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Nurses as Advocates

Monday April 3, 2000
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The nurse's role as an advocate for the client's health and well-being dates back to the days of Florence Nightingale and Lillian Wald, who in 1902 convinced the New York City Board of Education to place nurses in schools to provide and monitor children's healthcare. Still an integral part of nursing practice today, advocacy has evolved from acting on behalf of an individual client to acting as guardian of client rights and empowering clients by promoting autonomy, self-determination and free choice for all health consumers.
In our currently tumultuous healthcare environment, advocating for patients includes a complex set of behaviors that place the nurse in the roles of mediator, health promoter and educator. Margot L. Nelson, RN, PhD, author of the book Advocacy, says that a central characteristic of advocacy in nursing is that it is a "way of being in relationship with a patient/client in a way which respects and promotes the uniqueness of the individual as a total human being in the context of his or her health experience," and adds that "Advocacy will continue to evolve along with the shift in health-care toward a paradigm of health rather than illness, increasingly community-based care models, and further development of advanced practice roles in nursing."1
The current role of the nurse as patient advocate is multidimensional, and includes -
Legal advocacy - in which the nurse serves as the guardian of patient rights, for example, promoting the right to competent care, the right to receive appropriate information to make informed decisions, and the right to refuse care.
Moral-ethical advocacy - in which the nurse works to represent and preserve patient values, supporting clients and families as they attempt to clarify their belief systems so they may make congruent decisions regarding types of medical intervention desired, end-of-life advance directives, and the right to terminate treatment.
Substitutive advocacy - the nurse serves as conservator of patient's best interests; advocating for those patients who are unable to do so for themselves. This may entail intervening with family members, physicians or other members of the healthcare team.
Political advocacy - the nurse serves as champion for social justice by working as a change agent to modify existing policies, institutional systems or laws which negatively impact the health and well-being of a large group or community of people.
Spiritual advocacy - in which the nurse communicates sensitivity to personal values and belief systems, providing spiritual comfort and access to the spiritual counsel of choice.2
Nurses are often the primary caregivers to intervene on the patient's behalf and are advocates for our healthcare clients in our social, economic, and culturally diverse population.
Advocacy Today
"Serving as patient advocates by presenting options, encouraging self-determination and, when necessary, interceding on the patient's behalf with family, medical staff and other members of the healthcare delivery team has always been an integral part of professional nursing practice," says Patrick Coonan, EdD, RN, CNAA, vice president of nursing and patient care services at Kingsbrook Jewish Medical Center in Brooklyn, NY, who adds "Changes in the healthcare delivery system and advances in "miracle technology" which offer many options for extending life have made advocacy and mediation even more critically important skills for nurses, necessitating their autonomous use of decision-making and critical thinking strategies. The role of leadership in nursing management is to empower the staff to do their best for the patient, even in difficult situations such as when the nurse's opinion is juxtaposed with the physician's."
Coonan points out that in today's highly competitive environment, "Hospitals have many customers - the patients, the physicians, and the managed care companies. This places additional stresses on nurses as they strive to negotiate the system while caring for the patient." Nurses have historically been advocates for access to quality, cost-effective healthcare services for all people. As managed care systems assume a larger role in healthcare, nurses must continue to promote the ethical concepts of the profession, advocating for the right of all patients to receive competent, compassionate, and responsible care based on need rather than economic factors.
Cleary suggests that the keys to becoming a successful nurse advocate include -
develope networking systems within work agencies and professional associations to assist in the provision of information and services to patients
acquire the knowledge needed to access systems
learn about community resources and support networks
develope skill in engaging, counseling and referring patients
"There is no cookbook approach to patient advocacy," says Coonan, pointing out that each individual case requires careful assessment followed by interventions targeted to the specific needs of the patient and family. "Nursing professionals are the pivotal people who manage care across the continuum, insuring that the patients' best interests are always at the forefront, and empowering consumers and families to actively participate in the healthcare decisions that will affect their lives."