A New Paradigm for Advocacy
Saturday April 1, 2006
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"It's exciting to think about the amount and nature of changes that are occurring and their impact on nursing practice," says Karen Stanley, RN, MSN, AOCN, FAAN, president of the Pittsburgh-based Oncology Nursing Society. Exciting, because these advances should increase access to care, she explains. "We must problemsolve now for future health care needs, because the current nursing shortage, coupled with the health care issues of an aging population, predict a shortage of qualified caregivers."
In this interview, Stanley, who just returned from Tokyo and the Sixth National Cancer Institute-sponsored international conference, where she spoke about Cancer Care and Nursing in the Future, addresses the role of nurses, especially oncology nurses, as patient advocates.
Q: Would you please tell us your definition of nursing advocacy?
Advocacy is an essential role for all nurses. It addresses one's individual responsibility to be informed about issues, to educate one's colleagues and the public about those issues, to collaborate with those who can
offer solutions to identified problems, and to effect change in nursing practice that delivers better outcomes.
Q: Describe the need for advocacy as a function of nursing.
Advocacy, on behalf of an improved health care system and the patients for whom we care, ensures that nursing is part of the solution to a growing problem. Nurses are well qualified to speak on behalf of patients and their families.
It is difficult to be a strong self-advocate when one is ill and vulnerable, unfamiliar with the health care system, and/or doesn't know what rights one has. In these instances, the patient and family must rely on health care providers to advocate for them, and it is our ethical obligation to do so.
There is an unequal relationship between the health care system and the patients it serves. The goal of advocacy is to equalize that relationship by assessing patient/family needs and understanding the circumstances, providing culturally sensitive information and education, ensuring equal access to appropriate care, and supporting the patient and family's decisions within the context of a multidisciplinary team.
Q: How has the philosophy of advocacy changed?
Historically, advocacy was viewed as ensuring that physician's orders were carried out. Nurses helped patients conform or comply in order to be well. Today, nursing advocacy requires critical thinking skills, appropriate assessment and intervention, speaking for the patient within the context of the multidisciplinary team approach, and ensuring that patient's wishes are honored and care is respectfully delivered.
Q:Describe some of the responsibilities nurses undertake in the new paradigm of advocacy for patients.
In addition to being informed about issues and speaking to patients in a way that improves their outcomes, nursing has an ethical obligation to address priority patient needs - physical, psychosocial, and spiritual. It can take courage to speak out for the most appropriate intervention when there is disagreement among the members of the multidisciplinary team. Collegiality is to be honored, but nursing's responsibility to the patient trumps all else.
Concrete examples of how oncology nursing practice provides advocacy include: supplying information to members of our professional organization about legislative and regulatory issues affecting nursing and cancer care, collectively and individually speaking to legislators and policy makers on Capitol Hill about those issues, keeping involved in reimbursement and access to care issues because our patients are significantly affected in these arenas.
This kind of advocacy represents the new paradigm in a global way, addressing issues that historically were not considered nursing issues.
Q:Give a clinical example of how an oncology nurse can speak up courageously for a vulnerable patient.
Individual patient advocacy occurs on a daily basis in a multitude of settings. In one instance, I consulted about a patient with metastatic cancer who had been admitted with a bowel obstruction and a tremendous pain burden. The obstruction was attended to, but there was an order for "no narcotics," since the obstruction had been secondary to the use of oral opioids without a concurrent bowel regimen.
Patient-centered advocacy requires the safe and effective management of pain. After consulting with the physician, who was extremely reluctant to order opioids, I was able to initiate intravenous opioids and a concurrent aggressive bowel regimen. I personally administered the first opioid dosage and watched the patient break into tears when his pain was relieved for the first time in several weeks.
Q:You've said that evidence-based
practice, almost a buzzword, relates to advocacy today. How does it relate to oncology nursing?
The Oncology Nursing Society has done a significant amount of work defining evidence-based practice in the oncology nursing arena. We see this as another part of our organization's advocacy role for oncology nurses and patients. We have compiled a meta-analysis of evidence-based practice in oncology nursing care. Topics include management of symptoms such as fatigue, nausea and vomiting, and depression, as well as other physical and psychosocial symptomatology. We have compiled evidence that supports best practice for oncology nurses and improved outcomes for patients. The next step is to educate oncology nurses so that practice can be changed.
At present, we're moving into phase two - nursing sensitive outcomes. We will use evidence-based practice as the nursing intervention and examine patient outcomes in the light of "best practice" nursing care. Our goal is to document the "worth of the work."
Q:With the need for so much emphasis on scientific evidence, how do nurses keep caring in nursing?
Nurses have to be available to patients in a way that works for patients. We have to be present. Presence seems a vague, almost ephemeral term, but it can be translated into concrete nursing practice. Being present to patients has multiple "faces." It requires being comfortable with and knowing oneself, an affirmation of the patient's value, a recognition of the patient's vulnerability, and a connection with the other person. Remaining in the moment when the conversation becomes existentially difficult is part of the oncology nursing role. It may mean being quiet and allowing the other person to speak the "unspeakable."
Q: Is there a discrepancy between nursing and patient perceptions of nurse caring?
Nurses have always distinguished themselves as caring individuals. The issue is how we define caring and what behaviors are perceived as the most important in defining caring.
RNs say care means being available for and present to patients. Patients say that these caring behaviors are very important to them, but in the majority of settings they prioritize clinical skills essential for good care. I believe the divergence results from nursing's assumption that expert physical care and critical thinking skills are a given and that caring behaviors are part of what makes nursing unique. Oncology patients in the diagnosis and treatment phase of the illness continuum prioritize clinical skills, whereas those nearing the end of life are more likely to prioritize psychosocial interventions in tandem with expert symptom management.
Q: What characteristics do you think nurse advocates need to be effective?
Nurse advocates must be tactful, assertive, and effective communicators and problem-solvers, who are willing to take risks while working within the system. The goals of nursing advocacy are improved patient care and outcomes.
Q: How exactly does culture affect nursing advocacy?
A patient and family's cultural background must be taken into account when planning care. That requires careful nursing assessment and subsequent interventions based on what we learn about the patient's values, not what we assume to be true based on stereotypical approaches. Advocacy is predicated, then, on those values. Family members of many cultures may request that the patient not be told of his or her illness and/or prognosis. In these instances, nursing's role is to identify the patient's preferences regarding information-sharing, inform other members of the health care team, speak to the patient's family if there is a difference of opinion between patient and family, and honor the patient's wishes.
Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum.
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