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 2 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 4 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 5 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 6 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 7 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 8 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 9 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.