Advocacy in Nursing and

Health Care

Prepared by: Eslam Bani Mohammad

Supervised by: Prof. Fathieh Abu-Moghli
12/4/2022
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Course outlines:
 The Definition of Advocacy
 The Nurse as Patient Advocate
 Consumerism, Feminism, And Professionalization Of Nursing: The Emergence of
Patients' Rights Advocacy
 The Emergence of Patients' Rights Advocacy
 Philosophical Models of Nursing Advocacy
 Advocacy Outside the Clinical Setting
 Barriers to Successful Advocacy
 Critique of nursing advocacy
 Discussion Questions
 References WWW.SLIDEFOREST.COM
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Objectives:
By the end of this lecture students will be able to:
Understand the nurses role as patient advocator
Identify the Emergence of Patients' Rights Advocacy
Explain Philosophical Models of Nursing Advocacy
Identify Barriers to Successful Advocacy
Summarize the practical way to get involved in advocacy

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The Definition of Advocacy

Advocacy derived from latin word advocatus , meaning to plead the
cause of another.
In the community setting, nurses frequently work with residents and
community leaders to advocate for healthier neighborhoods.
community health nurses seek to mitigate the social determinants of
illness through advocacy at the individual, system, and policy levels.
Nurses are also frequently engaged in issue advocacy, addressing
such issues as: access to care and disease prevention.

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The Definition of Advocacy

Advocacy is most frequently associated with legal and political
settings, the definition has expanded to encompass a wide range of
activities undertaken in support of
• Individuals
• Families
• Systems
• Communities
• Issues

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The Definition of Advocacy

In modern practice, nurses serve as advocates when:
1. patients understand the treatments they are receiving
2. serve as a translator between the patient and members of the health
care team
3. coordinate care and help patients navigate the complexities
of the health system.

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• Through professional organizations such as the American Nurses 7

Association (ANA) and the American Association of Nurse

Anesthetists (AANA) , nurses serve as advocates for the nursing
profession itself by: educating and appealing to state and federal
legislators and policymakers to promote safe workspaces for
nurses and to safeguard the nursing scope of practice.

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The Nurse as Patient Advocate

A central tenet of nursing practice
Advocating for social justice
nursing functions adequately and safely.
independent practice and accountability
Winslow (1984) identify two major metaphor -loyalty and advocacy.
Re-conceptualization of the dominant nursing metaphor from
• loyalty to physicians to advocacy for patients

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The Nurse as Patient Advocate

• The primary goal of loyalty by nurses was to project and reinforce
confidence in the health care enterprise. Nurses were explicitly
taught that loyalty to the physician equated with faithfulness to the
patient (Winslow, 1984).

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REAL STORY in 1929 (loyalty and advocacy )
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• The primacy of loyalty as a nursing ethic came under attack in 1929 in a

most unusual place. In a hospital in Manila, The Philippines, a physician
ordered a new graduate nurse, Lorenza Somera, to administer cocaine
injections, instead of procaine injections, to a tonsillectomy patient.
Somera loyally carried out the physician's order, resulting in the death of
the patient. Although it was clear that the physician had erred in ordering
the incorrect medication, he was acquitted of all charges while Somera
was found guilty of manslaughter for failing to question the orders of the
physician (Winslow, 1984).
• The Somera case sparked worldwide protests from nurses and served to
push nursing toward independent practice and accountability
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The Nurse as Patient Advocate

 Significant part of every nurse’s is to act as a patient advocate

 Nurses have an image of trust and goodness

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Consumerism, Feminism, and Professionalization of
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Nursing: the emergence of patients' rights advocacy.

During the 1960s and 1970s, influenced by feminist and consumer-
rights ideologies, nursing advocacy became the dominant metaphor
for nursing.
“nurse as advocate for the patient” recognized the inherently
oppressive nature of patienthood.
Advocacy for the patient framed as rejection of loyalty to the
physician, freeing nurses to develop their own professional identity.
patients' rights advocacy formed the basis of nursing advocacy

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The emergence of patients' rights advocacy.
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ANA Code of Ethics in 1978

• “the role of client advocate, the nurse must be alert to and take
appropriate action regarding any instances of incompetent, unethical,
or illegal practice(s) by any member of the health care team or the
health care system itself, or any action on the part of others that is
prejudicial to the client's best interests” (Bernal, 1992, p. 18.)

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Consumerism, Feminism, and Professionalization of

Nursing: The Emergence of Patients' Rights Advocacy
Some U.S. state boards of nursing have codified, and thus mandated,
nursing advocacy by:
including language in nurse practice acts that either explicitly or
implicitly defines an advocacy role.
For example, the Indiana Nursing Practice Act defines Registered
Nursing to include “advocating the provision of health care services
through collaboration with or referral to other health professionals”
(Indiana Nursing Practice Act, 2008).

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 Philosophical Models of Nursing Advocacy
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1. Gadow, 1983
2. Curtin, 1979
3. Kohnke; model of functional advocacy

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Philosophical Models of Nursing Advocacy
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1. Gadow, 1983
Existential Advocacy
The nurse's role is to help patients clarify their values and the illness
experience, and exercise their right to self-determination.
• nurses are uniquely situated to advocate for patients, because they
frequently
• spend the most time with patients
• have an intimate connection with patients and their families.
• Gadow viewed advocacy as a moral imperative, with the ultimate goal
being to increase patient autonomy (Hanks, 2005).

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2. Curtin, 1979
Curtin sought to situate nursing advocacy as “human advocacy”
 Curtin invited nurses to help patients:
 identify meaning and purpose in their illnesses with the ultimate goal
of enhancing patient autonomy (Curtin, 1979; Mallik, 1997a).

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3. Kohnke; model of functional advocacy

• Kohnke developed a model of functional advocacy that called nurses
to serve as brokers of information and supporters of patient decision
making.
• Kohnke expressly suggested that physicians persecuted patients
(whom she calls victims) through their “we know best” attitude.
• nurses lack the institutional and personal power required to advocate
for patients' rights .
• Hewitt (2002) points out that “for the nurse to be in a position to
empower patients, it is necessary for the nurse to be first
empowered”
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• An illustration appearing with her work in the American Journal of

Nursing depicts the physician as a puppet-master manipulating a
helpless patient, with the nurse as a “rescuer,” attacking the
physician with the banner of health (Kohnke, 1980).

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Advocacy Outside the Clinical Setting

Nursing advocacy is not limited to clinical settings.
Three types of nursing advocacy influence policy, population health,
and the profession of nursing:
1. Issue advocacy
2. Community and public health advocacy
3. Professional advocacy.

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Advocacy Outside the Clinical Setting

1. Issue Advocacy:
The nursing care of patients necessarily extends beyond the hospital or
clinic.
Consider that symptom management for many patients requires
interventions that are not purely medical.
• E.g, mental health nurses frequently set goals with their patients to integrate
patients into the community.
• program for children with autism.
Issue advocacy is best accomplished through the formation of coalitions.
• bringing evidence-based expertise and professional credibility to any
debate. WWW.SLIDEFOREST.COM
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2. Community and Public Health Advocacy

nurses' input into reform the health care system is critical, advocacy in
support of health extends beyond issue advocacy.
There is wide agreement among researchers, policymakers, and providers
that social structures and behaviors have a significant impact on health
Community health nurses routinely interact with community leaders to
improve community conditions that impact health.
powerful determinants of health status
The quality of the environment
 the nature of human relationships
 the durability of the social infrastructure
the justice inherent in the social order
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3. Professional Advocacy
Nursing, and nurses, matter. Consider the following:
 Nurses compose the largest segment of the health care workforce.
Patients are in frequent contact with nurses who deliver almost all
of the care to patients in the hospital setting
Research has demonstrated that the amount and quality of nursing
care that patients receive is directly related to a number of health
outcomes

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3. Professional Advocacy
Because nurses have a direct relationship to the health of patients,
advocacy on behalf of the nursing profession is a powerful form of
patient advocacy.
 Advocacy on behalf of the profession frequently involves:
workplace safety
nurse/patient ratios
expanded scope of practice
limitations on malpractice liability
ANA attempt to provide broad representation of nursing interests
to members of congress, policymakers, and thought leaders.
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 Barriers to Successful Advocacy

• Advocacy is time-consuming and requires a significant
commitment on the part of the nurse.
• other barriers may exist, including lack of education and
training about advocacy skills or outright fear of
retribution from employers or governmental organizations

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1. Education and Training Barrier:
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lack of education and training in advocacy skills during formal

nursing education.
some schools of nursing offer programs to expose students to
political processes, typically limited to visits to state board of
nursing meetings or legislative committees, few educational
programs are designed to promote advocacy skills in nurses.
Although this training approach is likely to be useful to build skills in
advance of a specific legislative encounter and is certainly valuable, it is
not clear if a political-organizing framework is sufficient to prepare
students to act as advocates in their practice upon graduation.
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1. Education and Training Barrier:
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 students could have engaged in any number of advocacy activities

related to the environmental exposure.
 Benner and colleagues (2010) call for greater attention to nursing
advocacy in the schooling, learning, and teaching process.
 They accurately point out that “[e]nthusiasm for nursing as a social
good is a motivation for both students and teachers, and a ‘moral
source’ against frustration and fatigue” (p. 206).

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2. Institutional Barriers and Fear of
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Retribution
Many nurses avoid advocating for better workplace
conditions, or for patient safety, for fear that their
employers will retaliate against them.
outright fear of retribution from employers or
governmental organizations as a result of advocacy
activities

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 REAL CASES (Institutional Barriers and Fear of Retribution)

• Consider the interesting, and perhaps troubling, case of Ellen Finnerty,

a Registered Nurse from California who was terminated from her job
and had her Registered Nursing license revoked by the California
Board of Registered Nursing based on her advocacy for a patient
under her care and failure to follow direction from the treating
physician.

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 Research Article
Swedish nurses’ perceptions of influencers on patient
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advocacy: A phenomenographic study by Josse-Eklund

Objective:
This study’s aim was to describe Swedish nurses’ perceptions of influencers on patient advocacy.
Research design :
Interviews with 18 registered nurses from different Swedish clinical contexts were analyzed using
the phenomenographic method.
Findings:
Three levels of hierarchically related influencers on patient advocacy were found:
1- The fundamental influencer, the nurse’s character traits, was described in the perceptions that
advocacy is influenced by nurse’s having a moral compass, having control over the care situation,
being protective and feeling secure as a nurse.
2- The second influencer, the nurse’s bond with the patient, was expressed in the perceptions of
knowing the patient and feeling empathy for the patient.
3- The third level of influencers, the organizational conditions, was described in the perceptions
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that the organizational structures and organizational culture influence patient advocacy. 32
Research Article 33

Patient Characteristics that Influence the Advocacy Role of Nurses in Ghana: A Qualitative
Study in 2018

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Critique of nursing advocacy

Despite substantial attention to nursing advocacy since the early 1970s,
there is a dearth of scientific research exploring the phenomenon.
The utility of nursing advocacy as a framework for practice; few nurses
are actually engaged in advocacy activities.
Several critics have questioned whether or not nurses have the capacity
to serve as advocates:
• nurses lack the institutional and personal power required to advocate for
patients' rights
• “for the nurse to be in a position to empower patients, it is necessary for the
nurse to be first empowered”

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Discussion
Q1: Give examples of advocacy do you see in your own nursing
practice, or the nursing practice of others??

Q2: What are the barriers you have experienced to effective nursing
advocacy? What are ways to mitigate those barriers??
Q3: How can schools of nursing more effectively prepare nurses to
serve as advocates?

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Summary
Advocacy is a fundamental nursing role, whether on behalf of
patients, communities, or the profession, and in crafting policy
solutions.
Barriers to successful advocacy are include: time, commitment,
education, training, and institutional barriers.
 Despite the barriers, advocacy on behalf of health can be extremely
rewarding, and nurses are in a unique position to advance the
cause of patients' interests in the complex health care system.
Nurses have a direct relationship to the health of patients, advocacy
on behalf of the nursing profession is a powerful form of patient
advocacy.
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References
• Al-Ananbeh, E., Abu-Moghli, F., & Khalaf, I. (2018). Perception and experiences
of nurses regarding patients involvement in health care decisions: An Integrative
Review. International Journal of Applied and Natural Sciences (IJANS), 7, 99-110.
• Dadzie, G., Aziato, L., & de-Graft Aikins, A. (2018). Patient Characteristics that
Influence the Advocacy Role of Nurses in Ghana: A Qualitative Study. J Nurs
Patient Care 3, 1, 2.
• Josse-Eklund, A., Jossebo, M., Sandin-Bojö, A. K., Wilde-Larsson, B., & Petzäll,
K. (2014). Swedish nurses’ perceptions of influencers on patient advocacy: A
phenomenographic study. Nursing ethics, 21(6), 673-683.
• Mason D., Dickson E., McLemore M.., Perez A. (2020). Policy and politics in
nursing and health care.8th ed. Elsevier/Saunders.
• Oliveira, C., & Tariman, J. D. (2017). Barriers to the patient advocacy role: An
integrative review of the literature. Journal of Nursing Practice Applications &
Reviews of Research, 7(2), 7-12. WWW.SLIDEFOREST.COM
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Any Questions ?

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THANK YOU

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