Rebecca Puchkors; Jeanne Saunders; David Sharp

Learning Objectives

By the end of this section, you will be able to:

Define the concepts involved in advocating for clients with a mental health problem
Outline opportunities where nurses can advocate for clients
Suggest ways that nurses can overcome any barriers to client advocacy

The ANA Code of Ethics defines one of the roles of a nurse as client advocate. In general terms, advocacy is supporting a cause or proposal; in nursing, advocacy for individual clients can include giving clients a voice; opening access to information and education on their condition; protecting and informing clients of their rights; ensuring accuracy, updates, and access to client records; and locating the resources the client needs. Some results of advocacy in nursing are improvement in quality of care, increases in client empowerment, enhancements to client safety, and improved access to health care (Hawai’i Pacific University, 2023).

Advocating for Clients

Client advocacy is an integral part of the nurse-client relationship, beginning with admission and gathering data concerning the client, their health, their medications, and their living conditions. True advocacy requires trust between the nurse and the client. Through the process of spending time listening to the client, the nurse and client establish a trusting relationship, which enables the client to share information. This kind of information is instrumental in nurses advocating for their clients, protecting clients’ rights, and avoiding disparities in health care.

More broadly, some of the principles involved in client advocacy include protecting and advocating for the client’s safety, rights, and health; providing optimal care and promoting clients’ health; upholding clients’ rights across the continuum of care; and incorporating social justice principles in health policies (ANA, 2015).

The American Psychiatric Nurses Association (APNA) notes that “As trusted healthcare professionals psychiatric-mental health nurses are positioned to be a voice for persons living with mental illness and those who care for them” (para 1). They provide a range of tools and links that can be used by psychiatric-mental health nurses to advocate for clients in the wider sense, for example with government representatives, newspaper editors, health-care organizations, and so forth (APNA, n.d.).

Real RN Stories

Nurse: Jordan
Years in Practice: Nine
Clinical Setting: Mental health inpatient facility
Geographic Location: Arizona

In the critical unit in a psychiatric hospital, Jordan, a registered nurse, encountered a challenging situation with a client named Harrison, a forty-year-old male admitted for treatment of severe bipolar disorder. Harrison had a history of recurrent manic episodes and had been involuntarily admitted due to concerns for his safety and the safety of others. Despite his psychiatric diagnosis, Harrison was highly articulate and expressed a strong desire for autonomy in his treatment.

Upon admission, Harrison adamantly refused to take any psychotropic medications prescribed by the psychiatric team. He argued that the medications interfered with his creativity and autonomy, and he believed he could manage his symptoms through alternative therapies, such as meditation and exercise. Despite the medical team’s concerns about the potential risks of untreated bipolar disorder, Harrison insisted on his right to refuse treatment.

Jordan recognized the importance of upholding Harrison’s right to self-determination while also ensuring his safety and well-being. She engaged in therapeutic communication with Harrison, taking the time to listen to his concerns, validate his feelings, and understand his perspective. Jordan acknowledged Harrison’s autonomy and his right to participate in decisions about his treatment plan.

Using her clinical judgment and advocacy skills, Jordan collaborated with the treatment team to explore alternative approaches to address Harrison’s symptoms and promote his recovery. She advocated for the incorporation of nonpharmacological interventions, such as cognitive behavioral therapy, mindfulness techniques, and lifestyle modifications, into Harrison’s treatment plan.

Jordan also facilitated open communication between Harrison and the psychiatric team, ensuring that his treatment preferences and goals were respected and considered in the decision-making process. She encouraged Harrison to actively participate in therapy sessions, psychoeducation groups, and self-management strategies to empower him in managing his condition.

Throughout Harrison’s hospitalization, Jordan maintained a therapeutic relationship built on trust, empathy, and mutual respect. She monitored his mental status and safety closely, collaborating with the treatment team to develop contingency plans in case of symptom exacerbation or crisis situations. Jordan remained committed to supporting Harrison in his journey toward recovery while honoring his right to self-determination.

Despite the complexities of managing Harrison’s bipolar disorder without medication, Jordan’s client-centered approach and advocacy efforts resulted in positive outcomes. Harrison gradually engaged in therapy and adopted self-care practices to manage his symptoms effectively. With Jordan’s support and encouragement, Harrison developed a sense of empowerment and self-efficacy in managing his mental health, paving the way for a more collaborative and autonomous approach to his treatment.

Opportunities for Nurses to Advocate for Clients

Nurses encounter the opportunity to advocate for clients throughout their day. Some areas include double-checking for errors in medication dosages, being proactive in communicating with the client’s health-care team to avoid errors in treatment, ensuring family members understand the client’s diagnosis and treatment plan, protecting the client’s privacy rights by asking permission prior to discussing care while others are present, and teaching clients how to advocate for themselves (Hawai’i Pacific University, 2023).

Link to Learning

According to this article about the role of the nurse in client advocacy from Hawai’i Pacific University, nurses spend a great deal of time with their clients, and fulfilling their obligation under the nursing code of ethics to advocate for their clients can make a significant difference in client outcomes.

In relation to how to conduct advocacy, Abbasinia et al. (2020) conducted a concept analysis of client advocacy and identified the following attributes: apprising, mediating, safeguarding, valuing, and championing social justice.

Apprising Clients

The definition of apprising is communicating something that is important to someone and updating when new information is available. With clients, this involves updating them concerning lab results, new orders, and responding to questions. Apprising is one way that a nurse advocates for an individual client. After all, an informed client has more autonomy and is able to self-advocate more effectively, so this is one way of boosting client self-determination.

Mediating for Clients

There are situations when the nurse may be asked to speak for a client, to settle a dispute, or create agreement, which is called mediating. In such situations, a nurse is a liaison for the client with family members, other medical professionals, or the criminal justice system. This can involve informing other health-care professionals concerning the cultural values and preferences of the client. Dos and don’ts for mediation are listed in Table 12.3.

Do	Don’t
Set realistic goals	Lose your temper
Listen/speak with respect	Be uncompromising
Be open-minded	Disparage the other party
Focus on the instant issue (not past grievances)	Lose perspective
Remember you all must live in the same community afterward	Forget this is a chance for the client to control the outcome

Table 12.3 Dos and Don’ts for Mediation (Texas Dispute Resolution, 2021)

Safeguarding Clients

Through attention to details, asking questions, checking in regularly with clients, and reviewing treatment plans, medications, and new orders, the nurse can protect, or safeguard, the client from mistakes, incompetence, or emotional or physical abuse. Reviewing the medical record for accuracy and protecting the confidentiality of client information are other essential actions. At the organizational level, nurses can participate in care conferences and ethics committees. Safeguarding is another subtle form of client advocacy.

Valuing Clients

Another way nurses can advocate for clients is by showing them that they have value, or respect for the person regardless of social factors, through meeting clients’ physical, safety, belonging, self-esteem, and self-fulfillment needs. By demonstrating true caring through each of these needs, nurses show clients that they have value. Referrals to the appropriate outside resources also demonstrate that they have value (Sage et al., 2021).

Championing Social Justice in Health Care

Nurses also have a broader societal role to advocate for social justice in health care. Championing social justice in health care includes facilitating clients’ access to health resources, addressing inequalities in health-care delivery, and identifying and confronting rules or policies in a health-care system that are inappropriate.

Nurses can champion social justice through the following strategies (Harris, 2023):

creating a safe and inclusive space
educating themselves and others
providing resources and support
taking breaks and prioritizing self-care
seeking outside support

Barriers to Nursing Advocacy in Mental Health Care

Barriers to nursing advocacy exist in health-care settings and in mental health care. A major barrier is the overall lack of cooperation from clients, health-care providers, and health-care organizations. Other barriers include health-care organizations’ bureaucracy, lack of support from doctors or limited supplies/medical equipment, inadequate communication among staff, lack of support from legal teams of the health-care organization and from families of clients, client lack of financial resources, fear of repercussions for advocating for clients, and limited knowledge about client advocacy. Advocacy issues are often specific to the health-care setting in question, so solutions call for individualized approaches.

Life-Stage Context

Self-Determination and Client Advocacy

In psychiatric-mental health nursing, client self-determination is a fundamental principle that applies regardless of age. Self-determination refers to the right of individuals to make decisions about their own treatment and care, based on their preferences, values, and goals, even in the context of mental illness. This principle is grounded in ethical principles such as autonomy and respect for persons. While self-determination is applicable to individuals of all ages, the capacity for decision-making may vary depending on developmental stage, cognitive abilities, and mental health status. Psychiatric-mental health nurses must assess each client’s decision-making capacity on an individual basis, and advocate for them based on considering factors such as cognitive functioning, insight into illness, and ability to understand and appreciate treatment options.

In pediatric psychiatric nursing, nurses may encounter challenges related to assessing the self-determination of children and adolescents with mental health disorders. While younger clients may have limited decision-making capacity due to their developmental stage, nurses still strive to involve them in treatment decisions to the extent possible, advocating for their needs considering their evolving capacity for autonomy and involvement in care planning.

Cultural beliefs, values, and preferences may influence clients’ attitudes toward self-determination and mental health treatment. Psychiatric-mental health nurses must consider cultural factors when engaging clients in discussions about treatment options and respecting their autonomy within cultural contexts.

Client self-determination in psychiatric-mental health nursing transcends age and requires a holistic approach that considers individual needs, capacities, and cultural backgrounds and these are used as a basis for advocating for the needs of the client.

Resources and Support

The lack of support from doctors or legal teams of the health-care organization, lack of client financial resources, and limited supplies were found to have interfered with nurse advocacy.

Possible solutions include the following:

creating and disseminating guidelines for bringing advocacy issues forward
developing policies protecting advocates from negative consequences
promoting an overall culture of advocacy with necessary reporting and oversight
involving nurse leaders and front-line nurses in resources planning

Knowledge and Communication

Limited knowledge about client advocacy; nurses’ concerns surrounding clients’ culture, religious beliefs, and literacy; and health-care organizations’ bureaucracy hindered advocacy efforts. Inadequate communication among staff was also an obstacle. Possible solutions include the following:

Organizational leadership should make information available throughout the institution and work to streamline processes connected with advocacy.
Nurses should allow for cultural variation and let clients know they have choices, for example, asking, “How can we work within your values to provide your care?” or inviting the spiritual advisor to a care conference.
Organizational leadership should provide nurse training on the implementation of clients’ rights, which may include refusal of care, so that advocacy can be appropriately applied.
Organizational leadership should include therapeutic communication and interpersonal skills training in all nursing educational offerings.

Fear

Nurses may be afraid of repercussions from advocating for clients. Nurses may not be assertive at heart, similar to members of other service professions where giving is the intended action and the dissenting voice is not natural. Hierarchal relationships may prevent communication flow.