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Transcript
Running Head: PATIENT ADVOCACY: THE NURSE’S ROLE
Patient Advocacy: The Nurse’s Role
Courtney Masse
University of New Hampshire
1
PATIENT ADVOCACY: THE NURSE’S ROLE
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Patient Advocacy: The Nurse’s Role
At 06:45 a nurse recieves report on a patient who was admitted to the hospital after the
involvement in a severe automobile accident. At this time the patient’s vital signs are stable, but
his hematocrit and hemoglobin are critically low, and he has sustained injury to both legs and
possibly his head. He is only oriented to person, can’t recall the time or day, and seems to be
confused. He complains of overwhelming pain in his abdomen as the doctor examines his entire
body. The nurse oversees as the physician completes his assessment and reflects on what the
patient has already told her prior to the doctor entering the room. She remembers that the patient
had told the previous nurse upon admission that he was a Jehovah’s Witness and that any
therapeutic procedures may be done, but he asked that no blood be transfused. As the doctor
finished his assessment, he came to the conclusion that in order for this patient to have an
optimal recovery he must receive two units of blood to increase his hematocrit and hemoglobin
since a significant amount of blood was lost from the sustained injuries. The physician doesn’t
realize that the patient is confused and as he is leaving the room the nurse speaks out. “He can’t
receive blood. He is a Jehovah’s Witness and he had asked upon admission that no blood be
administered. You will have to come up with a different plan as this is not in the patient’s best
interest.”
Since the time of Florence Nightingale, nurses have played a key role in the care of their
patients and one of the most important components of this role is playing the patient’s advocate
(Beyea 2005). Nurse’s constantly and consistently influence the outcomes of patient care, by
providing bedside support and communicating with others in the clinical setting to determining
the best overall plan of care for each individual patient. In the case presented above, the nurse is
advocating for the patient by voicing what the patient is unable to verbally communicate. Playing
PATIENT ADVOCACY: THE NURSE’S ROLE
3
a patient’s voice and supporting a patient’s autonomy are major roles involved with nursing
advocacy. Nursing advocacy is a key component to competent patient care and is one portion of
nursing that all nurses should consider when caring for any patient.
Definition
According to the American Heritage dictionary, the word advocate means to speak, plead
or argue in favor of (2009). It is the act of supporting a cause or, in a nurse’s case, a patient, and
is an essential component to optimal nursing practice. “Regardless of the practice setting, every
encounter a nurse has with a patient provides an opportunity for that nurse to serve as a patient
advocate” (Beyea 2005, p. 1). The American Nurses Association Code of Ethics (2001) reflects
its commitment to advocacy for patients in all settings and under all conditions. It states that the
nurse will promote, advocate for and strive to protect the health, safety, and rights of all patients.
As Beyea (2005) states in her article on patient advocacy, clinicians often decide what is
best for patients based solely on clinical data and lab test values rather than asking or fully
considering what the patient might actually want. This is most likely to occur in situations in
which patients choose to rely on and give their complete trust to their primary health care
providers. Other times, patients may be afraid to voice their concerns or preferences. Using the
definition of advocacy, it is the nurse’s role to help the patient voice his or her wishes and
support the patient in every way possible. The nurse most likely will have a better understanding
of the patient’s actual feelings regarding their health and current status since they are constantly
at the bedside discussing these feelings. The nurse must use assessment skills to fully understand
every patient’s scenario in order to properly advocate for every need that they may have.
Nursing Interventions
PATIENT ADVOCACY: THE NURSE’S ROLE
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One aspect of patient advocacy that is consistently at a focus is the interventions that
should be implemented into practice by the nurse. According to Paynton (2009), the “nurses' use
of a variety of communicative techniques to advocate appropriate patient care effectively has
gone largely unexamined” (p. 2). In his article he examines the results of a qualitative study
involving the narratives of six registered nurses, gathered over a period of six months, that
revealed the many ways nurses use informal power and communication to influence the
outcomes of patient care. It revealed the way that these six nurses were able to use this power to
manage both organizational and hierarchical constraints in order to advocate for proper patient
care. Although there were some obstacles involving hierarchal issues within the health care
team, the nurses stated, “they were generally able to perform their professional roles despite the
many challenges they face each day” (Paynton 2009, p. 13). The intervention that should be
performed by nurses as proved in this article is direct confrontation with physicians to validate
clinical decisions and care plans. This raises the question of when should the nurse use this direct
confrontation? When is confrontation considered inappropriate? Further research in this field
will hopefully gain a greater knowledge about these questions, but for the time being, direct
confrontation is still a provisional intervention that should be implemented into practice to
support patient advocacy.
Interventions involved with preventing medical errors and keeping the patient safe are
also discussed in literature. As said by the American Nurses Association Code of Ethics in 2001,
“as an advocate for the patient, the nurse must be alert to and take appropriate action regarding
and instances of incompetent, unethical, illegal, or impaired practice by any member of the
health care team or the health care system or any action on the part of others that places the
rights or best interests of the patient in jeopardy” (p. 1). If any behavior by a member of the
PATIENT ADVOCACY: THE NURSE’S ROLE
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heath care team is questionable in terms of the patient’s care, the nurse must intervene to protect
that patient. Instances such as not washing hands, improperly administering medications, and not
adhering to safety precautions should be reported by the nurse to supervisors and charge nurses.
By reporting this behavior, the nurse can help prevent injury to the patient and protect the patient
from harm. This intervention may be difficult for some nurses because it raises the question:
what type of behavior needs to be reported and what behaviors are deemed appropriate for
practice? Nurses should adhere to the facilities particular protocol, but should also always keep
the patients safety in mind.
Another element intertwined into the concept of patient advocacy is maintaining a
therapeutic relationship with the patient and establishing trust. According to Welch’s article on
therapeutic relationships, the most prominent way for nurses to implement a therapeutic
relationship is to use empathy, trust, power, mutuality, self-revelation, congruence, and
authenticity (2005). The benefits of having a therapeutic relationship include: openness from the
patient to confide information to the nurse that may be pertinent to their health and wellness,
willingness of the patient to comply with procedures, and motivation of the patient to enhance
their physical and mental health. A therapeutic relationship is considered to be patient advocacy
because it focuses on the patient’s well being and will help the nurse develop an understanding
of the patient’s entire situation. Understanding a patient’s entire story is necessary when voicing
something they are unable to communicate or when making recommendations to the physician.
The question of what is considered to be therapeutic is left up to the nurse, as different nurses
with different backgrounds and experiences may have different strategies for projecting this
therapeutic relationship onto the patient.
PATIENT ADVOCACY: THE NURSE’S ROLE
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One strategy that many nurses find to be effective in terms of advocating for a patient is
speaking out and giving recommendations based on observable data that may be gathered during
the nurse’s assessment. According to a study from Payton’s review of literature a point is made
that since nurses spend considerably more time with patients than do physicians, and because of
their strong belief in their patient advocate role, nurses should assess a patients' conditions and
advise physicians on how to provide necessary care (2009). Although this is true, it raises the
question: How much can the nurse recommend based on his or her educational background and
experience and when is too much considered inappropriate? The nurse has a more distinct care
base background where as the physician has a more scientific background. The goal of
recommendations and communicating is to find a balance between these two realms and
incorporate the patient’s feelings as well as his or her physical assessment. Therefore it is
necessary for the nurse and physician to cooperate and combine knowledge to come up with the
best plan of care.
Encouraging a patient to voice his or her wishes and desires or giving voice to a patient
when the patient cannot speak is one of the nurse's most important roles according to Beyea
(2009). Nurses should frequently ask the questions, "What does this particular patient want or
need? What is important for this patient and what are his or her preferences? What are his or her
wishes and values?" Sometimes the answers to these questions may not always be obvious and it
is the nurse’s job to seek out the answers to provide proper care. It is important that the nurse
establishes the answer to these questions but it should be done in a non-invasive manner as to not
make the patient feel uncomfortable. The balance between comfort of the patient and the need
for information must be established, which may not always be easy. Where does the nurse draw
the line and decide that questions asked of the patient are too intrusive or offending? Nurses must
PATIENT ADVOCACY: THE NURSE’S ROLE
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use best judgment and understanding of the patient’s situation and background to answer this
question.
Outcomes
Optimal patient care in a safe, effective, and timely manner is the goal of all outcomes
involved with advocating for patients. Another hopeful outcome of all nursing advocacy is that
the patient will be satisfied with care and that he or she will remain free from preventable harm.
As said by Schumacher and Meleis (1994) in their essay about the transitions patients will go
through within the healthcare setting, “effective planning requires comprehensive identification
of the problems, issues, and needs which may arise during a transition” (p. 123). Therefore it is
necessary in planning a patients care plan to advocate for the best care possible as this will ease
transitions and prevent complications and problems during these transitions. Overall if a patient
can leave the hospital feeling as if everyone in the health care team, primarily the nurse, has done
everything that is expected of them and possibly more, and the patient is happy with the care
they have received, then the nurse has done his or her job.
Issues Hindering Patient Advocacy
According to Payton (2009) participants in one study stated that organizational and
hierarchical constraints both facilitated and hindered their ability to act as patient advocates.
Working in complex systems can make it challenging for nurses to act as advocates. The
hierarchal issue that arises implies that some nurses may feel inferior to most physicians and this
can impede on a nurses willingness to speak up or express his or her opinion on the situation.
The hierarchal issue is one that will hopefully resolve in time, but as for right now every nurse
should do his or her best to maintain positive relationships with those that are a part of the
medical team, and avoid any type of superiority from forming.
PATIENT ADVOCACY: THE NURSE’S ROLE
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There also may be competing priorities for a nurse's attention and efforts, perhaps placing
tasks before advocacy. Other clinicians may not listen or respond in a timely manner. The
nursing shortage that causes nurses to take on more patients than may be manageable may hinder
a nurse’s ability to advocate for them. With too numerous patients, a nurse is unable to form the
proper therapeutic relationship, unable to gather enough information about a patient’s situation to
make recommendations, and unable to express the proper empathy to gain the patients trust. But,
although all of these factors may influence a nurse’s ability to advocate for patients, he or she
should still do her best to advocate for every patient as much as possible.
Reflection and Conclusion
According to Corbin (1998) the overall goal of care is to keep populations free of chronic
conditions and when chronic conditions do strike, nurses must assist those affected to control
symptoms, prevent complication, and maintain stability so that there may be quality and quantity
to life. In order for nurses to ensure that symptoms are controlled and complications are
prevented, they must advocate for patients. They must evaluate every patient’s background,
illness, history, and general personality to determine what their personal preferences may be in
order to make decisions when forming their care plans. Nurses should also consider the use of
therapeutic relationships, empathy, and establish trust to make the patient feel comfortable so
that in situations such as the one described in the introduction, the patient can rely on the nurse to
keep them safe and comfortable. Nurses play a key role in patient care and one of the most
important aspects of this role should be playing the patient’s advocate.
PATIENT ADVOCACY: THE NURSE’S ROLE
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Works Cited
Advocate. (n.d.). The American Heritage® Dictionary of the English Language, Fourth Edition.
Retrieved December 07, 2009, from Dictionary.com website:
http://dictionary.reference.com/browse/advocate
American Nurses Association. The code of ethics. 2001. Retrieved from: http://nursingworld.org/
ethics/code/protected_nwcoe813.htm#3.5
Beyea, S.C. (2005). Patient advocacy: Nurses keeping patients safe. AORN Journal. Retrieved
from: http://findarticles.com/p/articles/mi_m0FSL/is_5_81/ai_n13793213/
Corbin, J.M. (1998). The Corbin and Strauss Chronic Illness Trajectory model: an update.
Scholarly Inquiry for Nursing Practice. 12, 33-41.
Hanks, R. (2008). The lived experience of nursing advocacy. Nursing Ethics, 15(4), 468-477.
Retrieved from CINAHL Plus with Full Text database.
Paynton, S. (2009). The informal power of nurses for promoting patient care. Online Journal of
Issues in Nursing, 14(1), 3.
Schumacher, K. L. & Meleis, A.I. (1994). Transitions: A central concept in nursing. Image:
Journal of Nursing Scholarship. 26(2), 119-127.
Welch, M. (2005). Pivotal moments in the therapeutic relationship. International Journal of
Mental Health Nursing, 14(3), 161-165. Retrieved from CINAHL Plus with Full Text
database.