NursingIssues
Ethical Science Quarterly, 13:3, July 2000
Ethical Issues
Advocacy: Helpful or Harmful?
Constance L. Milton, RN; PhD
Professor of Nursing, Olivet Nazarene University, Kankakee, Illinois
How often were you told in your traditional nursing educa-
tion program to be a patient advocate? Did you readily agree
that, indeed, a major role of professional nursing was a patient
advocate? In the following thought-provoking article, Dr.
Gail Mitchell, Chief Nursing Officer of Sunnybrook &
Women’s College Health Sciences Centre, and Debra
Bournes, a recent doctoral graduate of Loyola University
Chicago, present an argument and alternative view of advo- NursingIssues
Ethical Science Quarterly, 13:3, July 2000
Nurse as Patient Advocate?
In Search of Straight Thinking
Gail J. Mitchell, RN; PhD
Chief Nursing Officer, Sunnybrook & Women’s College Health Sciences Centre,
Toronto, Ontario, Canada
Debra A. Bournes, RN; PhD
Loyola University Chicago
T he term patient advocate is commonly used in the nursing
literature. It has even been written into the definition of nurs-
ing in the United Kingdom (Cameron, 1996; Willard, 1996).
But what exactly does the term mean? And what value does
advocacy offer in nursing practice—if any? The answer to
these questions depends on how advocacy and practice are
defined in light of the context of the situation and in light of
the responsibilities and intentions of the practitioners who
choose to advocate for a client. This column represents an at-
tempt to search for straight thinking on the topic of advocacy
and to invite consideration among readers about coherence
Editor’s Note: Send ideas, columns, and responses to columns to
Constance L. Milton, RN, PhD, Professor of Nursing, Olivet
Nazarene University, Box 6046, Kankakee, IL 60901; phone: (815)
939-5304; E-mail: cmilton@olivet.edu.
Nursing Science Quarterly, Vol. 13 No. 3, July 2000, 204-209
© 2000 Sage Publications, Inc.
Constance L. Milton, Contributing Editor
cacy. Mitchell and Bournes challenge the discipline of nurs-
ing to contemplate what it means to have straight thinking
about the meanings of advocacy and, ultimately, question
whether advocacy may be more harmful than helpful to those
whom nursing serves depending on the theoretical underpin-
nings. Readers are invited to consider, to comment, and to join
the dialogue on this most important subject.
among values, theory, actions, and outcomes in practice.
Straight thinking is about disclosure, consistency, and integ-
rity. It will be suggested in this column that advocacy can be
harmful and self-serving, or helpful and other-serving, and
that the choice surrounding these possible outcomes re-
quires nurses’ attention. Moreover, the whole issue of advo-
cacy as a meaningful notion will be challenged. But first
some definitions.
The term advocate is used to express a variety of mean-
ings. Advocate is a noun and a verb. As a noun, an advocate is
customarily defined as one who pleads for or protects another.
According to the Oxford English Dictionary, an advocate is
“one called upon . . . to defend or speak for” another (Murray,
Bradley, Craigie, & Onions, 1989, p. 194). In legal parlance,
an advocate is “one whose profession is to plead the cause of
[another] in a court of justice. . . . It is one who . . . inter-
Keywords: human becoming, paternalism, patient advocacy

cedes . . . speaks for . . . or defends another” (p. 194). To advo-
cate, then, is to act for, plead for, or defend another. Advocacy
is “the function of an advocate, the work of advocating, plead-
ing for, or supporting” (p. 194).
The literature offers several overviews of the concept of
advocacy (e.g., see Cameron, 1996; Mallik, 1997a; Martin,
1998), and there are diverging perspectives about the role of
advocacy in nursing practice (Becker, 1986; Cameron, 1996;
Mallik, 1997a; Martin, 1998; Norrie, 1997; Willard, 1996).
Among these views are legitimate questions about whether it
is possible, or even desirable, for nurses to be patient advo-
cates. Some authors question whether advocacy is inherently
harmful, self-serving, or paternalistic (Cameron, 1996;
Norrie, 1997). It becomes clear when reading the literature
that advocacy, like caring, is a concept that requires theoreti-
cal ties before its meaning can be understood or before it can
be evaluated as harmful and self-serving, or helpful and
other-serving. This means that the nurse’s theoretical view of
human beings and their health experience sets the stage for
the intent that underpins acts called advocacy. This link with
theory is often neglected in discussions about advocacy and
consequently nurses are faced with myriad models, ideas,
recommendations, and questions that tend to generate in-
consistent and superficial discourse that threaten straight
thinking.
The lack of coherence and the superficiality of discourse
are sustained because the assumptions about human beings,
as defined in the guiding theory of the nurse, remain con-
cealed and unexamined. A parallel way of thinking about this
concealment can be drawn with an example from parenthood.
Suppose a government protection agency decided that all
children under the age of 5 years required a professional ad-
vocate in the home to protect the child’s interests and well-be-
ing. The unstated assumption in this example is that parents
cannot be trusted to care for and protect their children, and
thus they require an advocate to represent their interests. It is
easy to imagine in this example that people would loudly pro-
test the government’s assumptions. In nursing, the idea that
patients need an advocate follows the same logic, except we
have not yet heard the public outcry against nursing’s as-
sumptions and theoretical ties. The logic of the example sug-
gests that patients need advocates because nurses cannot be
trusted to represent their interests. The idea that nurses cannot
be trusted is disturbing, to say the least. Authors have sug-
gested that bureaucracy and the inequities of power and au-
thority explain why some nurses are not able to advocate for
clients (Mallik, 1997b; Martin, 1998; Norrie, 1997). Addi-
tionally, it is suggested here that some nurses, because of their
theoretical ties and assumptions, have not been representing
patient/family interests.
For instance, consider the traditional nursing process. The
problem-solving approach to nursing practice has theoretical
ties to biological, psychological, sociological, and medical
knowledge. This biomedical knowledge encompasses multi-
ple theories that together form a coherent and holistic view of
humans as bio-psycho-social beings who respond to disease
Ethical Issues 205
and professional interventions in predictable ways. Nurses
using the nursing process act according to what they believe is
best for others, and interventions are selected based on the
professional’s desired outcomes. The obvious question is
how do nurses know they are acting in the patient’s best inter-
ests? The answer is, because the biomedical theories are un-
derpinned by assumptions that propose that there is an objec-
tive human reality that can be known, predicted, and managed
by professionals. The problem-based model of nursing is in-
herently paternalistic, and until this theoretical belief is ac-
knowledged, respect for persons and their voices in
healthcare systems will be minimal and haphazard at best.
The literature shows that even when nurses claim to be act-
ing with the intent to respect and protect people, assumptions
about patients and their health influence the actions called ad-
vocacy in ways that may not, in actuality, respect the person.
Sanchez-Sweatman (1997), for instance, proposes that a fidu-
ciary-advocacy model is appropriate for the nurse-patient re-
lationship. The fiduciary-advocacy model “requires that pa-
tients be trusting. . . . It allows nurses and patients to be equal
moral agents . . . [and] it requires a dialogue about values and
technical information such that the whole person can be cared
for” (p. 48). Advocacy, in this model, is defined from a legal
perspective—that is, it means that nurses “are expected to as-
certain and defend their clients’ rights and wishes” (p. 38).
The fiduciary aspect of the model obliges nurses to keep pa-
tient information in confidence and to provide patients with
information in a way that is sensitive to the patient’s wishes
and to the nurse’s assessment of how much and when infor-
mation should be given. It also requires patients to trust that
nurses will competently act in their best interest and implies
that the nurse, who is more knowledgeable than the patient, is
responsible for protecting the patient from the adverse effects
of the inequality of knowledge and power. This protection is
necessary because, according to Sanchez-Sweatman,
Patients are not only physically or emotionally vulnerable but
they also lack information. When persons are ill, their physi-
cal and mental strength is decreased. Illness challenges per-
sons’ values, priorities and relationships. . . . Patients become
a body without personal characteristics . . . [they] are in a
weakened, vulnerable and altered condition, unable to effec-
tively express and negotiate for themselves. This vulnerabil-
ity is exacerbated because they are usually ignorant of medi-
cal and nursing technical information. (p. 46)
Clearly, when the nurse’s guiding theory defines people as
weak, vulnerable, and ignorant, it makes sense that they
might be in need of an advocate who can protect their inter-
ests. Healthcare systems typically disregard the patient’s
worth and contribution to the processes of care. But are sys-
tems not the people who work in them? Does not the limited
view of people described in the Sanchez-Sweatman (1997)
quote threaten respect for all patients? From our perspective,
the view of persons embedded in the quote directs profession-
als to assume a paternalistic stance with patients. The nurse
with paternalistic ties believes that he or she really does know
206 Nursing Science Quarterly, 13:3, July 2000
best. Paternalism is not respectful of unique persons and their
right to participate and decide what is best, given their op-
tions. Perhaps advocacy, as a concept, makes sense in settings
where nurses practice according to paternalistic models, but
what happens when nurses do not subscribe to paternalistic
theories? One wonders whether, if there were different guide-
lines, ones instructing nurses to see the patient as leader and
teacher—guidelines that do not recommend nurses use their
expertise to decide what is best—patients would need to be
protected by advocates.
Theoretical ties and their related guidelines are also evi-
dent in other “models” of advocacy. Abrams (1978/1990), for
example, outlines five models of patient advocacy that collec-
tively specify the role of a patient advocate. The five models
include the following activities: counseling patients, alleviat-
ing patients’ fear, consoling patients, helping patients reach
decisions about their healthcare, providing information to pa-
tients, representing patients when they cannot represent
themselves, monitoring quality of care, informing patients of
their rights, and ensuring that patients’ rights are respected
(Abrams, 1978/1990). Each of these models may or may not
be consistent with nurses’ most important responsibility—to
practice in ways clients find helpful. This is so because the ra-
tionale for nurses’ actions in practice must be known before
the issue of “rightness” can be decided.
The issue of rightness is underpinned by values that guide
advocacy in paternalistic or in altruistic ways. Values are con-
tained in the theories that guide nursing actions. Therefore,
actions taken by nurses in the name of advocacy will be differ-
ent—in intent and outcome—depending on the knowledge
and intent circumscribed by their guiding theoretical frame-
work. The knowledge base of the traditional, problem-based
model of nursing, for instance, directs nurses to advocate in
order to promote health and well-being. Patients may or may
not be involved in defining what will promote their health and
well-being, however, because these things are already defined
in the guiding theory. Nurses who decide independently to
represent patients’ interests are making paternalistic judg-
ments about people, and this judgment obstructs opportuni-
ties for people to make and own their choices. Ultimately, the
question of rightness can be answered only by patients—by
the ones who are supposed to benefit from the nurse’s actions.
Conversely, what if nurses were guided by theories that
clearly directed nurses to respect patients as the leaders,
teachers, and experts about what was happening in their lives?
What if the nurse-person process guided by that theoretical
perspective was based on the premise that nurses participate
in people’s lives, not as knowing experts but as unknowing
strangers (Parse, 1996)? Would that change the intent and
thus the outcome of the nurse-person process? It would cer-
tainly eliminate the need for an advocate role designed to pro-
tect the interests of patients in the nurse-person process.
Nurses guided by non-paternalistic ties, like those defined in
the human becoming theory, respect persons as knowing part-
ners, and nurses represent the patient’s/family’s views,
wishes, concerns, and choices with team members and when
documenting. But this representing is not an additional role.
Rather, respecting and representing the patient’s perspective
is an essential aspect of human becoming practice (Parse,
1998). The nurse shares the patient’s perspective with the be-
lief that only the patient can know what might be helpful,
harmful, or hurtful. During times when there is no person or
family that can dialogue and lead the nurse-person process,
nurses make the best decisions possible according to be-
neficent principles and guidelines for best practice. In most
situations, however, it is possible to learn the patient/family
perspective.
The patient’s perspective of any situation is required to un-
derstand the straight thinking of any advocacy work. Con-
sider the following situation described by a man living with a
chronic illness. Allan Mccurdy (1997) lives with muscular
dystrophy, and he has had many years of experience with
healthcare professionals. His story is one that highlights the
importance of listening to and respecting people as leaders of
care and as equal partners in the processes of health “care.”
Mccurdy contends that his vulnerability during times of ill-
ness was due not to his medical disease and its treatment, but
rather to the hospital staff who trivialized his humanness and
his desire and right to participate in all decisions about his
care. Mccurdy says it is all about power, and he suggests that
the biomedical ideology guides professionals to make unilat-
eral decisions based on their judgment about what is best,
without consulting the patient and without understanding and
respecting that the patient is the most interested party in any
decision being made. The quote below provides an example
of paternalistic advocacy and the harmful consequence it can
have for clients.
Far too commonly, a doctor or nurse enters my hospital room
and speaks to another professional or to a family member
rather than to me. Medical staff have also tried to order for me
in restaurants, make requests for me in department stores, and
take it upon themselves to reprimand the concierge in my
apartment building because the elevator was not work-
ing—all in the name of my health care. Such actions are not
only corrosive to my self-esteem but undermine my personal
interactions and professional integrity by advancing the per-
ception that my needs are so extensive as to render me irrele-
vant and nearly invisible. (p. 13)
How many times do nurses, and other healthcare staff, “ad-
vocate” for clients without knowing what the advocacy
means to the patient? It has come to our attention that some
nurses believe that doing multisystem assessments is a way of
advocating for clients, as are the activities of teaching, in-
forming, and explaining. For example, people can enter the
hospital for a specific concern or illness and once labeled a
patient, they are assessed to detect any actual or potential psy-
chological, sexual, personal, cultural, or social problems. The
assessments are often performed without asking clients for
consent, and professionals often justify assessments in the

name of doing what is best for the patient. Are multisystem
assessments self-serving and even harmful at times?
Mccurdy’s (1997) words show that professionals some-
times identify problems and take actions even when the ac-
tions have harmful consequences for clients. One wonders
why people cannot decide what kind of professional assess-
ments and actions, if any, they want when they enter a clinic or
hospital. It is somewhat absurd that people have more control
over their day-to-day activities and automobiles than they do
over their own bodies and lives when they happen to come
into the company of a health professional. Often, profession-
als believe that people do not know what they do not know,
and that they (the people experiencing the illness) cannot
know what is best for their own life situations. However, the
belief that people do not know what they do not know can be
said of all people, including health professionals. No person
knows what he or she does not know. But in everyday life,
people generally believe that if we ourselves or others do not
know about something, we will take steps to find out what it is
we want to know. Taking action on another’s behalf on the as-
sumption of the other’s ignorance is viewed by some as advo-
cacy, but it is suggested here that such advocacy is self-serving
and paternalistic. In our experience, paternalistic advocacy is
not welcome by clients and, as shown above, paternalism can
be harmful. Consider the next example.
Professionals in one hospital had discussions about what
policies to develop to protect women from abusive relation-
ships. A number of professionals wanted a “full response” ex-
ecuted if any nurse witnessed a suspicious physical or behav-
ioral symptom of abuse. Physical and behavioral symptoms
of abuse identified by the professionals included tearfulness,
anxiety, fear of intimacy, and withdrawal. A checklist of sus-
picious actions to observe in spouses or male partners was
also composed by the experts. If partners were uncommuni-
cative or if they expressed a desire to be alone with their part-
ners, they might trigger a response from the team. In the name
of advocacy, frontline providers were to call the team if suspi-
cious indicators were observed or suspected in any couple.
The call would trigger a more thorough assessment by profes-
sionals who served on a team dedicated to eliminating vio-
lence against women.
Now, let us be clear—the goal of eliminating violence
against women is a right one, and eliminating all violence in
the world would be even better. But the means of eliminating
violence through a team that responds to an observer’s inter-
pretation of predefined indicators, without any involvement
of the woman, represents a total disregard for the person liv-
ing in the situation. In this instance, professionals are focused
on achieving their goals, and this focus raises issues of serv-
ing personal interests. From our view, the disregard for indi-
viduals in these rescue situations is not justified and is, para-
doxically, an expression of violence perpetrated by the very
people advocating no violence. This is the kind of paternalis-
tic advocacy that can rightfully be called self-serving. Experts
spend a lot of time and energy trying to isolate and name dif-
Ethical Issues 207
ferent kinds of abuse, like physical abuse, emotional abuse,
psychological abuse, and sexual abuse. Each type of abuse is
defined and operationalized with the hope that when observed
the abuse can be managed by experts. But this is inconsistent
with what people themselves describe about abuse, and such
simplistic presentations diminish respect for the complexity
of living with abuse.
In contrast, nurses who practice with women who live with
violence have opportunities to act in ways that can be
other-serving. Nursing theories that are different from the tra-
ditional biomedical models, that respect the person’s life
choices, and that describe persons as experts about their own
lives—these theories can provide a different guide for action
and a different perspective of acting in the patient’s best inter-
ests. Again, Parse’s (1981, 1998) theory of human becoming
provides an example of an alternative framework for nurses
who want to practice with people in non-medical, non-pater-
nalistic ways. In any practice situation, the person’s perspec-
tive of his or her reality is the starting place for nurses guided
by Parse’s theory. The idea of making judgements based on
observed behavior is inconsistent with the human becoming
theory. Rather, the nurse’s intent with human becoming is to
be truly present with persons as they illuminate meaning, syn-
chronize rhythms, and move beyond.
The nurse’s action with the human becoming theory is to
follow the lead and direction of the person. If a woman living
in an abusive relationship says she is not ready to leave her sit-
uation because her husband would kill her, for instance, the
nurse respects this belief and does not act in ways described
by the woman as dangerous. The nurse guided by human be-
coming believes the woman knows her situation best and that
her fear of life-threatening harm is real and must be respected.
The nurse might ask the woman what she does want to do in
light of her reality. They might discuss ways of leaving as well
as what might be helpful from the woman’s perspective. But
the nurse would not act in a paternalistic way without the re-
quest and direction of the woman. Health professionals can-
not live the lives of others, and although professionals can
give advice, it is the patient, or in this example, the woman,
who must choose and act. Professional activities called advo-
cacy that occur outside a person’s requests for help are dan-
gerous and disrespectful. Reasons that women give for stay-
ing in an abusive relationship can be complex, as discovered
by Pilkington (1999).
Pilkington (1999) explored the phenomenon of persisting
while wanting to change, and some of her participants de-
scribed themselves as living with violence. In her findings,
women describe their realities of living, and choosing to per-
sist with living, with abuse and suffering. Some women in the
study described that they hated being abused and thought
about leaving the situation, and yet they stayed or kept going
back. Their reasons for staying in abusive relationships in-
cluded the following: love, the 3 weeks of good times that
come between each episode of violence, desire to try harder to
make the relationship work, and the children. The women
208 Nursing Science Quarterly, 13:3, July 2000
said they knew that some friends and family could not under-
stand their choices to stay in an abusive relationship but leav-
ing was not simple or easy. Some professionals may explain
the women’s reluctance to leave with theories of oppression,
for instance, but the simple fact remains that it is the woman’s
choice to act, and professionals who disregard that choice, or
dismiss it with paternalistic justifications, risk harming cli-
ents. Healthcare professionals cannot “fix” lives—the only
luxury we hold is the chance to participate in ways that are
helpful from the women’s perspectives. The way profession-
als participate with women will open doors or close them.
Each situation calls for straight thinking, or coherence be-
tween our theories and intentions to be helpful to clients from
their perspectives. If there is no straight thinking, there can be
no confidence that acts of advocacy are truly in the patient’s
best interests. When nurses are guided by paternalistic theo-
ries based on tenets of controlling others’ lives, they are, from
our perspective, wholly inconsistent with being there to help
others.
Even authors who identify specific philosophical ties with
their definition of advocacy fall short of recognizing that it is
the theoretical knowledge base that shapes advocacy. For in-
stance, Curtin (1979, 1983/1990) proposes a model of human
advocacy as the philosophical foundation for nursing. Human
advocacy is underpinned by the fact that nurses “are human
beings, [their] patients . . . are human beings, and it is this
commonality that should form the basis of the relationship
between [them]” (Curtin,1979, p. 3). Because all health pro-
fessionals are human, this rationale fails to justify why nurses
and not other professionals might be defined as human advo-
cates. For Curtin, humans are unities that are interrelated and
interdependent with all other creatures and the world. Human
advocacy requires that nurses be sensitive to and address is-
sues that threaten the unity of each person. Curtin (1979) pos-
its that human needs are magnified by disease and the disease
process itself “renders the [patient] far more vulnera-
ble . . . and may well create new, fundamental needs . . . that
must be addressed if the person is to maintain unity-integrity
as a unique human being” (p. 4). But as reported by Mccurdy
(1997), and consistent with other reports from patients
(Deegan, 1993; Edwards, 1997), it is not the illness that pa-
tients identify as the reason for the vulnerability but, rather,
the way health professionals relate with them—specifically,
the disregard, dehumanizing, controlling, punitive, judgmen-
tal practices of biomedical nursing.
From the perspective of Curtin’s (1979) human advocacy,
illness threatens the unity of humans in three ways: it limits
their autonomy or independence, it removes their freedom of
action, and it interferes with their ability, not their right, to
make choices. But this view of persons who have an illness as
dependent and unable to make choices is a very narrow view
of human freedom. The notion of situated freedom, a basic
tenet of existential philosophy, for instance, proposes that
persons are free to choose meanings, their attitudes and
hopes, as well as actions, and these things cannot be taken
away—they are inherently present in human life. One’s op-
tions may change, but there are always choices to ponder.
Gadow’s (1980/1990) work on existential advocacy comes
closest to recognizing the nature of situated freedom, but
again Gadow’s alignment with traditional biomedical nursing
reveals her belief that the nurse is still the expert who holds
the ultimate power to integrate patients’ unity and integrity.
Gadow goes as far as identifying existential advocacy as the
philosophical foundation of nursing. According to Gadow,
“Existential advocacy . . . is the nurse’s participation with the
patient in determining the unique meaning which the experi-
ence of health, illness, suffering, or dying is to have for that in-
dividual” (p. 42). It is based on the principle that “freedom of
self-determination is the most fundamental and valuable hu-
man right” (p. 43). The nurse’s role is to assist individuals to
“authentically exercise their freedom of self-determination”
(p. 43). Authentically exercising their freedom means that in-
dividuals reach decisions that are truly their own and reflec-
tive of their values. Gadow says there are two problems that
prevent authentic self-determination: the dichotomy between
the personal and professional involvement of the nurse, and
the dichotomy between the lived and the object body of the
patient.
Gadow (1980/1990) maintains that “only [patients] can
experience their body as an interiority, a living subjectivity,
and only someone other than the patient can experience [his
or her] body as a technical object, a thing to be regarded
strictly scientifically” (p. 46). Patients know and understand
the uniqueness of their bodies, whereas professionals know
and understand patients’ bodies in relation to how they com-
pare to predefined norms (Gadow, 1980/1990). Professional
involvement requires nurses to unify and direct their entire
selves toward the needs of patients. Nurses mediate the
lived-object body duality by “affirm[ing] the value of the
lived body through physical care and comfort . . . [while si-
multaneously] affirm[ing] the reality of the object body by in-
terpreting to patients their experiences in terms of an objec-
tive framework” (p. 49). Interpreting patients’ experiences
within a broad, objective framework enables nurses to “com-
plement and complete the partial perspective of the patient”
(p. 50). The nurse unifies, for the patient, the experience of the
object and lived body—thus making possible authentic
self-determination. It is this integration and purposeful unifi-
cation of the object and lived body that advocacy nursing aims
to assist individuals to achieve—because “that unity is more
fully expressive of one’s totality than even the lived body is”
(p. 49).
The responsibility of the nurse to unify and integrate, and
the nurse’s ability to make authentic self-determination pos-
sible, as proposed by Gadow (1980/1990), clearly places
power and authority with the nurse—not the patient. This
view of persons is in stark contrast to other philosophical
views that place the person and his or her experience as al-
ready whole and irreducible (Dilthey, 1961; Parse, 1981,
1998; Rogers, 1970, 1994). Furthermore, the idea that people

must be authentic in their self-determination places the nurse
in a position of judgment of the person, who may choose ac-
tions or meanings inconsistent with what the nurse thinks is
authentic, because it is the nurse who holds the power to inte-
grate others’ experiences. It is interesting that Gadow’s exis-
tential advocacy, by placing power and authority with the
nurse, carries a paternalistic stance along with its focus on
self-determination. This inconsistency diminishes straight
thinking about advocacy.
In contrast, if nurses practiced in ways consistent with the
mandate, to be helpful to people from their perspectives, pa-
ternalism would not be a concern and perhaps advocacy in the
nurse-person process would not be required. Indeed, one
study by Watt (1997) suggests that some nurses believe that to
truly respect human beings, and to live the belief that the pri-
mary obligation of nursing is to the patient and his or her in-
terests, nurses must step outside of the normal boundaries of
professional nursing. The nurses did not specify the bound-
aries they stepped beyond, but the current authors suggest it
could be that the nurses realized that traditional nursing is pa-
ternalistic in the way it guides nurses to assess, judge, label,
and manage how human beings experience health and illness.
Interestingly, Watt (1997) considered the nurses’ awareness
of boundaries as a limitation. Conversely, it is suggested here
that their awareness may have been the insight that freed the
nurses from the restrictions of paternalistic nursing.
Does paternalism then require advocacy to counter the
controlling practices of nurses? Do nurses who practice
non-paternalistic models act in the best interests of the client?
Where is the straight thinking? We submit that both of these
statements may be true depending on the person’s perspective
and the nurse’s theoretical underpinnings. In view of the mul-
tiple interpretations of advocacy, and the possibility that it can
be harmful and self-serving, or helpful and other-serving,
perhaps the term should be seen as a concept that conceals
more than it reveals. Furthermore, advocacy promoted in the
absence of explicit theoretical ties has little value for nursing.
It may be more helpful for nurses to continue to reflect on
their guiding theories and to ensure that the theories chosen
for guiding practice embody values and principles that guide
nursing actions that consistently offer clients unconditional
regard, unwavering respect, and honest, open dialogue.
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Becker, P. H. (1986). Advocacy in nursing: Perils and possibilities.
Holistic Nursing Practice, 1(1), 54-63.
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