Concept Analysis in Nursing Advocacy - Essay Example

CONCEPT ANALYSIS: NURSING ADVOCACY Advocacy is alleged to be a means of safeguarding good patient care. A variety of professionals claim to be best suited for the position, many stating that the role of patient advocate is inherent to their professions (Schwartz 2002). Advocacy is an important concept in nursing practice; it is frequently used to describe the nurse-client relationship. It is an ethic of practice(Gaylord 1995). Nursing advocacy has generated considerable attention and controversy in the nursing literature in recent years. It has been proposed as the philosophical foundation for nursing, championed as the guardian of patient rights, and rejected as inappropriate or impossible given the nurse's lack of legal and bureaucratic power and authority.(Adeline, 1995). Historically, patient advocacy has been a moral obligation for nurses. During recent years, nursing literature has been focused on the advocacy role and nursing professions has adopted the term 'patient advocacy' to denote an ideal of the practice. Nurses assume that they have an ethical obligation to advocate for their patients. They also frequently describe their judgments and actions on behalf of a patient as "being a patient advocate. An examination of advocacy in the nursing literature reflects broad and at times different perspectives. Advocacy has been described in ethical and legal frameworks and, more recently, as a philosophical foundation for practice. It has also been described in terms of specific actions such as helping the patient to obtain needed healthcare, assuring quality of care, defending the patient's rights, and serving as a liaison between the patient and the health care system. Although multiple factors influence the need for advocacy, it is generally true that someone in the healthcare environment must assume the role of client advocate, particularly for the client whose self-advocacy is impaired. Generally, advocacy aims to promote or reinforce a change in one's life or environment, in program or service, and in policy or legislation. In healthcare delivery, these activities focus on health conditions, healthcare resources, and the needs of patients and the public. When nurses advocate for patients, they face certain risks and obstacles associated with the settings within which they work. Therefore, there is always the possibility that attempts to advocate for a patient can fail, and that nurses can experience many barriers when addressing the rights, choices, or welfare of their patients (Negarandeh 2006). The term "advocacy" has been used in nursing literature to denote a variety of nursing roles, each derived from a specific set of beliefs and values. The changing forms of advocacy may actually reflect the metamorphosis of nursing from the role of loyal, subservient handmaiden to autonomous health care provider. Strong yet diverse feelings regarding the appropriateness of nurses to be advocates are evident in the nursing literature and may stem from the use of one word label, "advocate," to represent several related and sometimes conflicting concepts. These concepts are defined as follows: beneficence-the principle of doing good; nonmaleficence-the principle of do ing no harm; unitary-transformative paradigm-a perspective that views human beings as unitary, self-organizing energy fields interacting with a larger environmental energy field; and utilitarianism-an ethical doctrine in which actions are focused on accomplishing the greatest good for the greatest number of people. Simplistic advocacy Mitty (1991) defined an advocate as one "who pleads the cause of another. She asserted that this role is implicit in the social contract between society and a profession such as nursing. She noted that although advocacy may occur at the individual or sociopolitical level, the underlying ethics guiding it varies from nurse to nurse. Ethics of justice might lead one nurse to advocate for a client's right to certain health care procedures, for example, whereas a nurse guided by an ethics of utilitarianism might advocate for rationing health care. Simplistic advocacy is implicit in Malin and Teas-dale's depiction of the nurse caring when she does things for patients (Malin1991) and in Sine's definition of advocacy as "acting for, or on behalf of, another person (Sine 1993). Paternalistic advocacy Haggerty (1985) described paternalistic behavior as "doing something for or to another without that person's consent and on the premise that it serves that person's own good. Because paternalism values the client's health above his or her autonomy, the client's right to self-determination is always at least partially compromised. Paternalism is guided by principles of beneficence and nonmaleficence, with good and harm being defined from the perspective of an authority such as the physician, institution, or nurse. Taylor and associates (1989) suggested that it is based on an ethics of justice and duty wherein the client's freedom of choice is limited because the caregiver's expertise carries with it the duty to make the "best decision" for the client. A clear example of paternalistic advocacy may be seen in Malin and Teasdale's alternate definition of caring as "when . . . [the nurse] protects them (patients') from harm or unnecessary wor-ry." Paternalism creates a twofold dilemma for the nurse. First, it places the nurse in the position of making an "expert" judgment for the client, and second, it frequently requires defense of that judgment to the client, family, and other caregivers. Consumer advocacy In contrast to paternalism, consumer advocacy underscores the right of the client or consumer to information and services. Acting in the role of consumer advocate, the nurse is required to provide the patient with information to make a decision and then withdraw so as not to unduly bias the client. Gadow criticized this approach as dehumanizing to clients because it reduces them to machines. Such a role is, however, reflected in ethical codes that address only the need for information in the facilitation of client self-determination CAN 1991 & CNO 1995). Another aspect of consumer advocacy is the role of the nurse as patient rights or legal advocate. Arising from the patient rights movement of the 1970s, such a role requires that the nurse advocate not only for the patient's right to information but also for the rights to services and participation in decision making. This aspect of consumer advocacy is evident in both the Canadian Code of Ethics for Nursing (CNA 1991), which stresses the client's active participation in decision making, and in the American Code for Nurses, in which nurses "act to safeguard the client and the public when health care and safety are affected by incompetent, unethical, or illegal practice by any person. This nursing role has been severely criticized because it requires an advanced knowledge of the law,27 places nurses in an adversarial role against physicians and administrators, and places the nurse in a precarious legal situation. Rawls's justice-based ethics to a large degree provides the philosophical underpinnings of rights advocacy. Justice, to Rawls, is "the first virtue of social institutions and includes concepts such as fairness and equality. Although Rawls valued individual freedom, considering the lack of it an injustice, his ethics lacks dimensions of caring and nurturing that are central to nursing. Consumer-centric advocacy Kohnke (1982) ruled out simplistic advocacy as inappropriate for nursing and suggested that clients' needs are best met if the nurse provides information and then supports clients in their decision. This type of advocacy was endorsed by Bramlett and associates (1990) as consumer-centric advocacy. It is an approach that, according to the authors, synthesizes the strengths of paternalism and consumerism and ensures the client's rights to information, participation in decision-making, and freedom to implement decisions. It again stems from an ethics of justice and duty and combines the principles of beneficence and nonmaleficence with the right to self-determination. Existential advocacy and human advocacy At least two nursing authors rejected advocacy as an extrinsic role that nursing may or may not choose to adopt and proposed rather that it is the very essence of nursing (Curtin 1979 & Gadow 1980.). This philosophical foundation for nursing is referred to by Gadow as existential advocacy and by Curtin1 as human advocacy. They are treated together because both value self-determination above all other human rights, both consider advocacy as a philosophy within the context of the nurse-client relationship rather than a specific set of behaviors, and both view the client as an irreducible but interrelated and interdependent unity. Gadow rejected paternalism, simplistic advocacy, and consumer advocacy as philosophically opposed to existential advocacy. Furthermore, she moved beyond the idea of the nurse merely supporting the client's decision, as is proposed in consumer-centric advocacy. Existential advocacy involves the nurse's active participation with the client in "determining the unique meaning which the experience of health, illness, suffering, or dying is to have for that individual." Such participation is required before decisions about responding practically to that experience are made and facilitates the expression of "all that one believes important about oneself and the world" in the client's decision. Gadow (1980) rejected paternalism, simplistic advocacy, and consumer advocacy as philosophically opposed to existential advocacy. Furthermore, she moved beyond the idea of the nurse merely supporting the client's decision, as is proposed in consumer-centric advocacy. Existential advocacy involves the nurse's active participation with the client in "determining the unique meaning which the experience of health, illness, suffering, or dying is to have for that individual. Such participation is required before decisions about responding practically to that experience are made and facilitates the expression of "all that one believes important about oneself and the world in the client's decision. Both Curtin and Gadow described the potentially damaging effects of illness and institutionalization on the integrity of the person. Curtin described it from the perspective of altered human needs, Gadow from the perspective of human values requiring clarification within the context of the new situation. If the nurse cannot help clients clarify their values within this new context and reach decisions based on a reaffirmed set of values, the clients may be forced to recreate them according to the dominant values of the caregiver or institution (e.g., health is more important than autonomy). Gadow identified two reductionist concepts in health care that prevent authentic self-determination: the belief that health care providers should limit their involvement with their clients to a professional rather than a personal relationship and the separation of clients as objects from their lived experience. One fragments the client, the other the nurse. Both need to be resolved if advocacy is to be based on the common humanity of the nurse and the client. To paraphrase Gadow, it is only when the whole nurse nurses that the whole person can be nursed. To underscore the importance of the nurse's participation in client decision-making, Gadow identified disclosure of the nurse's views as a critical component of advocacy. Curtin proposed that once the shared humanity of both the client and the nurse are accepted as the basis of the nurse-client relationship, the nurse and client can freely determine the form that relationship will take (e.g., client and counselor, friend and friend, parent and child). Gadow also supported a situational, mutually defined nurse-client relationship provided that if clients waive their autonomy, that waiver is "consciously and freely given, not assumed nor coerced. ". Both existential and human advocacy are based on the value of client autonomy; however, both stress autonomy as within the context of a relational way of being rather than as independence. In this way, both are congruent with an ethics of care such as that proposed by Gilligan or Noddings and with Gadow's more recent work in relational ethics (Adeline, 1995). Maggie (2000) performed a bibliometric analysis in order to examine the growth and diffusion through the USA and UK literature of nurses' claims to patient advocacy. Analysis of articles cited under the key descriptor "patient advocacy" in the International Nursing Index (INI) was undertaken. Analysis included output in 5-year accumulations from 1976 to 1995, and was focused on quantity of output and exposition of concerns through interpretation of the titles. Citation mapping was undertaken to trace dominant influences in the diffusion process. Titles and countries of origin of the journal along with year of publication were organized into a database to provide quantitative material on comparative output from the USA and the UK. Citation profiles of key influencing authors were examined. It was found from the study that a role in patient advocacy was proposed in the American nursing literature in the late 1970s and in the British literature a decade later. Support for the role was evident in its use in professional organizations and schools. The pattern of dissemination illustrates the influence of American nursing on the professional role of nurses in the U'K. Maggie concluded that on the basis of a stages model for diffusion of an innovation, patient advocacy has reached only preliminary stages of acceptance as an innovation in nursing. A limitation of the study is that the "aggregationist" approach, adopted for this analysis, can produce a reasonable descriptive account of a complex phenomenon. (Maggie 2000). The literature contains convincing arguments in favor of nurses assuming the role of patient advocate. Nurses are medically educated, professional members of the team. They tend to spend the most time with hospitalised patients and are therefore more able to assess their needs and aspirations (Schwartz 2002). In the year 2002 Hewitt critically reviewed the arguments for and against undertaking the role of nurse advocate. It was concluded that nurses needed to be empowered first, if they are to empower their patients. There may however, be more suitable candidates for the role of patient advocate and nurses should recognize that they do not have a monopoly on ethical decision-making (Hewitt 2002). Harrison (2005), in a review article stated that nurses must first understand which clients are at risk and how to recognize the consequences of racial disparities in the delivery of healthcare. In order for this understanding to be achieved, however, nurses need to recognize and study racism and disparity in healthcare delivery. In the meantime, it is important to act aggressively to challenge racism by developing new frameworks of nursing care and transforming nursing curricula to reflect the responsibility as nurse advocates. (Harrison 2005). The study by Negarandeh in the year 2006 reported the findings about barriers and facilitators that Iranian registered nurses perceive affecting their advocacy role from a large-scale grounded theory study. This research used a constant comparative method to analyze data collected through an extensive grounded theory study, enabling the researchers to discover, describe, and discuss the factors which influence nurses' patient advocacy role. The approach was selected for the study because patient advocacy takes place in a complex workplace relationship and social context. The sample consisted of 24 nurses (staff nurses, head nurses and supervisors) working in a large university hospital in Tehran. Eighteen nurses, 3 head nurses and 3 supervisors were interviewed. The participants' age ranged from 23 to 50 with an average of 33.45. Nursing practice experiences ranged from 1 to 26 years with a mean of 10.59 years. Twenty-three of participants had BS degree in nursing, and one participant had MS degree in physiology. Twenty-one of participants were female and three were male. All the nurses who worked full-time in the period of study were considered as potential participants. Purposeful sampling was used for the initial interviews and, according to the emerging codes and categories data was collected by means of theoretical sampling. Through the process of data analysis, several categories emerged that explain the process of patient advocacy and factors that act as barriers or facilitators to patient advocacy. Participants cited Powerlessness as a key barrier to advocacy. Several nurses noted that Lack of Law and Code of Ethics act as barriers to advocacy role. Lack of Support for nurses was identified as another advocacy barrier. Participants felt that they did not receive any support for advocacy action from managers. Almost all of the nurses believed that a physician leading was the most important factor that produced obstacles to advocacy. Informants also noted that time constraints forced them to revise work patterns to complete many tasks in a limited time. Limited communication was also viewed as an important barrier for nurses to be as patient advocate. Finally lack of motivation was also described as a critical barrier. Informants also spoke about the factors that facilitated the practice of patient advocacy. The development of functional nurse-patient relationship was identified as a key factor to facilitating advocacy. Nurse-patient relationship recurred more than other themes in this study. Recognizing and paying attention to patients' needs and conditions was another factor that could facilitate patient advocacy. All nurses believed that comprehensive patient assessment enabled them to understand patients' real needs and be more effective in patient advocacy. They also believed that patients had different and varying needs and conditions; therefore, it was necessary for nurses to become aware of patient's needs and conditions in order to act on behalf of the patient. Another theme that emerged from the data collected was nurses' responsibility, which could facilitate the patient advocacy. All nurses described the knowledge and skills are essential to advocacy. Clinical knowledge and some skills were reported as crucial factors to effective advocacy. Although the data provided a rich description for advocacy facilitators and barriers from participants' viewpoint, generalization of research findings to the larger population of nurses is limited. It was concluded that advocacy is contextually complex, and is a controversial and risky component of any nursing practice. Different workplaces and cultures may affect the findings of the study. It is recommended that future quantitative research be conducted to identify the correlation between the identified barriers and facilitators and the use of advocacy, if any. In addition specific knowledge and behaviors that support the advocacy role should be examined (Negarandeh 2006). Vaartio in 2006 suggested that there is a scarcity of empirical evidence on nursing advocacy process and most of that evidence concerns nurses' views on the care of certain vulnerable patient groups in acute care settings. Before nursing practice can truly adopt advocacy as an inherent and natural part of nursing, a clearer understanding is needed of how it is defined and what activities are needed to accomplish advocacy. A study was carried out in order to understand the activities through which nursing advocacy is accomplished and the way that nursing advocacy is experienced by patients and nurses. Based on a qualitative approach, the study was limited to adult patients experiencing procedural pain in somatic care. Interviews were conducted in a convenience sample of patients (n = 22) and nurses (n = 21) from four medical and four surgical wards in Finland. Vaartio reported that nursing advocacy seems to integrate aspects of individuality, professionalism and experiences of empowering, exceptional care. It is not a single event, but a process of analyzing, counseling, responding, shielding and whistle blowing activities in clinical nursing practice. He concluded that in nursing practice the abstract concept of nursing advocacy finds expression in voicing responsiveness, which integrates an acknowledged professional responsibility for and active involvement in supporting patients' needs and wishes (Vaartio 2006). References Adeline, R., & Folk, R. (1995). Advocacy and empowerment: Dichotomous or synchronousconcepts AdvNursSci,18, 25-32. Bramlett, M.H, Gueldner, S.H, &Sowell, R.L. (1990) Consumer-centric advocacy: its connection to nursing frameworks. Nurs Sci Q, 3:156-161. Canadian Nurses Association.(1991) Code of Ethics for Nurs ing. Ottawa, Ontario: CNA; 1991. College of Nurses of Ontario (1995). Guidelines for Profes sional Behaviour. Toronto, Ontario: CNO; 1995. Curtin L. (1979).The nurse as advocate: a philosophical foundation for nursing. ANS, 1:1-10. Gadow S. (1980).Existential advocacy: philosophical founda tion of nursing. In: Spicker S, Gadow S, eds. Nursing Images and Ideals. New York, NY: Springer. Gaylord, N., & Grace, P. (2006). Patient advocacy: barriers and facilitators. BMC, 5, 3. Haggerty, M.C. (1985).Ethics: nurse patron or nurse advocate. Nurs Manage, 16:34O-34U Harrison, E., & Suzanne, M.F. (2005). Health Disparity and the Nurse Advocate Reaching Out to Alleviate Suffering.. Advances in Nursing Science, 28, 252-264. Hewitt, J. (2002). A critical review of the arguments debating the role of the nurse advocate. J Adv Nurs, 37, 439-45. Kohnke,M.F. (1982) Advocacy: Risk and Reality. StLouis.Mo: Mosby. Maggie, M., & Anne, M.R. (2000). Diffusion of the Concept of Patient Advocacy. Journal of nursing scholarship, 32, 399-404. Malin, N., &Teasdale, K. (1991). Caring versus empowerment: considerations for nursing practice. J Adv Nurs, 16:657-662. Mitty, E.l. (1991) The nurse as advocate: issues in LTC. Nurs HealthCare, 12:520-523. Negarandeh, R., Fatemeh, O., Fazlollah, A., Mansoure, N., & Ingalill, R.H. (1995). Nursing Advocacy: an ethic of practice. Nurs Ethics, 2, 11-8. Schwartz, L. Is there an advocate in the house The role of health care professionals in patient advocacy. J Med Ethics, 2002, 28, 37-40. Sine D. (1993) Advocacy: balance of power. Nurs Times, 89:52-55. Taylor, S.G., Pickens, J.M., & Geden, E.A. (1989). Interactional styles of nurse practitioners and physicians regarding patient decision making. Nurs Res, 38:50-54. Vaartio, H., Leino-Kilpi, H., Salantera, S., & Suominen, T. (2006). Nursing advocacy: how is it defined by patients and nurses, what does it involve and how is it experienced Scand J Caring Sci, 20, 282-92. Read More