enough frequency to develop the tools needed for effective self-determination (Dineen-Griffin et al., 2019). The most effective interventions to promote patient self-determination involve ensuring patients feel supported and informed about their own healthcare conditions, encouraging them to believe they have the right to act autonomously, motivating them to act on their own behalf, and encouraging healthy behaviors for both physical and psychological health (Ntoumanis et al., 2020).
Self-Advocacy
The act of speaking up for oneself and one’s needs is self-advocacy. While nurses are excellent at speaking up for their patients and for at-risk populations, they are not always good at speaking up for themselves and ensuring they are providing the same care for themselves that they do for others (Eaton, 2021). Consider the instructions that airlines provide: in case of an emergency, put on your own oxygen mask before helping others. Otherwise, you may not be able to help others. It is the same for nurses. Nurses must remember to take care of themselves so that they can take care of others. Otherwise, they can become exhausted, burned out, and unable to supply the high level of quality and skill their patients need.
Safe Harbor is one mechanism for expressing self-advocacy. Safe Harbor in nursing is a legal and ethical concept designed to empower nurses to refuse specific patient assignments under circumstances where carrying out the assignment would compromise patient safety or violate professional standards. When a nurse identifies a situation that raises concerns about patient well-being or adherence to nursing standards, the Safe Harbor process is initiated. The nurse assesses the situation, promptly notifies the appropriate supervisor, and collaborates to find a resolution that addresses the identified issues, such as redistributing assignments or providing additional resources. If an acceptable resolution cannot be reached, the nurse may refuse the assignment without fear of retaliation or disciplinary action. It is important to note that the existence and specifics of Safe Harbor provisions vary by state, with some states having well-established regulations, while others may have different mechanisms to address workload issues. Nurses should stay informed about the regulations in their specific state and facility to ensure compliance with professional standards and legal obligations.
Whistleblowing
Advocacy can be frightening, particularly if a nurse recognizes a need to report larger-scale issues such as environmental safety or patient care issues and is afraid their employer will punish them as a result. If a nurse (or any employee) has followed the proper leadership structure to report legitimate concerns that have not been addressed, then other steps may need to be taken; it may be the only ethical way forward (Wiisak et al., 2022). The reporting of misconduct, such as fraud, abusive patient care, or unsafe conditions to outside authorities is known as whistleblowing. An individual making such a report is a whistleblower.
Whistleblowing should never be done in anger or trivial situations. It is an important ability that workers have to protect themselves, their patients, and even their agencies from problems caused by others. However, people intentionally engaged in inappropriate activities will not be happy to be questioned about their actions.
Link to Learning
The ANA offers some advice about whistleblowing that suggests a variety of things to consider when preparing to blow the whistle and when it should be done.
While it should not be done lightly, whistleblowing is an important protection for nurses and other healthcare professionals. Seeing unethical or illegal misconduct on the part of other employees or agencies can lead to moral distress and increased turnover among healthcare workers (Wiisak et al., 2022). Reporting unsafe and illegal practices can be a frightening thing to do; however, there are multiple federal and state laws in place to protect whistleblowers from retaliation by protecting their jobs (Kakacek, 2022). Table 16.7 explores the federal laws and protections related to whistleblowing.
| Law | Protections Provided |
|---|---|
| Whistleblower Protection Act (WPA) | This act protects federal workers if they make a disclosure about laws they believe are being violated within federal workplaces. It includes disclosure of broken laws, rules, and regulations; mismanagement of federal funds; abuses of authority; and compromising the health and/or safety of the public. |
| No FEAR Act | This act strengthened the protections of federal workers who file antidiscrimination or whistleblower claims. It establishes fines and damage claim procedures for federal employees whose rights are violated under the act. |
| Occupational Safety and Health Act | This act is administered by OSHA. It protects workers who make claims related to safe and healthy work environments. |
| Affordable Care Act | This act protects workers from whistleblowing related to insurance fraud. |
Importance of Nursing Advocacy
With over four million RNs in the United States, nursing advocacy has the potential to make changes, both large and small, throughout the healthcare landscape (Eaton, 2021). Nursing advocacy can take many forms. Individual nurses can work with their agencies, call their legislators, write letters, make phone calls, visit a legislator’s office, volunteer, and even march for causes they find important. Individual nurses can also join coalitions or groups of like-minded individuals who are all advocating for the same initiatives (Association of Public Health Nurses, 2022. Organizations such as the Association of Public Health Nurses and the Alliance of Nurses for Healthy Environments offer a vehicle for many nurses to make their voices heard at one time. At a local level, nurses can work with their agencies to develop collaborative efforts to meet patient needs in conjunction with other agencies and public service sectors (Latham et al., 2020).
Link to Learning
An advocacy toolkit that offers practical suggestions and advice for public health advocacy is provided by the Association of Public Health Nurses, and it can also be used with all types of nursing advocacy.
Improve Public Health
Nursing ethics, values, and even laws all offer a focus on equal access to health care, social justice, and nondiscrimination for all patients, leading naturally to nursing advocacy for public health (Williams et al., 2018). Nurses can advocate for policies that address public health by promoting justice, health equity, and the social determinants of health (SDOHs), such as education, financial stability, and housing. The SDOHs powerfully influence overall public health. For example, when life expectancy mapping was performed over an urban area in Virginia, differences in life expectancy (average age at death) of up to nineteen years were noted between different zip codes in the same city (Lathrop, 2020). Only by addressing the root causes of poor health can the entire public’s health truly be improved (Lathrop, 2020; Williams et al., 2018). Table 16.8 offers a few different ways in which nurses can engage in public health advocacy.
| Area | Rationale | Evidence-Based Programs | Advocacy Opportunities |
|---|---|---|---|
| Early childhood education (ECE) | Lack of ECE is linked to poor academics in later years, depression, and attention deficits. | ECE programs Early childhood health visits Food assistance |
Support universal access to ECE. Support public funding of programs for 3- to 5-year-olds. |
| Job security | Poor job security decreases the ability of families to make permanent choices in terms of housing and safety. | Family and Medical Leave Act Paid parental leave |
Support policies that keep jobs available for those having children or experiencing major life events. |
| Safe working conditions | Lower paying jobs are frequently more dangerous. | Laws for workplace safety including OSHA and workers’ compensation | Support labor laws that provide safety standards for work environments. |
| Social status | Social status is related to health outcomes. | Business training | Support development programs for women, children, and youth. Support job training programs. |
| Food security | Food insecurity leads to poor health outcomes, developmental impairments in children, malnutrition, and obesity. | School nutrition programs Federal nutrition programs (such as WIC and SNAP) Community gardens |
Advocate for school subsidies. Support or start a local community garden. |
Clinical Judgment Measurement Model
Recognize Cues: Identifying Social Determinants of Health
Identifying patients who are struggling with SDOHs can easily be achieved through screening tools that allow for integrating questions about health-related social needs (HRSNs) into patient assessments. This assessment can help the nurse identify patients who need assistance beyond their immediate health concerns. It can also help nurses find areas where their agencies may be able to aid individuals or communities in their own charitable endeavors.
Questions may include items such as the following:
- What is your living situation today?
- In the last twelve months, how often did you worry that your food would run out before you had money to buy more?
- In the last twelve months, how often did you miss or worry about missing medical appointments due to lack of transportation?
- How often does anyone, including family and friends, scream or curse at you?
- If, for any reason, you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, and so on, do you get the help you need?
Knowing the answers to such questions may help nurses advocate both for the patient in front of them, as well as for the public health of the communities their patients live in.
The full HRSN questionnaire developed by the Centers for Medicare and Medicaid Services provides additional information (CMS, n.d.; Latham et al., 2020).
The Seven Domains of Health
One strategy to explore overall clinician health and well-being is by looking at the seven domains of health. This holistic framework of seven life dimensions that encompass various dimensions of well-being and health can be used by nurses to explore ways to advocate for themselves (Figure 16.8) (Kerley & Toney-Butler, 2023). Nurses can then explore ways to improve their own life and conditions within this framework.
Optimizing the Workplace Environment
One area where nurses can lend their voices in advocacy is in improving their workplaces and improving working conditions. Issues such as safe staffing levels, high-quality training and orientation, physical and mental health support for staff, and technical education and support are all areas where nurses can advocate to improve workplace environments, patient care, and their own experiences. When advocating for change, always be solution focused. Rather than simply presenting problems that need to be addressed, present problems along with one or more possible ways to address them.
While direct care nurses are often best able to name opportunities for improvement, having an open line of communication with nursing leadership is important in workplace advocacy efforts (Cole et al., 2019). When leadership is not immediately responsive, work to determine whether others on your unit or in your facility are having similar issues or concerns. A group of nurses presenting a united front, advocating for their workplace environment, and presenting clearly thought-out suggestions for improvement can often succeed where an individual may fail (Wells & Delgado, 2023).
Enhancing Healthcare Team Outcomes
Nurses are adept at enhancing healthcare team outcomes through their advocacy for patients. A large piece of advocacy in nursing is either helping patients find their voice or speaking for them when they are unable to. Because nurses spend more time with patients than any other healthcare team member, they frequently develop the strongest therapeutic relationships and can facilitate enhanced team outcomes (Ganz, 2019). On teams, nurses can serve as mediators or liaisons between patients and their families and other healthcare professionals (Abbasinia et al., 2019; Ganz, 2019). Nurses can prepare other team members in advance of meeting a patient for cultural considerations, patient wishes, and expected healthcare literacy. They can help ensure that treatment decisions made by the team are fully understood and agreed to by the patient and that the patient is able to manage any treatments necessary on their part. Further, as the person to administer medications and perform written patient care orders, nurses can improve team outcomes by safeguarding their patients from incorrect interventions (Abbasinia et al., 2019). In primary care settings, nurses working as care coordinators develop relationships with their patients that enable them to advocate for patient needs with the team and improve their health-related outcomes (Karam et al., 2021).
Barriers to Nursing Advocacy
Despite the importance of nursing advocacy, there are also many barriers to nurses being able to advocate appropriately for their patients. Barriers for nurses can be as simple as not having the time to appropriately advocate for their patients (Blackwood et al., 2019; Nikitara et al., 2019). Alternatively, patients may need advocacy in areas in which nurses are unfamiliar, such as substance use, advanced care planning, or diabetes care. Another barrier to advocacy can be the lack of resources in terms of equipment, educational materials, space, specialists to consult with, or available information technology (Nikitara et al., 2019). Other key barriers include lack of cooperation (among patients, among nurses, or among organizations), fear of negative outcomes, and patient-related factors.
Lack of Cooperation
For nurses to engage in active and healthy advocacy, there must be some level of cooperation between people and entities. Despite the importance of advocacy to professional nursing, lack of cooperation in terms of environmental conditions and personal relationships or feelings may negatively impact nurses’ ability to be effective advocates. For instance, in a high-stress clinical setting with inadequate resources, nurses may find it challenging to advocate for optimal patient care when faced with systemic barriers. Similarly, if there is a breakdown in communication or collaboration within the healthcare team, it may hinder the nurses’ collective ability to advocate for the best interests of their patients. In such scenarios, the effectiveness of advocacy efforts becomes compromised, highlighting the need for a collaborative and supportive professional environment to fully realize the advocacy role in nursing.
Among Patients
Patients who have had previously negative experiences with the healthcare setting and/or nurses may not trust nurses to advocate for them and may actively work against their nursing staff (Kwame & Petrucka, 2021). Other patients are simply angry, afraid, or unable to move out of their own concerns to cooperate with nurses in both patient care and advocacy efforts. Further, patients who are uncomfortable in healthcare settings are often less able to cooperate constructively with nursing staff. For example, a patient who is too hot or cold or overwhelmed by environmental noise may be unable to focus on other needs because of their immediate discomfort (Kwame & Petrucka, 2021).
Among Healthcare Professionals
While nurses often act as patient care coordinators, are the healthcare professionals closest to the patient, and have the greatest ability to advocate for the patient, they are often left out of meetings between patients and providers. Being asked after the fact to explain issues and having to return to the provider with patient questions takes time and energy away from direct patient care. Consider the example of end-of-life care. Studies have shown that nurses are the healthcare staff most likely to identify medical futility (the point at which further interventions will not improve a patient’s life expectancy) (Ganz, 2019). Further, they have been acting as the patient’s advocate in the time leading up to end-of-life discussions, and they tend to be the healthcare professional most trusted by the patient. However, healthcare providers often do not include nurses in their end-of-life discussions with family members (Ganz, 2019). So clearly, even in environments where nurses have been able to advocate well for patients up to the final stages of their illness, they are often not invited to the table by other healthcare professionals.
Among Healthcare Organizations
In many healthcare organizations, particularly those that lack a strong shared decision-making culture between front-line staff and leadership, nurses may find it difficult to advocate effectively for themselves and for effective policies and procedures (Newans & Siddiqui, 2021). This type of barrier leads to leadership enacting policies that front-line staff are unable or unwilling to implement fully because leadership does not work in the given practice setting. Subsequently, nurses begin implementing work-arounds to provide more effective patient care, and these work-arounds may not take into account some of the goals of the leadership. As a result, when healthcare organizations place barriers to nurses’ ability to advocate for themselves and their patients in the policy development process, patient care and organizational goals may be negatively affected.
Other barriers to effective advocacy are system-level barriers. Issues such as staffing shortages, inability to spend time with patients, and nursing burnout often impact nursing staff’s ability to provide care, effective communication, and advocacy (Kwame & Petrucka, 2021). Further, when agencies have a strong focus on the completion of tasks associated with patient care, advocacy and communication with patients may be changed. Both completing patient care tasks and engaging with patients are important pieces of patient advocacy, but too often, different aspects are sacrificed based on policies and procedures at the institutional level (Kwame & Petrucka, 2021).
Fear of Negative Outcomes
In healthcare environments in which nurses lack autonomy, they may be afraid to aggressively advocate for patients. Particularly in situations in which advocating for a patient’s needs flows contrary to a facility’s culture, nurses may be afraid of the impact their advocacy will have on their own careers (Nsiah et al., 2019). Some nurses even fear losing their jobs. Further, no nurse wants to do additional harm to a patient, and many will doubt themselves, letting their anxiety over making a mistake impact their willingness to speak up for their patients (Nsiah et al., 2019).
Patient-Related Factors
Another barrier to patient advocacy can be factors intrinsic to patients and patient populations. For example, it may be difficult for nurses to effectively communicate with patients experiencing poor health literacy or who speak a language other than the nurse’s language. Many nurses have reported difficulties in accessing interpreter services, and some studies have shown that even certified medical interpreters often rephrase questions and answers inappropriately and/or leave out information (Gerchow et al., 2021). Other patient-related factors such as gender nonconformity, religious differences, and culture may impact the nurse and create unintended biases in terms of advocacy and active engagement in advocacy.
Life-Stage Context
Ageism in Critical Care Settings
While advocating for patients is intrinsically linked to nursing practice, there is good evidence that nurses are less aggressive advocates for older patients. As patients age and become sicker, they often use more healthcare resources and have greater needs. Some patients become “frequent fliers,” moving in and out of the hospital multiple times, and their health conditions become progressively worse. In critical care settings, where there may be resource limitations in terms of equipment and time, some nurses may make conscious (or unconscious) decisions to provide higher levels of advocacy for younger patients who they feel have a better chance of returning to their baseline and high-level quality of life. Nurses must guard against expressing ageism (prejudice, discrimination, or stereotyping based on a person’s age, particularly when directed toward individuals who are older or younger than the perceived societal norm) in their patient care, and advocate for all patients equally (Moniem et al., 2019).