Patient Advocacy - an Important Part of the Daily Work of the Expert Nurse
Segesten, Kerstin Rn, PhD, Scholarly Inquiry for Nursing Practice
Over the past two decades, patient advocacy has been recognized as a part of nursing. For the most part, the issue has been treated by means of theoretical reasoning and case studies. Narratives describing lived experiences of nursing by expert nurses from Sweden were analyzed in this study. The nurses were identified by their superiors as expert nurses, as having a special gift, a "green thumb" for nursing. One third of the narratives concerned patient advocacy situations. The analysis of the narratives showed that the patient advocacy situation is composed of the following elements: apowerless patient, aproblem concerning the patient's own will or what is good for him or her, and an adversary. Further, it includes a trigger situation, and a prompt decision and action by the nurse. The nurse acts out of conviction, accepts an additional work load, and takes the risk of being punished.
Patient advocacy has received international recognition over the past two decades. According to Clark (1982), patient advocacy means informing the patients about their rights in a particular situation, making sure they have all the information necessary to make informed decisions, supporting them in the decisions they make, and protecting and safeguarding their interests. Stated more simply, to be an advocate means to speak up for someone who is unable to speak for him or herself. In the Concise Oxford Dictionary, an advocate is defined as "one who intercedes or pleads the cause of another." Patient advocacy implies that this other, in some respect, is dependent on the health care system, that is, that he or she is a patient The dictionary definition was used in this paper.
The person in need of advocacy has been described as vulnerable (Copp, 1982), ill-treated (Bangs, 1986), powerless, helpless, and dependent (Ashby, 1987), threatened by the system (Sawyer, 1988), ignored, shunned, or abandoned (Selby, 1988), and unable to speak for him or herself (Sawyer, 1988). The connection between the need for advocacy and the Patients' Bills of Rights is focused on by some authors (Ashby, 1987; Musgrave, 1987). Others focus more directly on the patients' needs and their right to decide for themselves (Beaman, 1989; Copp, 1986; Schaefer, 1989). Patient advocacy on the political level is also mentioned (Clarke, 1989). In this respect, the concept of advocacy is related to the concepts of powerlessness and empowerment.
Hokanson Hawks (1991, p. 760) defines power as "the actual or potential ability or capacity to achieve objectives...." The author also identifies antecedents to power. Power skills such as communication skills, knowledge, and concern are mentioned, and so are power sources such as informational, referent, and expert or legitimate ones. Powerlessness is identified as a harmful state for the person to be in. Empowerment is defined by Gibson (1991, p. 359) as "a social process of recognizing, promoting, and enhancing people's abilities to meet their own needs, solve their own problems... ." One aspect of the empowerment process, according to Gibson, is to act as a patient advocate.
Patient advocacy has been viewed by some authors (Nelson, 1988; Schaefer, 1989; Selby, 1988) as a fundamental duty of nurses and an integral part of nursing. Others have discussed advocacy as an extended role of the nurse, a role to be considered and included in the nursing care arena (Christy, 1973; Jenny 1979; Kosik, 1972; Sawyer, 1988). In a Canadian survey of nurses, 95% stated that nurses should act as patient advocates. The most frequently mentioned rationale was that good nursing care was not possible without such advocacy (Romaniuk, 1990).
It has also been argued that patient advocacy should not be the duty of the nurse. Three main reasons have been stated: 1) Nurses are in a dependent position in relation to the physicians and to their employers, who expect obedience and loyalty from them (Nelson, 1988). It could be difficult for them to disobey orders given by their superiors. …