Introduction
“Advocacy is the heart and soul of nursing,” (Wood 2010, p. 5). This statement was advanced by the director of practice in Texas Nurses Association to highlight the importance of advocacy in nursing. Today, nurses practice advocacy at different levels of specialization. Indeed, Wood (2010) explains that, “Whether calling attention to a potential medication error, helping the rest of the health care team to hear a patient’s voice or shaping policy by speaking from first-hand experience, advocating for patients comes naturally to today’s nurses” (p. 5). Indeed, almost as a natural instinct for nurses, they have improved their patient’s welfare and improved the profile of the profession through advocacy and its antecedents.
By emphasizing the relationship between advocacy and patient autonomy, this paper discusses advocacy as part of the nursing role. This analysis is used as a background understanding of the continuum of advocacy (within the confines of the nursing practice) and the limitations, advantages and opportunities that exist for advocacy. Further emphasis is given to explain the actual and potential costs of advocacy on personal and professional levels. These analyses will be undertaken within the Australian context and therefore, the guidance provided by the ANMC (regarding advocacy in the nursing practice) will be explored. Finally, the relationship between advocacy and the law will be established.
Relationship between Advocacy and Patient Autonomy
There is a potential conflict between patient autonomy and advocacy. Boundary violations and boundary crossings are just a few examples of possible conflicts that define the relationship between advocacy and patient autonomy. For example, nurses may become too involved in a patient’s personal life, thereby brewing conflict in the profession. Such circumstances may prompt nurses to make decisions for the patient, thereby infringing on a patient’s right to autonomy. Negarandeh (2006) explains that, ideally, nurses need to protect patients’ right to autonomy and refrain from infringing on the same. However, the overwhelming and intimidating atmosphere in the healthcare environment often prevents the realization of ideal outcomes from patient-nurse relationships. Through advocacy, nurses are required to be their patients’ advocate by helping them do what they are unable to do (Hyland 2002). For example, patients may have the knowledge and ability to make their decisions but they may not know how to navigate the fragmented nature of healthcare systems. Advocates are required to help them in this regard.
The main role of the advocate is therefore to ensure that holistic care is given to the patient by ensuring that the patient gets the right level of care, in the right environment, and at the right time (Funnell 2008, p. 35).
The boundaries to be observed between patient autonomy and advocacy can be defined by the core competencies and responsibilities expected of advocates. The role of advocates should always be to educate the clients, provide them with emotional support, provide them with language translation services (where applicable), and refer them to other medical services. Notably, none of the roles described above include making decisions for the patients. Concisely, after considering the above advocacy roles, the role of the nurse (as an advocate) is therefore to empower the patients to make the right decisions and possibly inform them about surrounding dynamics regarding their decisions. This role should not extend into making decisions for the patients (Funnell 2008).
Continuum of Advocacy in Nursing
Advocacy has different impacts not only on the nursing profession but also within the wider society. So far, this paper demonstrates that nursing advocacy plays a huge role in promoting patient rights but Wright (2007) shows that nursing advocacy also helps to improve the healthcare industry by portraying a positive image of the profession to outsiders. Like any other public service sector, maintaining a positive image for the nursing profession is an important aspect of the industry. The scope of positive self-image is widespread, but it largely involves maintaining a positive image for nurses in the press and any other public forum. For example, nurses may be required to participate in the television or film industry to portray their roles and contributions to the industry. Through the positive portrayal of the profession in the press, the respectability of nursing is improved. From this understanding, almost every nurse is considered an advocate, even though some nurses primarily work as advocates (Wright 2007).
Albeit there are numerous incidents cited in this report showing how nurses advocate for patients’ rights, their contributions are not only confined to the hospital context. Nurses have always contributed to policy debates, which are aimed at improving the policy environment in the healthcare system. This way, nurses have taken part in campaigns aimed at improving the ethical and safety standards of the profession. Under this path, nurses have been actively involved in political action by providing an insider’s view to the healthcare practice. Here, nurses have been able to help policy formulators to pinpoint specific areas of concern, which need improvement in the profession. Relatively, nurses have also contributed to training and mentorship programs by conducting conferences and volunteering in nursing education programs that are aimed at shaping new nurses to fit into their advocacy role (Wright 2007, p. 53). These activities define the continuum of nursing advocacy.
Actual and Potential Costs of Advocacy
The actual and potential costs of advocacy are widespread. These costs stem from the actual roles, that nurses are required to perform as advocates. However, the actual and potential costs of advocacy can be categorized into two groups of personal and professional costs. They are discussed below
Professional Costs
Education
From the earlier depiction, that part of a nurse’s role (as an advocate) is to mentor and volunteer other nurses to practice advocacy, education stands out as an actual cost of advocacy. Indeed, educating new nurses require adequate resources, which may stretch from paying educators to providing learning resources. Occasionally, nurses volunteer their services and therefore, they do not receive any compensation in this regard. However, often, nurses are paid to teach new nurses about patient advocacy. Such educational activities are undertaken in special programs and vocations that require adequate funding (Wood 2010).
Legal Costs
Like many legal disputes, nursing advocacy may result in legal costs. Such legal costs often range from legal counsel costs to compensation costs. Rarely do medical disputes reach a court settlement, but nursing advocacy has the potential to ease the realization of such an eventuality. Often, when a medical malpractice has been reported and it is established that a healthcare provider is wrong, a hospital’s medical board may settle the case internally. However, when there is a significant level of contempt from any of the parties involved, the possibility of such cases moving to court is high. Medical incidents where a patient dies are often commonly arbitrated in court. Nurse-doctor disagreements are also usually settled this way. Depending on how a case is ruled, legal compensation may be given to the winning party. Usually, in serious cases where medical practitioners are found to be on the wrong, a hospital may be required to pay hefty damages, which may have a huge blow on a hospital’s finance. These legal costs constitute part of the actual cost of nursing advocacy (Wood 2010).
Time
Advocacy often requires adequate time. As patient advocates, nurses are often required to inform their clients about their health conditions, make sure the patients understand their diagnosis, work with the patients and doctors to ensure the patients get the best treatment options, and represent the patients when the doctor’s treatment plan opposes their will. Most of these activities require adequate time. However, with the immense responsibilities, that nurses are given (and the shortfall of healthcare practitioners, viz-a-viz patient numbers), it is often difficult to find adequate time to attend to every patient (let alone advocate for every patient). However, nurses are required to meet their patients’ needs and still be their advocate, without any additional time to undertake both duties (Wood 2010). Albeit most healthcare experts define advocacy to be part of the nursing profession, the insufficient time to address all nursing roles often compromises the quality of their services. For example, most advocacy activities are protracted and instead of attending to other responsibilities, nurses become embroiled in legal and bureaucratic tussles with other parties, thereby compromising the overall quality of care (Wood 2010).
In addition, the portrayal of a good public image (of nursing) by nurses also has a significant toll on the nurses’ time because nurses are often required to leave their work stations and attend to other promotional activities that do not have a direct link with their work as nurses. Every hour spent out of the workplace, implies patients suffer a high risk of being improperly cared for by the nurses. Therefore, even as nurses participate in promotional programs as patient advocates, the short-term impact of the advocacy program is detrimental to the patients’ wellbeing (Wood 2010).
Personal Cost
Poor Working Relationships
Part of the issues this paper highlights as obstacles to nurses working as advocates is the potential friction that may be realized when nurses differ from their superiors or doctors. Throughout the continuum of advocacy in nursing, nurses may experience opposition from different stakeholders. Indeed, nurses are often faced with a significant level of resistance, not only from opposing groups in the industry, but also from established systems of governance. For example, through the endless strings of bureaucracies that are evident in the healthcare system, nurses are often faced with an up-hill task of ensuring their advocacy roles are respected. Nurses may rub politicians, hospital administrators, or even family members the wrong way, thereby distorting the working relationships in the institution and decreasing the quality of healthcare in this regard (Chang and Daly 2011). Indeed, when doctors and nurses differ, there is bound to be tension between them and even though such outcomes are not expected, they may distort the good working relationship that nurses and doctors have. The same friction can also be witnessed among nurses, hospital administrators and government officials. The lack of proper understanding and good working relationships between healthcare providers is likely to impact negatively on the quality of healthcare (Chang and Daly 2011).
Guidance by the Australian Nursing and Midwifery Council (ANMC)
Based on the close relationship that nurses and patients share, advocacy is subject to several ethical and professional boundaries. Whenever these boundaries are breached, a subsequent repercussion is often witnessed. The withdrawal of practice licence, suspension, and dismissals are only a few repercussions that may be witnessed in this regard (Severt 2008). Wood (2010) documents a case in Texas, USA, where two nurses lost their jobs because they reported a physician to the Texas medical board for putting a patient at risk (because they believed the physician put the life of a patient in danger). The nurses lost their jobs because they were perceived to have used confidential information incorrectly. The Texas Nurses Association however defended the nurses and appealed this decision. The two nurses were later acquitted of all the charges (Wood 2010). This incident highlights the threat that nurses faces, but more critically, it highlights the sensitive ethical and professional boundaries that surround its practice. Indeed, advocacy should be practiced within strict professional boundaries stipulated by the appropriate nursing accreditation body. In Australia, the Nursing and Midwifery board safeguards these professional boundaries.
Different issues addressed by the board cover the guidelines for nursing advocacy. First, ANMC emphasizes the importance of ensuring all patients get quality care (as part of a nurse’s role as an advocate) (Sherman 2007). This provision is directly related to the nurse’s role as the patient advocate because the best nursing advocacy practices center on the importance of ensuring patients get the best possible care. The second principle of ANMC (that directly guides nursing advocacy in Australia) stems from its stipulation that, patients have the right to participate in healthcare decision-making. This provision is encompassed in the board’s articulation of the right to decision-making. Through this articulation, nurses are supposed to ensure that, patients are given all the information regarding their health, and the possible alternatives that exist within this periphery (Maddock 2006). This action has been defined in earlier sections of this paper as an important role that constitutes nursing advocacy. Lastly, through the ethical management of information provision of the ANMC guideline, nurses are required to ensure that information is treated as confidential and secure, always (Australian Nursing and Midwifery Council 2012). The same provision also ensures that, nurses manage patient information professionally because the failure to do so may have a negative implication on a patient’s wellbeing.
Advocacy and the Law
Advocacy and the law share a close relationship. While nursing advocacy strives to ensure that, patients get the best possible care (in the right environment), the law defines the right procedures that need to be undertaken to achieve this objective (Australian Nursing and Midwifery Council 2012). However, advocacy can be a precursor to the law because advocacy is part of the policy formulation process. Indeed, this paper has shown that part of a nurse’s role, as an advocate is to champion for sound legislation that benefits the patients. This way, nursing advocacy helps to inform the law-making process and overall, it acts as a precursor to the establishment of laws (Hyland 2002). Through the supportive framework, that nursing advocacy helps the law-making process; nursing advocacy also helps patients to self-advocate, thereby acting as a facilitator to the understanding of the law (Australian Nursing and Midwifery Council 2012). Concisely, through nursing advocacy, patients are able to know their possible courses of redress whenever they are faced with ethical or medical dilemmas. Nurses often understand the bureaucratic procedures and laws governing the healthcare system and therefore, they are similarly able to help patients to understand the existing laws. Through the above relationship that nursing complements the law, the two concepts share a very close relationship (Hyland 2002).
Conclusion
Nursing advocacy constitutes an integral part of the nursing profession. Through nursing advocacy, nurses stand out as the first-line of defense for patients because they are well versed with the wishes of their patients. This way, nurses are in the best position to advocate for patients’ rights to doctors, relevant authorities and even to the public. Several obstacles can be realized in advocacy, but after weighing the personal and professional costs of the practice, it is important to highlight that, the possible benefits to be realized from the practice outweighs its costs. In the Australian context, it is important to ensure that all nursing advocacy roles are undertaken within the provisions of ANMC. More so, emphasis should be given to information management, informed decision-making, and the provision of quality nursing care (for all) as the main provisions of ANMC, which guide nursing advocacy as a practice. Comprehensively, it is crucial to highlight that overall, healthcare quality is heavily dependent on the quality of nursing advocacy.
References
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