nursing advocacy thesis

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Usama Saleh 1,* , Ahmad Aboshayga 2 , Tom O’Conner 3 , Moath Saleh 4 , Declan Patton 5 and Ailyn May G. ampang 6

Aim: The aim of this review is to report on nurses’ attitude and perception toward patient advocacy. Design: Systematic reviews. Data Source: We searched for evidence regarding nurses’ attitude, perceptions, feelings, thoughts, or behaviors toward patient advocacy in three databases: CINHAL, MEDLINE, and OVID. Review Methods: The inclusion criteria were studies on nurses’ attitude, perception, feelings, thoughts, and behaviors toward patient advocacy published in academic journals in English language. Qualitative, quantitative, or mixed-method research studies were included. The Critical Appraisal Skills Program (CASP) as a quality assessment tool was used as a framework to review the quality of the full-text articles. Each article was awarded a value score out of 20. Results: A total of 21 studies were eligible, of the 998 studies retrieved from selected databases. The review resulted in two findings: (1) nurses consistently have positive attitude toward patient advocacy, and (2) the patient advocacy process includes four elements: (1) the client situation, (2) the nurse, (3) advocacy interventions, and (4) the advocacy consequences. Conclusion: Preparing professional nurses for the advocacy role is essential part of quality nursing care. Impact: Patient advocacy is a complex concept and there has been inconsistencies on the use of this concept in the literature. Patient advocacy should be defined as a process with four elements: the patient situation, the nurse, and advocacy action, and the advocacy consequences. Al nurses in different areas of nursing practice can utilize the findings of this study to improve patient care outcome.

1. Introduction

2. background.

Nursing advocacy is a relatively modern concept. It was officially introduced to the profession on 1973 when the ICN Code of Ethics for Nurses reflected that nurses should advocate for their patients. Other Bodies of nursing included the advocacy concept into their Code of Ethics for Nurses [2] . For example, in 1976, the ANA announced the advocacy role in the Code of Ethics for Nurses. The code requested nurses to advocate for and protect the health and well-being of patients [3] .

To fulfill the advocacy-nursing role, nurses need to understand the concept of advocacy by understanding its meaning, definitions and attributes. Several definitions of advocacy exist in the literature because it is defined in a variable way, depending on the context in which it is used.

2.1 Meaning of advocacy

Advocacy means ensuring those who are not always seen or heard have a voice to join other voices in decision-making and change process. The concept of advocacy originates from the Latin word ‘advocatus’, meaning one who is summoned to give evidence. The actions of advocacy are defined to verbally support argumentation for a cause. The action of advocacy is similar to the function of an advocate [5] .

2.2 Definitions of advocacy

The concept of advocacy is defined in variable ways, depending on the context in which it is used. Traditionally, the concept of advocacy originates from the legal profession where a person’s case is presented and defended [6 , 7] . Cole et al. [7] and Hamric [8] defined advocacy as an active support of clients in relation to their rights and choices. Nurses advocate for patients by clarifying healthcare decisions in support of patients’ informed decision-making and protecting basic human rights such as autonomy. According to Sorensen and Ledema [9] , there are three major definitions of the concept of nursing advocacy exist in the literature: (1) protection of patients against unwanted medical intervention, (2) the release of patients from discomfort of unnecessary treatment, and (3) empowering patients by making them aware of their rights. Malik and Rafferty [10] viewed advocacy from a triadic point that includes informing, advising, and counseling. The Word Health Organization [11] described advocacy as an action or a means of promoting well-being and patient’s health status in all domains, including social, economic, political, behavioral, cultural, biological, and environmental contexts.

2.3 Attributes of advocacy

Thacker [12] identified the following defining attributes of advocacy based on extensive literature review: protecting the patient, listening to the patient’s voice, moral and ethical decision making, and promoting patient well-being. Bu and Jezewski [13] developed a midrange theory of patient advocacy through concept analysis and identified three attributes of patient advocacy: safeguarding patients’ autonomy, acting on behalf of patients, and championing social justice.

2.4 Types of advocacy

Kubsch, Sternard, Hovarter and Matzke [14] discussed five types of advocacy that were presented in the Kohlberg’stheory of model stage development [15] : (1) legal advocacy is guarding the rights of patients to competent care, to reject care, informed consent, and privacy; (2) moral-ethical advocacy is upholding the patient’s values in decision-making; (3) political advocacy is the facilitation of equal access to healthcare; (4) spiritual advocacy is providing access to spiritual support and reassurance; and (5) substitutive advocacy is the protection of interests of patients who are incapable of speaking for themselves. Megson [16] discussed six various types of advocacy identified by the British Institute for Learning Disabilities [17] . First, case advocacy focuses on one issue or set of issues. It usually has a short duration. Second, self-advocacy is where the person speaks up for herself or himself-if the person is able to do so. The third type of advocacy is ‘peer advocacy.’ It is when the advocate and the advocacy partner share similar experiences or environment. The ‘paid independent advocacy’ is the fourth type. Citizen advocacy, the fifth type, involve volunteers developing long-term relationships with people and speaking up for them. Finally, statutory advocacy is acting and making decision on behalf of individual who lack the mental capacity to do so for themselves.

2.5 Active vs. Passive advocacy

The literature made distinction between two types of advocacy: (1) active and (2) passive. Passive advocacy is where the nurse supports the patient’s choices and decisions and take actions within the context of institutional policy. In active advocacy role, actions are undertaken on the client’s, not the institution’s behalf. The nurse’s action of advocacy is based on professional standards and personal beliefs about what is morally and ethically right [18 - 20] . Segesten and Fagring [21] stated that a patient advocacy situation can be triggered in three ways: (1) a verbalized request from the patient; (2) a stated problem; and (3) an independent decision by the nurse, particularly when the client is a child or very ill. Patient advocacy can be influenced by facilitators and barriers. One of the most important facilitators is the nurse-patient relationship [22] . In conclusion, the literature on the definition of nursing advocacy remain ambiguous, contested, and illusive.

This review aims to present the current state of evidence, undertaking a systematic review of literature in order to report on: What are nurses’ attitudes and perceptions toward patient advocacy?

The design of this study is a systematic review with mixed methods. The mixed studies review is a type of systematic review that synthesizes results from studies using quantitative and qualitative methods. We used mixed method systematic review to combine the strength of and compensate for the limitations of quantitative and qualitative methods. There were three reasons for using mixed method systematic review: (1) we need qualitative method to interpret quantitative results, (2) we need quantitative methods to generalize qualitative findings, and (3) we need both methods to capture a holistic view of the phenomenon [23] .

5. Search Methods

A systematic literature searches of databases (Medline, CINHAL, and Ovid) was performed in February 2018 to identify articles written in English and published in academic journals regarding nurses’ attitudes and perceptions toward patient advocacy. There was no restriction based on year or country of publication.

Inclusion criteria were studies that focused on nurses’ attitudes, perceptions, thoughts, feelings, or behaviors toward patient advocacy. The review considered studies that included nurses in different areas of practice settings. The review excluded studies focused on neonatal/ pediatric nurses; however, the review included studies that neonatal/ pediatric nurses were part of the sample of the study. The review also considered studies included undergraduate and/or graduate nursing students but included interns/trainees. Quantitative, qualitative, or mixed methods approaches were included in the review. The review excluded studies published in non-English languages.

Following an initial review of key words in relevant literature, the search terms, strategies, and overall search process were defined. Table 1 illustrates a detailed search strategy and search results. We retrieved 987 articles from the three databases. Of these, 511 were from CINAHL, 472 from Medline, and 4 from OVID. Other sources of information used were gray literature and online resources, resulting in the inclusion of 11 articles.

Two researchers independently and blindly conducted the initial screening of titles and abstracts of articles identified through the search. In this step, we excluded 923. We subsequently retained 75, following a review based on the inclusion/exclusion criteria.

6. Search Outcome

A total of 75 articles were subjected to full-text review by the three researchers. Figure 1 illustrates the result of the search process. A total of 21 (6 CINHAL and 10 MEDLINE, and 5 other sources) articles remained after we removed duplicates and screened full-texts. The PRISMA flow diagram (figure 1) summarizes the phases of the search studies [24] .

7. Quality Appraisal

The Critical Appraisal Skills Program (CASP) as a quality assessment tool, generated by the Center of Evidence-Based Medicine in the United Kingdom [25] , was used as a framework to review the quality of the full-text articles. Articles were assessed by two independent reviewers for methodological validity. Any disagreement that arose between the reviewers were resolved through discussion or with a third reviewer. The CASP Relevant questions were applied to the individual studies (Table 2 and Table 3). The 10 criteria of the CASP appraisal tool are listed in table 2 and table 3. The article was assessed against each CASP criterion. A value of zero was giving if the article contained no information, a value of 1 if the article included a moderate amount of information and a score of 2 if the article fully addressed the criterion. Each article was awarded a value score out of 20 to signify its adherence to the CASP criteria.

8. Data Abstraction

Data were extracted from papers included in the review using a standardized data extraction tool as illustrated in table 4 and table 5 (supplementary file). The extracted data included the author’s name, country of publication, aim of the study, methodology/design, sample, data collection method, key findings, and recommendations. A quality appraised (CASP) score of each article that resulted from the appraisal process was also included in the data extraction form.

9. Synthesis

Searches identified 998 studies. During the initial screening step, titles and abstracts were screened and resulted in excluding 923 papers. Of the remaining 75 papers, 8 studies were excluded due to duplication and 46 papers were excluded because they did not meet the inclusion criteria. Twenty-one (21) papers were eventually included for the review. The PRISMA flow diagram summarizes the included studies based on the eligibility criteria (figure 1).

10. Results

The 21 studies that addressed the aim of the systematic review are contained in table 4 and table 5. Most of selected studies were conducted in Iran (n = 6), USA (n= 4), and Sweden (n = 3). The remaining studies were conducted in Saudi Arabia (n = 1), Egypt (n = 1), Brazil (n= 1), Nigeria (n=1), Finland (n=1), Ireland (n = 1), United Kingdom (n = 1) and Australia (n = 1).

Eleven (n =11) of the studies used a qualitative methodology (Table 5) and the rest (n=10) of the studies used a quantitative methodological approach (Table 4) (supplementary file). Cross-sectional design was the dominant design used in quantitative studies. Phenomenology (n=4), grounded theory (n=1), focus group (n=2), exploratory/ descriptive (n=4). Surveys (n =10) was the only data collection method used in quantitative studies while interviews (n=11) was the data collection method used in qualitative studies.

The studies used nurses from different areas of clinical nursing practice. Nurses from the following clinical specialties were included in the studies: medical-surgical nurses, general ward nurses, nurse anesthetists, Oncology nurses, Critical Care (ICU, CCU, ED) nurses, Maternity, mental health, community health, elderly care nurses, hospice nurses, perioperative nurses, ophthalmology muses. Two studies [26 , 27] included a sample of nurses and patients to better capture the experience of patient advocacy. Kolawole (ND) [26] used 219 nurses in addition to 25 patients; meanwhile Vaartio et al. [27] used a sample of 21 nurses and 22 patients.

Two of the studies [28 , 29] were conducted on phases to develop advocacy instruments. Sundqvist et al. [28] used three phases to translate and adapt the Protective Nursing Advocacy Scale (PNAS) into a Swedish version. Translation on the PNAS items took place in phase I. Phase II included psychometric evaluation on the newly translated PNAS instrument. The final phase (Phase III) was a description of Swedish RNAs of advocacy beliefs. Bu and Wu [29] study consisted of two phases to develop an instrument to measure nurses’ attitude toward patient advocacy. The first phase consisted of two stages of psychometric evaluation (1) Defining the construct, and (2) Generating the items. The second phase of the study was to examine reliability and validity of the instrument.

The included studies were subjected to appraisal under the Critical Appraisal Skills Program [25] . Table 2 and table 3 illustrate the criteria and the results of the appraisal. Each article was awarded a value score out of 20 to signify its adherence to the criteria. The total appraisal points of the articles ranged from 13-19 out of 20 (m =16.9, SD =1.7). Fourteen studies (n = 14, 66%) score 17 and above. A total of seven (n= 7, 33%) studies scored between 13-16, indicating gaps and limitations in relation to aims, data collection methods, research relationship, and ethical issues. None of the studies scored less than 13 and all studies were considered suitable for the systematic review as they addressed and met the inclusion criteria.

Ten quantitative studies used different instruments to measure nurses’ attitude toward patient advocacy. All of these studies consistently reported that nurses, in many different specialties, have positive attitude toward patient advocacy [22 , 26 , 28 - 35] . In Abbaszadeh et al. [34] study, nurses reported they should provide protective nursing advocacy for their patients while Nurse interns believe that patents should be provided interpreter when needed as part of advocacy [36] .

The studies used different specialty nursing population such as oncology nurses [29 , 31] , nurse anesthetists [28] , nurse interns [30] , critical care nurses [32] , ER general nurses, and mental health nurses [33] , surgical nurses [26] , critical care, general, and mental health nurses [34] . Community health nurses caring for elderly [22] , critical care, general ward, and mental health nurses [35] .

The reviewed studies suggested that advocacy is viewed by nurses as a process that consists of four elements: (1) the client situation, (2) the nurse, (3) the advocacy actions, and (4) the consequences of advocacy.

The patient situation has been described in the reviewed studies as morally inappropriate situation [36] , ethically difficult situation [37] , a complex confrontation of significant ethical and moral dilemmas [38] , patient vulnerability [39] or conflict/potential conflict situation, patient’s fear, and threat to the patient’s human rights [40] .

The characteristics of the nurse is important for the advocacy role. The reviewed studies described the advocate nurse as autonomous [36] , professional [27] morally obligated [39] , values individuality [27] , and knowledgeable with legitimate expertise [40] .

The reviewed studies have listed advocacy actions delivered by the nurses. Some of these actions are within the nurse-patient relationship [20 , 38 , 40] and within open dialogue with the patients [36] . Protecting the patients [37 , 40 - 43] is one of the recurrent theme of the advocacy action. Protecting patients means: (1) taking care of patients; (2) prioritizing patient health, (3) defending patients’ rights, (4) commitment of the completion of the care period [36 , 37] , representing the patient [42] . Table 6 lists actions of advocacy described in the reviewed studies. Finally, in the advocacy process, nurses respond to unethical patient situations to prevent incompetent or inappropriate practice [40] to achieve best possible health outcomes [36 , 37 , 40] .

In conclusion, the findings of the reviewed studies suggest there is an advocacy process model. The process is triggered by a morally or ethically inappropriate patient situation that mandates a professional nurse to respond with an advocacy action, ending the process with more favorable patient’s health outcome.

11. Discussion

This comprehensive systematic review identified 21 studies that investigated nurses’ attitude and perception toward patient advocacy. It is clear that nursing advocacy is a complex concept that has ethical and clinical importance to healthcare. The findings of this systematic review showed inconsistencies in the definitions of nursing advocacy. This finding is consistent with other published studies [6 , 7] . Cole et. al. [7] and Hamric [8] defined advocacy as an active support of clients in relation to their rights and choices. Sorensen and Ledema [9] reported three major definitions of advocacy: (1) protection of patients against unwanted medical intervention, (2) the release of patients from discomfort of unnecessary treatment, and (3) empowering patients by making them aware of their rights. Malik and Rafferty [10] viewed advocacy as informing, advising, and counseling. In conclusion, the literature on the definition of nursing advocacy remain ambiguous, contested, and illusive. The literature reflects an ill-defined concept of advocacy. The variance in defining this concept may be due to the fact that the concept of advocacy is used in a number of different disciplines. In addition, this variance in definition may be the result of attempts to define an abstract concept that reflects differing fundamental values and philosophical issues.

There were consistent reporting that nurses, in different specialties, have positive attitude toward patient advocacy [22 , 26 , 28 - 35] . This finding support previous studies’ findings [44 - 47] . This finding explains nurses’ commitment to patient advocacy and very responsive to the International Council of Nursing (ICN) and the American Nurses Association (ANA) Codes of Ethics.

Another key finding of this systematic review suggests that advocacy is a process that is triggered by a morally or ethically inappropriate patient situation that mandates a nurse to respond with an advocacy action, ending the process with more favorable patient’s health outcome. This finding led us to think of advocacy in more conceptually that yielded the advocacy process model that consists of four elements: the patient, the nurse, the advocacy response, and the advocacy consequences. Viewing advocacy as a process is consistent with Bu and Jezewski [13] Theory of Patient Advocacy. According to Bu and Jezewski theory [13] , patient advocacy is viewed as a processor or strategy with a set of actions to support and maintain and safeguard patients ‘rights, best interests and values in the healthcare system. This process can be influenced by facilitating and obstructing factors, at an individual and at an organizational level.

The findings of this review have revealed a wide range of advocacy actions that can be undertaken by nurses (Table 6). These actions can be as simple as opening dialogue with the patients and providing dignified care to acting on behalf of the patient by helping, intervening, and assisting the patient to best health outcome. Advocacy actions are delivered at different levels: patient level, institutional level or community level. This finding is consistent with previous advocacy models such as the Functional Model of Patient Advocacy [48] , the Social Advocacy Theory [49] , the Theory of Patient Advocacy [13] , and the Sphere of Nursing Advocacy (SNA) model [1] . The Functional Model of Patient Advocacy focuses on informing patients about their disease processes, treatments, medications, and procedures, and placing the responsibilities of decision making where it belongs, in the patients’ hands. According to this model, advocacy involves informing-supplying patients with information needed to make informed choices-patients and then supporting the decision they make [48] . The Social Advocacy Theory calls nurses to not only advocate for patients at the bedside, but also advocate for change within and across institutions, communities, and societies [49] . Bu and Jezewski [13] stated that the patient advocacy includes three broad core attributes: safeguarding patients’ autonomy, acting on behalf of patients, and championing social justice. The first two core attributes take place at a microsocial level and the third at the macrosocial level. The SNA model [1] provides a protective shield for the clients who are unable to self-advocate. The client and the nurse can be simultaneously acting as advocates on the client’s behalf--the client is practicing self-advocacy through the pores; and the nurse advocate for clients through the protective spheres.

12. Conclusion

The patient Advocacy Process Model is a source of influence and inspiration in refining and validating the nursing advocacy concept. The Advocacy Process Model can guide research which result in information or data that add to the accumulated advocacy knowledge. Researchers need to use the theories of advocacy to guide the research process, forms the research questions, aids in design, and analysis and interpretation. In terms of practice, if theory is expected to benefit practice, it must be developed co-operatively with people who practice nursing. Advocacy theory should provide the principles that underpin practice and help to generate further nursing knowledge. However, a lack of agreement in the professional literature on nursing advocacy theory confuses nurses and causes many to dismiss nursing theory as irrelevant to practice.

The main strength of this review were the systematic approach and reproducible method. It was based on explicit search strategies. The review used three databases and used mixed studies review that included studies with diverse designs and addressed complex review question. The mixed studies reviews combined the strength of both quantitative and qualitative studies. The review team included five experienced researchers and one coordinator. The research team have extensive and diverse research experience.

As in any review, one primary concern is that so called grey literature. The depth of critical appraisal of the research articles was limited by the skills and ability of the researchers. In addition, publication bias may have occurred. Positive results are more likely to be submitted and published in scientific journals than negative results. Finally, the search was limited to three databases mainly in health; thus not all articles were identified in this review.

The twenty-one reviewed articles were all written in English but not from English speaking countries. The studies were published from different parts of the globe with different cultural beliefs. Advocacy can be influenced by different religious, cultural, beliefs, and traditional practices. These factors can be influential of the generalizability and the transferability of the findings.

Competing Interests

The authors declare that they have no competing interests.

Author Contributions

Usama Saleh: PI, searching, screening, critiquing, data abstraction, evaluating, synthesis, discussion, conclusion, coordinating, writing, and overall supervision. Ahmad Aboshayga: Searching, screening, evaluating, critiquing, data abstraction, synthesis, discussion, writing, reviewing. Tom O’Conner: Searching, screening, writing, synthesis, discussion, and reviewing. Moath Saleh: Searching, data abstraction, synthesis, writing, and reviewing. Declan Patton: Searching, writing, and reviewing. Ailyn May G. Ampang: Clerical and administrative support.

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Exploration of Gratitude in Cardiovascular Health: Mediators, Medication Adherence and Psychometrics , Lakeshia A. Cousin

Theses/Dissertations from 2018 2018

Fatigue-related Symptom Clusters and their Relationship with Depression, and Functional Status in Older Adults Hospice Patients with Cancer. , Suzan Fouad Abduljawad

Genetic Moderation of Pain and Fatigue Symptoms Resulting from the Mindfulness-Based Stress Reduction for Breast Cancer Program , Carissa Bea Alinat

The Moderating Effect of Religion on Death Distress and Quality of Life between Christian Cancer patients in the United States with Muslim cancer patients in Saudi Arabia , Doaa Almostadi

Prevention of Post Intensive Care Syndrome-Family with Sensation Awareness Focused Training Intervention: A Randomized Controlled Trial Pilot Study , Paula L. Cairns

Assessing Abstinence in Infants Greater Than 28 Days Old , Genieveve J. Cline

The Relationship Between Sleep Quality and Motor Function in Hospitalized Older Adult Survivors of Critical Illness , Maya N. Elías

The Role of Migration-Related Stress in Depression Among Haitian Immigrants in Florida: A Mixed Method Sequential Explanatory Approach , Dany Amanda C. Fanfan

The Effect of Depression, Inflammation and Sleep Quality on Risk for Cardiovascular Disease , Catherine L. O'Neil

Adapting SafeMedicate (Medication Dosage Calculation Skills software) For Use In Brazil , Samia Valeria Ozorio Dutra

Theses/Dissertations from 2017 2017

The Relationship Between Total Neuropathy Score-reduced, Neuropathy Symptoms and Function. , Ashraf Abulhaija

Validation of the Electronic Kids Dietary Index (E-KINDEX) Screening Tool for Early Identification of Risk for Overweight/Obesity (OW/OB) in a Pediatric Population: Associations with Quality of Life Perceptions , Patricia A. Hall

Theses/Dissertations from 2016 2016

The Effectiveness of an Intervention Designed to Improve Chlorhexidine (CHG) Bathing Technique in Adults Hospitalized in Medical Surgical Units , Janette Echemendia Denny

Levels of Distress Among Women Veterans Attending a Women’s Health Specialty Clinic in the VA Healthcare System , Debbie T. Devine

Examination of the Use of Accelerated Resolution Therapy (ART) in the Treatment of Symptoms of PTSD and Sleep Dysfunction in Veterans and Civilians , Marian Jevone Hardwick

Investigating the Mutual Effects of Depression and Spiritual Well-being on Quality of Life in Hospice Patients with Cancer and Family Caregivers Using the Actor-Partner Interdependence Model , Li-Ting Huang

The Change in Nutritional Status in Traumatic Brain Injury Patients: A Retrospective Descriptive A Retrospective Descriptive Study , Dina A. Masha'al

Exploring the Relationship Between Severity of Illness and Human Milk Volume in Very Low Birth Weight and Extremely Low Birth Weight Infants Over Six Weeks , Shannon Leigh Morse

Cardiovascular Disease Risk Scores and Novel Risk Factors in Relation to Race and Gender , Johanna Wilson

Theses/Dissertations from 2015 2015

A Comparative Evaluation of the Learner Centered Grading Debriefing Method in Nursing Education , Marisa J. Belote

Sleep, Depressive Symptoms and Cognition in Older Adults and Caregivers of Persons with Dementia , Glenna Shemida Brewster

The Relationship between Hearing Status and Cognitive Performance and the Influence of Depressive Symptoms in the Older Adult , Julie A. Daugherty

Basal Salivary Oxytocin and Skin to Skin Contact among Lactating Mothers of Premature Infants , Jessica Marie Gordon

The Relationship Between Nurses' Emotional Intelligence and Patient Outcomes , Mary Kutash

Sexual Functioning and Body Image in Younger Breast Cancer Survivors , Carly Lynn Paterson

Cognitive Load of Registered Nurses During Medication Administration , Sarah Faith Perron

A Comparison of Quality of Life between Intense and Non-Intense Treatment for Patients with Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome , Sara Marie Tinsley

Theses/Dissertations from 2014 2014

Acculturation, Self-Efficacy and Breastfeeding Behavior in a Sample of Hispanic Women , Ivonne F. Hernandez

Knowledge and Acceptance of HPV and the HPV Vaccine in Young Men and Their Intention to be Vaccinated , Brenda Renee Jasper

The Relationships Between Sleep Disturbances, Depression, Inflammatory Markers, and Sexual Trauma in Female Veterans , Ellen Marcolongo

Examination of Possible Protective Effect of Rhesus D Positive Blood Factor on Toxoplasma-related Depressive Symptoms in Pregnancy , Lisa Lynn Parnell

Knowledge, Attitudes, and Practice of Primary Care Nurse Practitioners Regarding Skin Cancer Assessmnets: Validity and Reliability of a New Instrument , Debra Michelle Shelby

Theses/Dissertations from 2013 2013

Knowledge and Practice of Reproductive Health among Mothers and their Impact on Fetal Birth Outcomes: A Case of Eritrea , Winta Negusse Araya

Race/Ethnicity, Subjective and Objective Sleep Quality, Physical and Psychological Symptoms in Breast Cancer Survivors , Pinky H. Budhrani

Factors Predicting Pap Smear Adherence in HIV-infected Women: Using the Health Belief Model , Crystal L. Chapman Lambert

The Relationship Between Socioeconomic Status and Body Mass Index on Vitamin D Levels in African American Women with and without Diabetes Living in Areas with Abundant Sunshine , Shani Vann Davis

Predictors of Quality of Life in Patients with Cutaneous T cell Lymphoma , Darcie Marie Deaver

Relationship between dysphoric moods, risk-taking behaviors, and Toxoplasma gondii antibody titers in female veterans , Allyson Radford Duffy

Prenatal Stress, Depression, and Herpes Viral Titers , Pao-Chu Hsu

Factors Associated with Fear of Breast Cancer Recurrence Among Survivors , Jean Marie Lucas

Sickle Cell Disease: The Role of Self-Care Management , Nadine Matthie

Factors Influencing Vaccination Decisions in African American Mothers of Preschool Age Children , Chauntel Mckenzie Mcnair

The Strong Black Woman, Depression, and Emotional Eating , Michelle Renee Offutt

Development of an Investigator-designed Questionnaire Concerning Childbirth Delivery Options based on the Theory of Planned Behavior , Chun-Yi Tai

Theses/Dissertations from 2012 2012

The Mediating Effect of Distress Caused by Constipation on Predictors of Quality of Life of Hospice Patients with Cancer. , Abdel Alkhalouf

Testing a Model of Bacterial Vaginosis among Black Women , Jessica Brumley

The Effect of Tight Glycemic Control on Surgical Site Infection Rates in Patients Undergoing Open Heart Surgery , Sierra Gower

Development of a Tool for Pressure Ulcer Risk Assessment and Preventive Interventions in Ancillary Services Patients , Monica Shutts Messer

Hospice Nurses- Attitudes and Knowledge about Pain Management , Amie Jacqueline Miller

Theses/Dissertations from 2011 2011

Literacy and Hazard Communication Comprehension of Employees Presenting to an Occupational Health Clinic , Christine Bouchard

A Meta-Analysis of Cultural Competence Education in Professional Nurses and Nursing Students , Ruth Wilmer Gallagher

Relationship Between Cancer-Related Fatigue and Depression: A Pilot Study , Gloria Michelle Guess

A Comparison of Oncology and Non-Oncology Nurses in Their Knowledge of Cancer Pain Management , Nicole Houle

Evaluating Knowledge and Attitudes of Graduate Nursing Students Regarding Pain , Eric Bartholomew Jackson

Bone Marrow Transplant Nurses' Attitudes about Caring for Patients Who are Near the End of Life: A Quality Improvement Project , Leslie Lauersdorf

Translation and Adaptation of the Center for Epidemiologic Studies-Depression (CES-D) Scale Into Tigrigna Language for Tigrigna Speaking Eritrean Immigrants in the United States , Mulubrhan Fisseha Mogos

Nurse Manager Emotional Intelligence as a Predictor to Registered Nurse Job Satisfaction and RN Perceptions of the Practice Environment and the Relationship to Patient, Nursing and Hospital Outcomes , Jacqueline Cecilia Munro

The Relationship of Mid-Pregnancy Levels of Cytokines, Stress, and Depression with Gestational Age at Delivery , Melissa Molinari Shelton

Prophylactic, Risk-Reducing Surgery in Unaffected BRCA-Positive Women: Quality Of Life, Sexual Functioning and Psychological Well-Being , Sharon Tollin

Theses/Dissertations from 2010 2010

The Relationship Between FAM5C SNP (rs10920501) Variability, Metabolic Syndrome, and Inflammation, in Women with Coronary Heart Disease , Jennifer L. Cline

Women’s Perceptions of Postpartum Stress: A Narrative Analysis , Nancy Gilbert Crist

Lived Experience: Near-Fatal Adolescent Suicide Attempt , Phyllis Ann Dougherty

Exploring the Relationships among Work-Related Stress, Quality of Life, Job Satisfaction, and Anticipated Turnover on Nursing Units with Clinical Nurse Leaders , Mary Kohler

A Comparative Study of Knowledge of Pain Management in Certified and Non-Certified Oncology Nurses , Sherrie A. LaLande

Evaluating Knowledge and Attitudes of Undergraduate Nursing Students Regarding Pain Management , Jessica Latchman

Evaluation of Oncology Nurses' Knowledge, Practice Behaviors, and Confidence Specific to Chemotherapy Induced Peripheral Neuropathy , Rebecca Denise McAllister

Moderating the Effectiveness of Messages to Promote Physical Activity in Type 2 Diabetes , Rachel E. Myers

Factors Affecting the Process of Clinical Decision-Making in Pediatric Pain Management by Emergency Department Nurses , Teresa A. Russo

The Correlation Between Neuropathy Limitations and Depression in Chemotherapy Patients , Melissa Thebeau

Theses/Dissertations from 2009 2009

Fatigue Symptom Distress and Its Relationship with Quality Of Life in Adult Stem Cell Transplant Survivors , Suzan Fouad Abduljawad R.N., B.S.N.

Nursing Advocacy and the Accuracy of Intravenous to Oral Opioid Conversion at Discharge in the Cancer Patient , Maria L. Gallo R.N., O.C.N.

Transitional Care for Adolescents with HIV: Characteristics and Current Practices of the Adolescent Trials Network Systems of Care , Patricia Gilliam

The Effect of Ethical Ideology and Professional Values on Registered Nurses’ Intentions to Act Accountably , Susan R. Hartranft

Falls in Bone Marrow Transplant Patients: A Retrospective Study , Lura Henderson R.N., B.S.N.

Predictors of cancer caregiver depression symptomatology , Henry R. Rivera

Psychosocial outcomes of weight stigma among college students , Sabrina Joann Robinson

The Experience of Fatigue and Quality of Life in Patients with Advanced Lung Cancer , Andrea Shaffer

The Relationship Between Uncertainty in Illness and Anxiety in Patients With Cancer , Naima Vera

Shifting Paradigms: The Development of Nursing Identity in Foreign-Educated Physicians Retrained as Nurses Practicing in the United States , Liwliwa Reyes Villagomeza

Theses/Dissertations from 2008 2008

Prostate Cancer Screening Intention Among African American Men: An Instrument Development Study , Susan Anita Baker

The Geriatric Cancer Experience in End of Life: Model Adaptation and Testing , Harleah G. Buck

Communication Systems and HIV/AIDS Sexual Decision Making in Older Adolescent and Young Adult Females , Rasheeta D. Chandler MS, ARNP, FNP-BC

Relationship of Anger Trait and Anger Expression to C-Reactive Protein in Post-Menopausal Women , Rosalyn Gross

Identifying Patients with Cancer at Risk of Experiencing a Fall While Hospitalized , Joann M. Heaton

Modulation of Monocyte-Derived Dendritic Cell Maturation and Function by Cigarette Smoke Condensate in a Bronchial Epithelial Cell Co-Culture Model , Alison J. Montpetit

Cancer Patients with Pain: Examination of the Role of the Spouse/Partner Relationship In Mediating Quality of Life Outcomes for the Couple , Mary Ann Morgan

Development of an Ecological Model to Predict Risk for Acquisition of Clostridium difficile -Associated Diarrhea During Acute Care Hospitalization , Susan Elaine Steele

Development and Psychometric Evaluation of the Chemotherapy Induced Peripheral Neuropathy Assessment Tool , Cindy S. Tofthagen

Health Decision Behaviors: Appropriateness of Dietary Choice , Daryle Hermelin Wane

Theses/Dissertations from 2007 2007

The Relationship Between Sleep-Wake Disturbance and Pain in Cancer Patients Admitted to Hospice Home Care , Marjorie Acierno

Wheelchair Positioning and Pulmonary Function in Children with Cerebral Palsy , Lee Barks

Structural Equation Model of Exercise in Women Utilizing the Theory of Unpleasant Symptoms and Social Cognitive Variables , Sarah Elizabeth Cobb

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Patient advocacy in nursing practice : a systematic literature review

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• OJIN Homepage
• Table of Contents
• Volume 25 - 2020
• Number 1: January 2020
• Beyond the Nurse Practice Act

Beyond the Nurse Practice Act: Making a Difference through Advocacy

As Director of Practice of the Texas Nurses Association, Ellen supports nurses’ efforts to influence policy through member engagement and assistance, collaboration, and communication. She is active in policy development, actively assisting policy committees in analyzing issues and developing policy positions. Ellen began her clinical practice in neuroscience nursing and for the past 20 years has focused on healthcare quality across the continuum of care from acute care hospitals, to community-based mental health, home care, and hospice. She received an ASN from Angelo State University, a BSN and MSN from Queens University of Charlotte where she was recognized as the outstanding graduate student, and a PhD in nursing from University of Texas at Austin.

As chief executive of the Texas Nurses Association, Cindy leads the strategic operations of the Texas Nurses Association, a professional membership organization of registered nurses that empowers Texas Nurses to advance the profession. She is active in policy development, actively negotiating legislative approaches to address nursing’s agenda. Cindy’s nursing career spans advanced practice, chief nurse executive, and academic roles. She has authored numerous publications focusing on nursing practice, advocacy, and care of persons with serious mental illness. She received a BSN from University of Detroit – Mercy, magna cum laude, an MSN in adult psychiatric-mental health nursing from Wayne State University, and a PhD in nursing from University of Texas at Austin where she was recognized as the outstanding doctoral student.

• Figures/Tables

Policy frames nursing practice in the most fundamental way: through state nurse practice acts (NPA) which date back over one hundred years in many states. NPAs frame nursing practice by defining a professional scope and educational requirements for practice. NPAs have not remained stagnant over the past century, rather they have evolved – but only with the active involvement of nurses in legislative efforts to change statute and update policies related to nursing practice. However, changing practice through policy does not stop with the NPA. This article will begin by briefly addressing the role of nurses in advocacy to advance professional practice , and offer background information about the changing healthcare industry that has influenced the example of advocacy we discuss. We offer exemplars that illustrate policies that regulate the environment of practice, such as nurse staffing, musculoskeletal injury prevention, and failure to advocate, and discuss needed protections , including whistleblower protections in our state. We conclude by considering implications for nursing organizations and nurses among these exemplars.

Key Words: nurse, nurse advocacy, health policy, legislation, nurse practice act, whistleblower

Nurses have been advocating for change since the day Florence Nightingale penned an urgent missive to the Secretary of State for War on the need for trained nurses to care for the wounded soldiers in the Crimea. Nightingale’s post-war work on hospital reform is among her most lasting accomplishments ( Small, 2017 ). She collected, analyzed, and presented evidence to decision-makers on improved nutrition and hydration, sanitation, and ventilation for hospitalized patients ( Kudzma, 2006 ). Establishing a foundation for the role of nurses in evidence-based advocacy, she emphasized the progressive nature of nursing, urging:

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” ( Nightingale, 1860 , p. 40-41).

As we begin 2020, designated by the World Health Organization ( [WHO], 2019 ) as the “Year of the Nurse and Midwife,” policy change remains among the most effective approaches to create the circumstances for the right thing to be done. Since the beginning of the profession, through individual and collective efforts, nurses have changed practice through policy by addressing systemic barriers to optimal patient care and healthy environments through establishment of standards, regulations, and policy.

Since the beginning of the profession, through individual and collective efforts, nurses have changed practice through policy... Although Ms. Nightingale was often successful in single-handedly influencing policy through her relationships with military and hospital leaders, most policy work involves collaboration among nurses and other stakeholders. The American Nurses Association ( [ANA], n.d. , para. 1) describes the organization’s history starting in 1896 as “the story of individual nurses everywhere” united in common cause to advance nursing practice. This article will begin by briefly addressing the role of nurses in advocacy to advance professional practice, and offer background information about the changing healthcare industry that has influenced the example of advocacy we discuss. We then offer exemplars that illustrate policies that regulate the environment of practice, such as nurse staffing, musculoskeletal injury prevention, and failure to advocate, and discuss needed protections, including whistleblower protections. We conclude by considering the common thread among these exemplars.

...most policy work involves collaboration among nurses and other stakeholders. Nursing practice is regulated at the state level, therefore most of the exemplars in this article are from Texas, our state. We offer these to affirm the work of these nurses and organizations as we celebrate nurses this year. However, we recognize that there are stories from every state that highlight the valuable work of many nurses that illustrate individual and collective nursing organization advocacy.

Advocacy to Advance Practice

Advocacy in Nursing Regulation: Nurse Practice Acts The original intent of nurse practice acts was the regulation of nursing practice through registration, now licensure ( Russell, 2012 ). North Carolina enacted the first nurse registration law in 1903. Licensure eligibility criteria and the first licensure exam were developed in 1904. ( North Carolina Board of Nursing, 2019 ). A few years later, nineteen nurses convened on February 22, 1907 to establish the Graduate Nurses’ Association of Texas, later renamed the Texas Nurses Association (TNA). One of the first objectives of the new organization was the passage of legislation in 1909 requiring registration of nurses through a Board of Nurse Examiners, creating the first nurse practice act in Texas ( Brown, 2010 ).

Nursing education programs first evolved outside of the general education system through hospital-based “education for service” models. Setting standards for nursing education was an important component of early nursing regulation ( Russell, 2012 ).

Nurses have an ethical imperative to engage in policy. Advocacy as an Ethical Duty Nurses have an ethical imperative to engage in policy. The ANA ( 2015 ) adopted its first formal code of ethics in 1950 to express the values and ideals for the nursing profession. Over the years, the core values of nursing have remained constant and principles upheld, while specific concerns have evolved and been clarified. Nurse participation in health policy was recognized with the inclusion of the nurse-as-advocate role, added in 1976. Revision of the code in 1995 expanded it to include social ethics, global concerns, and emphasis on the important role of nurses in health policy. The most recent iteration of the code ( ANA, 2015 ) addresses the ethical imperative for engagement in policy. Despite this emphasis, nurses do not often consider how policy affects the professional nursing role ( Taft & Nanna, 2008 )

Changing Healthcare Industry

Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations. A brief overview is offered here to provide perspective related to the specific exemplars we discuss.

Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations. Hospitals were compelled to focus specifically on safety when in 1999 the Institute of Medicine (IOM) released its groundbreaking report, To Err is Human ( Kohn, Corrigan, & Donaldson, 2000 ). This report revealed disturbing insights into the prevalence of medical errors in healthcare and the consequences of those errors. With the increasing availability of information about preventable errors and complications of hospital care, particularly those related to nursing care, hospitals were called to higher levels of accountability for patient outcomes. This accountability came in the form of changes in payment policy.

In the fall of 2007, the Centers for Medicare and Medicaid Services (CMS) announced that it would no longer reimburse hospitals for nursing-related, preventable complications occurring during a patient hospital stay (The George Washington University, 2007). Non-reimbursable conditions include hospital-acquired pressure ulcers and readmissions. Health insurance companies have followed suit with pay-for-performance and shared-savings programs ( Wallace, Cropp, & Coles, 2016 ).

Initially, outcomes data related to nurse staffing was sparse. Measurements of quality shifted away from an interest in structure and process, and instead targeted outcomes: patient, staff, and financial. Discussions of nurse staffing followed these trends. Where creative models of care to reduce costs dominated dialogue around nurse staffing in the 1990s, attention was cued to staffing outcomes following the IOM report. Initially, outcomes data related to nurse staffing was sparse. In the mid- to late-1990s, the American Nurses Association (ANA) led nursing efforts to identify measures that would link availability of nursing services to quality ( ANA, 1997 ; Montalvo, 2007 ).

These efforts culminated in the development of the National Database of Nursing Quality Indicators™ (NDNQI ® ). The NDNQI ® provided one of the first databases of patient and nurse outcome indicators and it is currently the only national database containing unit level data regarding nurse sensitive indicators. This database includes measures directly related to nursing care and patient outcomes ( Montalvo, 2007 ) such as: nursing hours per patient days; hospital-acquired infections and pressure ulcers; and skill mix (percent of total nursing hours supplied by different types of direct care providers).

For the first time, patient outcomes could be specifically mapped to nursing care... Because the NDNQI ® provided unit level data, it enabled comparisons across like units and like hospitals. For example, a telemetry unit in one small community hospital can compare its pressure ulcer and vacancy rates to a similar unit in another community hospital. For the first time, patient outcomes could be specifically mapped to nursing care, not just by morbidity or medical complications, but by outcomes that are specifically amenable to nursing management and intervention. This database became a powerhouse of information for researchers interested in studying relationships between nursing staff characteristics and patient outcomes ( Dunton, 2007 ).

Exemplars of Advocacy

Nurse Staffing Staffing involves a process of matching and providing staff resources to patient care needs. Nurse staffing is resource intensive and is the largest component of hospital operational budgets. Decades of research have confirmed the relationship between nurse staffing and patient outcomes such as mortality ( Aiken et al., 2012 ; Aiken, Clarke, Sloane, Lake, & Cheney, 2008 ), healthcare-associated infections ( Cimiotti, Aiken, Sloane, & Wu, 2012 ), financial, and nurse outcomes ( Unruh, 2008 ).

Nurse staffing is resource intensive and is the largest component of hospital operational budgets. The complexity of nursing characteristics (e.g., skill mix); patient characteristics (e.g., acuity and case mix); and the interaction of these variables within the hospital environment make it extremely difficult to define a template as simple as a nurse-to-patient ratio to ensure appropriate staffing ( Kane, Shamliyan, Mueller, Duval, & Wilt, 2007 ; Unruh, 2008 ). Nursing workload and hospital work environment variables, including culture, have a significant impact on the ability of the nurse to provide safe and appropriate care ( Kane et al., 2007 ; Unruh, 2008 ). Nurse researchers are working to describe these relationships and provide guidance for effective staffing models.

While the Medicare Conditions of Participation ( 68 Federal Register 3435, 2003 ) have long required hospitals to have policies in place to ensure “adequate” nurse staffing, specific policy has lagged. With the increasing body of evidence documenting the relationship between nurse staffing and patient outcomes, several states have passed legislation requiring organizations to adopt more specific policies and practices. For example, dissatisfied with the staffing by patient acuity model legislated in the early 1990s, ( Coffman, Seago, Spetz, 2002 ) members of the California Nurses Association successfully pressed 164 legislators to pass a prescriptive bill specifying the maximum number of patients to be assigned to a registered nurse in each patient care area ( California Assembly Bill No. 394, 1999 ). The statute was implemented in 2004. Other states have passed legislation ( ANA, 2019 ) with an alternative policy approach requiring hospitals to engage nurse staffing committees in the determination of appropriate staffing levels. The legislation prescribes that 60% of the committee seats are filled by direct care nurses to ensure nursing input in staffing decisions.

Nurse researchers play an important role in policy evaluation by studying the impact of policy changes. Such policies directly support nurse executives, often the decision-makers related to staffing, by offering a flexible approach to planning and budgeting nursing services. Nurse researchers play an important role in policy evaluation by studying the impact of policy changes. A study examining the effect of Texas’ staffing legislation ( Texas Senate Bill 476, 2009 ) found that hospitals with higher staffing levels did not significantly change after the legislation and hospitals the lowest staffing levels prior to the legislation increased staffing ( Jones, Bae, and Murry, 2015 ).

Musculoskeletal Injury Prevention Patient transfers, lifting, and handling are physically demanding and present clear risk for both the patient and the nurse. Frequent bending and standing contributes to fatigue and may increase the risk of slips of falls. The risks are not only damaging to the health of nurses and patients, but also are costly in terms workers compensation insurance and nurse turnover. Registered nurses experience musculoskeletal injuries at a rate of 46.0 cases per 10,000 full-time workers, much higher than the rate for all occupations, 29.4 cases per 10,000 workers based on data from the U.S. Bureau of Labor Statistics, Survey of Occupational Injuries and Illnesses. ( Dressner & Kissinger, 2018 ). In addition, rising obesity rates means that nurses are caring for patients who are heavier and have a higher rate of comorbid conditions. An estimated 12-18% of nurses leave the profession due to chronic back pain ( Nelson & Baptiste, 2006 ).

Texas was the first state to have safe patient handling and movement policies enacted in legislation. The national “Handle with Care” campaign, launched by ANA in 2003 to engage members of the healthcare industry in back injury prevention, spurred advocacy efforts to change policy ( de Castro, 2004 ). Texas was the first state to have safe patient handling and movement policies enacted in legislation. Nurses engaged in a major 2005 legislative effort in partnership with hospitals and nursing homes. Intended to improve the safety from physical injuries of both nurses and patients, SB 1525 was signed into law and took effect January 1, 2006. This law requires hospitals and nursing homes to adopt policies and procedures for the safe handling of patients that “control the risk of injury to patients and nurses associated with the lifting, transferring, repositioning, or movement of a patient.” ( Texas Senate Bill 1525, 2005 ). Since then, 11 states have either passed laws or promulgated regulations, 10 of which require healthcare facilities to develop and implement comprehensive safe patient handling programs ( Brigham, 2015 ). See Table for examples of these laws.

Table. Examples of State Legislation to Improve Safe Handling

( CDC, 2013 )

Failure to Advocate Policies that protect nurses who advocate for patients are a vital element of safe healthcare delivery. Policies that protect nurses who advocate for patients are a vital element of safe healthcare delivery. Unfortunately, the significance of nurse advocacy in protecting patients from harm is perhaps best illustrated in an example in which advocacy failed and patients were harmed. This example represents a missed opportunity for nurses to change practice through policy. Black ( 2011 ) described what, at the time, was thought to be the largest documented patient nosocomial bloodborne pathogen exposure due to inappropriate reuse of equipment and syringes intended for single use.

While many nurses recognized the reuse practice as inconsistent with safe infection control practices, complacency among coworkers and fear of retaliation inhibited reporting of concerns. As a result, 115 patients at two endoscopy clinics were infected with the hepatitis C virus. A joint investigation by federal and state agencies revealed violation of standard infection control practices. Twenty two nurses were investigated by the Nevada State Board of Nursing for alleged violations of the Nevada Nursing Practice Act, notably failure to safeguard patients ( Black, 2011 ). Black noted that while nurses are accountable for protecting patients from harm, often few protections exist for nurses raising patient safety concerns: “…employment at-will doctrine… places nurses who witness unsafe practices in a difficult catch-22: if they report unsafe practices, they risk losing their jobs; if they don’t, they risk losing their licenses.” (p. 28).

Advocacy and Whistleblower Protections

Given the outcome and scope of the outcomes of successful advocacy, and the failure to advocate discussed above, it is important to address the need for advocacy protections. This includes protections for whistleblowers. We discuss this in the context of practice in the state of Texas.

One example in Winkler County involved two nurses, Anne Mitchell and Vikki Galle, who were retaliated against for reporting unsafe medical practice. They reported first to hospital administration and then to the Texas Medical Board after their concerns were not addressed. The nurses were fired from their positions and were criminally indicted for a third-degree felony ( Thomas & Willman, 2012 ). After Mitchell and Galle were exonerated in a jury trial, nurse advocates went to work to strengthen nurse protections. The hospital broke the law when it retaliated against the nurses for making an external report. The Department of State Health Services fined the hospital the maximum allowable amount of $1,300 ( Thomas & Willman, 2012 ).

The Texas Nursing Practice Act includes several advocacy protections for nurses. Although policy cannot completely prevent retaliation, the Patient Advocacy Protection Bill strengthened existing protections by increasing the penalties state licensing agencies can impose. This law allows up to $25,000 per occurrence to deter retaliatory behavior ( Texas Senate Bill No. 192, 2011 ).

The Texas Nursing Practice Act includes several advocacy protections for nurses ( Texas Occupations Code Chapter 301, 303, 304, 2019 ). Safe Harbor Nursing Peer Review ( Texas Occupations Code 303.005, 2019 ) protects nurses who believe in good faith that they are being requested to engage in conduct that would violate a nurse’s duty to patient as defined in the board of nursing rules on standards of professional practice and unprofessional conduct. Further protections ( Texas Occupations Code, 2019 ) include refusal to engage in reportable conduct; reporting staffing concerns in hospitals; nurses who refuse to engage in conduct reportable to the board of nursing; and nurse reporting of concerns within a facility about patient exposure to substantial risk of harm or failure to conform to minimum professional, regulatory, or accreditation standards. Board of nursing rules outline the procedures nurses must follow to access these protections. For example, prior to 2019, nurses were required to invoke safe harbor in writing and notify the supervisor to receive the protections from employer discipline or board sanction.

As gaps in protection are identified, nurses work to address them through policy change. As gaps in protection are identified, nurses work to address them through policy change. The most recent example is a nurse who contacted the TNA practice hotline because she was retaliated against for speaking up for patient safety. Because she was in the middle of a procedure, she could not leave the patient’s bedside to invoke safe harbor in writing as required by existing law. Recognizing this gap in protection, TNA worked with Representative Stephanie Klick, RN, one of two nurses in the Texas Legislature, to pass House Bill 2410 Oral Safe Harbor ( Texas House Bill No. 2410, 2019 ), which allows nurses to invoke safe harbor orally in situations where patient needs prevents nurses from leaving the beside to complete safe harbor forms. The Figure offers additional information about Texas patient advocacy and whistleblower protections.

Figure. Texas Patient Advocacy and Whistleblower Protections

[ View full size ]

(Reproduced with permission of Texas Nurses Association.)

Implications for Nursing Organizations and Nurses

These exemplars describe the impact of nurse advocacy to influence policy that affects nursing practice or the practice environment. The nursing profession has a long history of nurses influencing decisionmakers to make positive change in health policy. Input from nurses is the foundation of this advocacy work to identify the need for policy change and make the case for why change is needed. Often policy change involves an incremental approach that requires persistence.

Often policy change involves an incremental approach that requires persistence. An example of incremental work is the many efforts to address workplace violence. In 2010, Texas emergency department nurse Jessica Taylor authored a commentary in the American Journal of Nursing about her experience of being assaulted at work ( Taylor, 2010 ). She encouraged all nursing associations to make violence prevention a top-priority and urged hospital leaders to adopt zero-tolerance policies.

An existing policy of enhanced criminal penalties for assaults against first responders, such as peace officers, firefighters, and emergency medical service workers (which elevated the seriousness of the offense from a misdemeanor to a felony) inspired a similar approach to deter violence against nurses. In 2011, the Texas Emergency Nurses Association with the support of the state’s Nursing Legislative Agenda Coalition (a coalition of 17 nursing organizations), supported HB 703 and SB 295 which provided for enhanced criminal penalties for assaults against nurses. Although both bills failed to pass in 2011 ( Willmann, 2011 ), similar legislation enhancing penalties for assault of emergency department personnel passed in the next legislative session ( Willmann, 2013 ).

Evidence about workplace violence was needed to understand the scope of the problem in Texas as well. Workplace violence is not limited to emergency departments and nurses in other settings desired similar protections. Yet, legislators had difficulty appreciating the reality of violence in healthcare settings (D. Howard, personal communication, February 5, 2015). TNA developed a strategy to obtain funding for a statewide study of health care organizations (including hospitals, free-standing emergency centers, long term care facilities and homecare agencies), to validate the extent of the problem and provide the foundation for future violence prevention initiatives. HB 2696 provided authority for the Texas Center of Nursing Workforce Studies to conduct a survey both healthcare organizations and nurses about their experiences with workplace violence ( Cates, 2015 ).

...legislators had difficulty appreciating the reality of violence in healthcare settings. The compelling study results were published in 2016 ( Texas Department of State Health Services, 2016 ) and the data supported efforts to pass legislation (HB 280) that funded grants for innovative approaches to reduce workplace violence in health care organizations. In 2019, legislation supported by NLAC as well as the Texas Hospital Association was proposed to establish Violence Prevention Committees within healthcare organizations (HB 2980); the effort failed ( Zolnierek, 2019 ).

Although the organizational policy changes that result from implementation of grant programs may help protect the nurses who work the facilities awarded grant funds, widespread protections remain elusive despite a decade of advocacy. During the most recent legislative session, TNA leaders negotiated bill language with the Texas Hospital Association that would have required workplace violence prevention plans with input from direct care nurses. This bill did not pass, and work is ongoing to ensure healthcare facilities implement robust strategies that protect not only nurses but all employees.

Protections can be eroded through subsequent legislation or agency rules, and enforcement mechanisms may be weak or non-existent. In sum, the need for evaluation of policies is vital. To this end, the Texas Nurses Foundation has a dissertation grant program to support research on the impact of nursing policies in Texas. Protections can be eroded through subsequent legislation or agency rules, and enforcement mechanisms may be weak or non-existent. To ensure policies are effective, the impact on nursing practice must be evaluated to make certain policies are having the desired effect and have not created unintended consequences. Both professional nursing organizations, and individual nurses, must continue advocacy at all levels. Successful advocacy requires the identification of concerns by individual nurses, coupled with leadership and persistence of nursing organizations with strength in numbers and a policy agenda.

After the hard work is finished and the policy becomes how we practice, the origin stories are lost, and progress is often taken for granted. Many nurses may remember the times before cars had seatbelts and smoking in the nurse’s lounge was a common practice. It is remarkable to reflect on the first nurse practice acts and consider that those empowered nurses advanced the profession more than a decade before women even had the right to vote.

In 2020, the Year of the Nurse and Midwife, let every nurse and professional nursing organization continue the forward progress that advocacy supports. Nurses know that a culture supporting collaborative, interdisciplinary practice that encourages both identification and reporting of problems and barriers to care delivery leads to optimum patient and nurse outcomes. Protections are imperfect, but that does not diminish their importance. Protection failures represent opportunities for future advocacy.

The profession of nursing has changed significantly in the 160 years since Florence Nightingale’s day, but her words still ring true today, “Unless we are making progress in our nursing every year, every month, every week, take my word for it we are going back” ( Nightingale, 1914, p. 1 ). In 2020, the Year of the Nurse and Midwife, let every nurse and professional nursing organization continue the forward progress that advocacy supports.

Ellen Martin, PhD, RN, CPHQ, CPPS Email: [email protected]

Cindy Zolnierek, PhD, RN, CAE Email: [email protected]

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January 31, 2020

DOI : 10.3912/OJIN.Vol25No01Man02

https://doi.org/10.3912/OJIN.Vol25No01Man02

Citation: Martin, E., Zolnierek, C., (January 31, 2020) "Beyond the Nurse Practice Act: Making a Difference through Advocacy" OJIN: The Online Journal of Issues in Nursing Vol. 25, No. 1, Manuscript 2.

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Advocacy in nursing: Speaking truth to power?

The work performed by nurses during the COVID-19 pandemic shone a light on the centrality of the nursing profession. Despite this increased public awareness of the importance of what we do, nurses continue to occupy subordinate positions within the healthcare system. There is a paradox here; where despite the essential contribution made by nurses, we are not driving forward health systems, not empowered to speak out on the critical issue of patient safety, not encouraged to draw attention to adverse events, nor raise our concerns when the system is simply not working. The regularity with which nurses' efforts to advocate are dismissed suggests that the nursing profession faces a major challenge. Nurses' subordinate positions in healthcare systems contribute to poor patient outcomes and prevent us from shaping a more rewarding and fulfilling profession ( Cole et al., 2019 ). We contend that when nurses occupy an inferior position in this context, it serves as an injustice to ourselves, our profession, and those for whom we are entrusted to care. Our view is that this injustice is symptomatic of a system that routinely ignores, resists or silences nurses who seek to advocate for their patients. The time has come to review the way that healthcare systems respond to nurses when they do speak out.

There is a well-established history of unnecessary, preventable deaths in healthcare, where better responses to nurses who voice concerns could have saved lives. If you believe that nurses need to be more persuasive when advocating, you may be mistaken. We contend that, rather than blaming nurses who speak out, it is health care organisations that need to change, not nurses or nursing practices. It is crucial for modern healthcare to embrace nurse advocacy and respond to it in ways that better reflect the safety, quality, and patient-centred philosophy so often woven through policy-driven care.

Toni Hoffman's attempts at advocacy were not embraced when she reported concerns over the negligent activities of Dr Patel (‘Dr Death’) in Bundaberg Queensland Australia. In response to voicing her concerns, Ms Hoffman was exposed to sustained and persistent ridicule and resentment from management ( Fedele, 2019 ; Thomas, 2007 ). Aishwarya Aswath's case at Perth Children's Hospital (Manfield & Perpitch, 2021), the Mid-Staffordshire Inquiry [and subsequently the Francis Report] ( Calkin, 2011 ; Donnelly, 2017 ; Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013 ) and the Gosport War Memorial Hospital Investigation in the UK ( Evans, 2018 ) are all examples where nurses advocated for their patients but were ignored. The question must be raised as to whether any other professional would be treated this way.

There has been growing, and frequently voiced concerns about patient safety among aged care nurses in Australia ( Meehan, 2021 ; “Residents suffer most”, 2018). Even when the precise nature of these concerns echoed 29 of the Australian Government's own major reviews and inquiries into the sector, they were ignored. In February 2022, the then Minister for Aged Care and Senior Australians, Richard Colbeck, said the aged care sector had “performed exceptionally well” ( Daniel, 2022 ). This comment came on a background of tens of thousands of staff and residents testing positive to COVID-19, and over 400 aged care deaths in the first two weeks of 2022 ( Coulter & Kewley, 2022 ). The nurses at Sydney Australia's Westmead hospital, still reeling from COVID-19, found themselves similarly in a system unwilling to acknowledge a problem. Authorities attempted to resist and ignore their safety concerns, when they obtained an order from the Industrial Relations Commission to ban industrial action (Ward, 2022). Are there any other professions that are also so powerless to shape the contexts in which they operate?

Nurses in our society should be seen as the allies of the patients within the healthcare system, as professionals looking out for the interests of the patient, as a fundamental part of their work. Despite strong community expectations that nurses will speak up for the vulnerable, their voices continue to be silenced. When nurses speak out about the COVID-19 outbreak, they are threatened with disciplinary action ( Johnson, 2020 ; Miles, 2022 ). Although hospitals may feel a need to limit scaremongering during the pandemic, many nurses feel that bans prevent them exercising their own autonomy and agency (Costa & Costa, 2021). As the pandemic persists, nurses continue to be threatened for indicating their refusal to work without proper protection and making comments about their fear of COVID-19 on social media (“Disciplinary action, terminations, gag orders”, 2020 ; Scheiber & Rosenthal, 2020 ). In a time full of misinformation and conspiracy theories, nurses' rich contextual voices should be perceived as an excellent foil to the explosion of fake news.

Within this context of the profession being silenced, resisted, or ignored, the Australian Medical Association National President Omar Khorshid called out the WA Premier Mark McGowan's alleged failure to prepare for COVID by describing him as a “one trick pony when it comes to COVID” ( Brown, 2022 ). Does the profession of nursing need to speak with the same candour and frankness to better engage with the wider political game within which our profession exists? The COVID-19 outbreak has been one of the biggest challenges facing healthcare in the last century, but it has also given the nursing profession the opportunity to examine the imbalances in power dynamics and coercive patterns of control it is experiencing in its relationship within the health care system. For the sake of the individuals and communities we serve, nurses, both individually and as a profession, need to work at making sure our voices are heard.

A revaluation of the relationship between nurse advocacy and power is required. Rather than simply victim blaming nurses whose attempt at advocacy goes unheard, there needs to be better understanding of the complex, overlapping and often conflicting influences on nurses when they choose to advocate, or not, for their patients. Failure to invest in the profession's relationship with the system within which it operates risks continued acquiescence, even complicity in the historical ideological hegemony that pervades healthcare systems and continues to persist to this day.

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• Open access
• Published: 13 August 2024

Nurses’ attitude towards patient advocacy and its associated factor in East Gojjam Zone Public hospitals, Northwest Ethiopia, 2023

• Abay Tadie 1 ,
• Mikiyas Muche 2 ,
• Tiliksew Liknaw 2 &
• Afework Edmealem 2  

BMC Nursing volume  23 , Article number:  561 ( 2024 ) Cite this article

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Introduction

One of the most important but underappreciated roles of nurses is patient advocacy. To advocate for patients effectively, the nurses should have a favorable attitude towards patient advocacy. Despite this fact, the nurses’ attitude towards patient advocacy was not known in Ethiopia. Thus, this study aimed to assess nurses’ attitude towards patient advocacy and its associated factors in East Gojjam Zone Public Hospitals, Northwest in 2023.

Institutional-based cross-sectional study design was conducted among 385 nurses in East Gojjam Zone Public Hospitals from March 1 to April 30, 2023. Nurses were selected using simple random sampling techniques from 11 public hospitals. The data were collected in a self-administered way. Binary logistic regression was used for data analysis. All independent variables having a P value of < 0.25 in the bivariable logistic regression were fitted into a multivariable logistic regression. The AOR at a 95% confidence interval was used to identify the strength of the association, and a p value of 0.05 was used to declare it statistically significant at the final model.

A total of 385 nurses participated in the study, for a 91% response rate. Among these, 49.9% of nurses had an unfavorable attitude. Being working in a primary hospital [AOR = 2.3; 95% CI: (1.4–3.8)], poor cooperation of nurses [AOR = 1.7; 95% CI: (1.1–2.8)], being unsatisfied with the job [AOR = 1.7; 95% CI: (1.1–2.7)], and poor perceived supervision of work [AOR = 6.2; 95% CI: (3.7–9.8)] were factors associated with nurses’ attitudes towards patient advocacy.

The number of nurses who had an unfavorable attitude towards patient advocacy was high. Working in a primary hospital, poor cooperation with others, being dissatisfied with the job, and having an unfavorable perception towards the supervision of work were the factors associated with the unfavorable attitude of nurses towards patient advocacy. It is recommended that all hospitals better support the nurses to increase their job satisfaction and have good supervision of the nurses’ activities.

Peer Review reports

Key messages

What is already known on this topic.

• Advocacy is one of the main roles for nursing professionals.

• Patient advocacy is vital to protect patients when practitioners engage in unsafe practices, mistakes are witnessed, caregivers are incompetent, and support is lacking.

• Advocacy improves public health, the safety of vulnerable patients, access to health care, and the quality of care.

What this study adds?

• Although advocacy is their main role, a significant number of nurses have an unfavorable attitude towards patient advocacy.

• Working in a primary hospital, poor cooperation with others, being dissatisfied with the job, and having an having an unfavorable perception towards the supervision of work are factors that make nurses have an unfavorable attitude towards patient advocacy.

• This study warrants hospitals having regular supervision activities and trying to improve the job satisfaction of nurses.

Advocacy is being a patient representative, defending the patient’s rights, protecting the interests of the patient, and contributing to decision-making [ 1 ]. It is a process with specific actions to preserve patients’ rights, best interests, and values in the healthcare structure [ 2 ]. It has three core features, which are safeguarding a patient’s autonomy, acting on behalf of patients, and championing social justice in the provision of health care [ 3 ]. Safeguarding a patient’s autonomy is concerned with actions, respect, and promoting a patient’s self-determination [ 3 , 4 ]. Acting on behalf of patients involves performing for patients who are unable to represent themselves or who do not wish to represent themselves, such as unconscious patients [ 1 ]. Championing social justice in the provision of health care is concerned with nurses actively struggling to make changes to address inequalities and inconsistencies related to the delivery of healthcare [ 5 , 6 ].

Florence Nightingale laid the foundation for patient advocacy by consistently insisting on quality of care, including a safe and clean environment, and basic human rights for all [ 7 ]. Patient advocacy is vital to protect patients when practitioners engage in unsafe practices, mistakes are witnessed, caregivers are incompetent and support is lacking [ 8 ]. It is required in situations where there is a lack of teamwork, disrespectful or disruptive behavior happens, and poor management is present [ 9 ].

Due to highly fragmented healthcare services, patients need patient advocates who can help them to talk with the health care organization [ 3 , 10 ]. A method for nurses to engage in the process of serving the healthcare needs of patient is through patient advocacy [ 10 ]. Nurses often find themselves in the position of supporting vulnerable people who are not able to speak up for themselves because of factors such as illness [ 11 ]. Patients may be neglected, helpless, complaining, or disinterested in their care. This also protects clients from the profit-oriented health system and the paternalist attitude of some health professionals [ 3 , 12 ].

Nurses’ attitude towards patient advocacy represents a nurse’s personal judgment that the nurse is in favor of or against performing a series of specific actions. Unfavorable attitudes of nurses would result in poor patient care outcomes, and could severely challenge the ability of the healthcare system to provide quality care and improve the outcomes of patients [ 10 , 13 ].

Globally, nurses’ attitude towards patient advocacy is an indicator of their forthcoming behaviors and future performances in patient care [ 13 , 14 ]. Studies showed that many patients were subjected to preventable complications, including estimates that range from 98,000 to 440,000 deaths per year, which could be prevented by patient advocacy [ 6 , 15 ]. African healthcare practitioners still tend to run through paternalistic treatment, with little patient participation in the decision-making of management options [ 16 ]. This could be due to unfavorable attitude of nurses towards patient advocacy that would result in poor patient care outcomes [ 17 , 18 ]. In a large study, 50% of nurses described situations that should have resulted in patient advocacy (speaking up for patients), and only 10% of the time nurses find patients’ voice [ 19 ]. Mostly nurses found to have difficulty of not speaking out regarding issues and concerns that can potentiate patient injury [ 20 ]. In accordance with a study in Ghana, fatigue and dissatisfaction delayed the nurses’ realization of patient advocacy role [ 12 , 20 ].

Patient advocacy improves public health, the safety of vulnerable patients, and access to quality health care. It also lowers health care gaps, decreases costs of complications, and increases patient satisfaction [ 21 , 22 ]. To advocate properly for patients, nurses should have a favorable attitude towards patient advocacy. Despite this fact, the attitude of nurses towards patient advocacy was not documented and well-known. This study was aimed to assess nurses’ attitude towards patient advocacy and its associated factors in East Gojjam Zone Public Hospitals, Northwest Ethiopia.

Methods and materials

Study area and period.

The study was conducted in East Gojjam Zone Public Hospitals. East Gojjam Zone had eleven public hospitals, including one comprehensive specialized hospital, one general hospital, and nine primary hospitals. These are, namely, Debre Markos Comprehensive Specialized Hospital, Dejen Primary Hospital, Bichena Primary Hospital, Motta General Hospital, Yejubie Primary Hospital, Debre Work Primary Hospital, Debre Elias Primary Hospital, Lumamie Primary Hospital, Bibugn Primary Hospital, Shebel Berenta Primary Hospital, and Merto-Lemariam Primary Hospital. The eleven public hospitals had a total of 820 nurses. The study was conducted from March 1 to April 30, 2023.

Study design

Institutional based cross-sectional study design was conducted.

All nurses employed in East Gojjam Zone Public Hospitals were source population. All nurses of East Gojjam Zone Public Hospitals who were available in hospitals during the data collection period were study population.

Eligibility criteria

Inclusion criteria.

All nurses who had been permanently recruited and worked in East Gojjam Zone Public Hospitals were included.

Exclusion criteria

Nurses who were on sick leave, maternal leave, or off-site training were excluded. Furthermore, nurses who are newly recruited (less than six months) were excluded.

Sample size determination

The sample size was calculated by using single population proportion formula by considering 95% confidence interval, 5% margin of error, and proportion of unfavorable attitude. Because of the absence of a previous study in Ethiopia, 50% was taken as a proportion.

n = (Z α/2) 2 P (1-P)/ d 2

Where n = minimum sample size

P = the proportion of the study 50%

d = Margin of error = 0.05

(Z α/2) = Standard deviation = 1.96 (at 95% confidence level)

n = (Z α/2) 2 P (1-P)/ d 2 = (1.96) 2 (0.5 × 0.5)/ (0.05) 2 = 384

Sample size for the second objective was calculated by using the StatCalc of Epi-Info software version 7.2.5 with the assumptions: Confidence level = 95%, Power = 80%, and Ratio of un-exposed to exposed almost equivalent to 1. However, the larger sample size was obtained by the first objective. Thus, the final sample size was 423 by adding 10% non-response rate.

Sampling technique and sampling procedure

A simple random sampling technique was used in all hospitals to select study participants. Study participants were selected with proportional allocation of sample size to each hospital by using lists as sampling frames at each hospital. From Shebel Primary Hospital and Debre-Elias Primary Hospital, 22 participants were selected from each. Dejen Primary Hospital, Debre Work Primary Hospital, and Mertole Mariam Primary Hospital each constituted 24 participants, 164 from Debre Markos Comprehensive Specialized Hospital, 43 from Mota General Hospital, 31 from Bichena Primary Hospital, 21 from Bibugn Primary Hospital, 23 from Lumamie Primary Hospital, and 25 participants from Yejubie Primary Hospital were selected (Fig.  1 ).

Sampling procedure for nurses’ attitude towards patient advocacy and its associated factors in East Gojjam Zone Public Hospitals, Northwest Ethiopia, 2023

Study variables

Dependent variable.

Nurses Attitude towards patient advocacy (unfavorable/favorable).

Independent variables

Socio-demographic variables: age, sex, marital status, educational level, work experience, working unit, current position and participation in patient support group.

Nurse related variables: cooperation, knowledge of nurses on patient advocacy, job satisfaction and fatigue of nurses.

Organization related variables: Hospital level, availability of patient support group, training on patient advocacy, working environment and perceived supervision of work.

Operational definition

Patient Advocacy is being a patient representative, defending the patient’s rights and interests having three core attributes (safeguarding a patient’s autonomy, acting on behalf of patients, and championing social justice) in the provision of health care [ 3 , 4 ].

Nurses’ Attitude towards patient advocacy was measured based on the median of the sum of thirty-three attitude questions which was 97 points with minimum and maximum scores of 33 and 165 points, respectively. The attitude score was dichotomized as favorable and unfavorable.

Unfavorable attitude

is if the score of the nurse was below the median score(97 points) of the sum of attitude questions of 33 items with 5 point responses [strongly disagree(1) through strongly agree(5)] with a range of scores of 33–165 points [ 23 ].

Poor cooperation

if the nurse’s score was below the median (61 points) of the sum of 21 cooperation questions, with a minimum and maximum of 21 to 105 points, respectively [ 24 , 25 ].

if a nurse scores above or equal to the median score (24 points) from the sum of 10 fatigue questions with range of scores 10 to 50 points [ 26 ].

Poor knowledge

if the nurse’s score was below the median(4) score of knowledge questions.

Not satisfied with job

if a nurse scores below the median score (< 59 points) from sum of 20 job satisfaction items with range of values 20 to 100 points [ 27 ].

Good working environment

if the score of nurse was above the median score which was 30 points from sum of 10 working environment questions with values from 10 to 50 points [ 28 ].

Poor perceived supervision of work

if the score was below the median score (42 points) from sum of 15 supervision questions with range of values 15 to 75 points [ 29 ].

Data collection tool

The data collection tool was adapted from different research studies. It includes four parts (socio-demographic characteristics, nurse related characteristics, organization related characteristics and attitude of nurses’ characteristics).

Sociodemographic characteristics

It contains 8 questions about sociodemographic characteristics of nurses.

Protective nursing advocacy scale

It was developed by Hanks RG [ 30 ] and original scale consists of 43 questions, answered by means of a Likert-type frequency scale of five points, using 1 for “strongly disagree”, 2 for “partially disagree”, 3 to “neither agree nor disagree” 4 to “partially agree” and 5 for “strongly agree”. Scale has 4 subscale: acting as an advocate, which reflects actions of nurses when advocate in health for patients, work situations and advocacy actions, which reflects possible health advocacy consequences in the work environment, environment and educational influences, which includes items measuring the influence of knowledge and internal environment of nurses, such as personal values, beliefs and confidence to work in health advocacy, support and barriers to advocacy, which consists of items indicating the facilitators and barriers to health advocacy in nursing, including the work environment as a whole. The scale version used in this study was adapted from 2014 Protective Nursing Advocacy Scale [ 15 , 31 ] and had 33 items with 5 point responses, from strongly disagree(1) to strongly agree(5) and three sub-scales.

Cooperation of nurses assessed by 21 items with tool adapted from the 2010 Nurse-physician Collaboration Scale [ 32 ].

Knowledge of nurses was assessed with 10 items regarding patient advocacy with reliability (Cronbach’s alpha = 0.92).

Job satisfaction was measured by a tool with 20 items, has reliability of (Cronbach’s alpha = 0.92).

Fatigue of nurses was assessed with 10 items by a tool adapted from Michielsen, 2012 FAS with reliability of (Cronbach’s alpha = 0.93).

Organization related characteristics have 4 items including training on advocacy, availability of patient support group, working environment, and supervision of work.

Work environment was measured by a tool with 10 items adapted from Practice Environment Scale of the Nursing Work Index of 2017 and modified Work environment scale, 1 for never to 5 for always [ 28 , 33 ].

Perceived supervision of work was measured by a tool with 15 items adapted from supportive supervisory scale with responses (1) for response of (never) through (5) for (always) [ 34 ].

The validity of this tool was assessed by different experts. The nursing ethical issues were considered to be seen, and experts agreed on the reasonable content validity and face validity of the current tool. The reliability of the tool was estimated to inspect the internal consistency of the items and calculated in a previous study to be 0.96. The reliability was reexamined for this study by pretest (Cronbach’s alpha = 0.95), indicating that the tool was highly reliable. The whole questionnaire, with a total of 129 items and an overall reliability of (Cronbach’s alpha = 0.94), was prepared in English and distributed as hard copies to study participants. Those questions having opposite implications for the computed items were inversely coded with respect to each tool for the measured variable.

Data collection procedures

The data were collected by eleven trained data collectors who have bachelor’s degrees in nursing using a structured, self-administered questionnaire given to participant nurses. The data collectors were supervised by two supervisors and the principal investigator. Two days of training were given to each of the data collectors on the meaning of every item of the questionnaire and the techniques of data collection, such as ways of greeting participants and approaches to taking informed consent. The data collectors explained the objective of the study to the participants before they let them fill out the questionnaire. The data collectors clarified any ambiguous and unclear questions when necessary for respondents.

Data quality control

To ensure the quality of the data, the data collection process was supervised, including properly designing the questionnaire and training data collectors and supervisors about the data collection procedures. The questionnaire was pretested on 5% of the sample at Dembecha Primary Hospital to check acceptability and consistency before the actual data collection. After reviewing the results of the pretest, modifications to the questionnaire were performed for clarity and completeness. Continuous supervision of data gathering and daily checking of the collected data were performed by supervisors and the principal investigator. To maintain the quality of the data, training was given to all data collectors and supervisors for two days by the principal investigator about the objective of the study and method of data collection. The confidentiality of information was maintained in the study.

Data processing and analysis

After data collection, each questionnaire was checked visually for completeness. The collected data were numerically coded, and entered into EpiData software version 4.6 and exported to SPSS software version 26 for analysis. Binary logistic regression model fitness was performed by the Hosmer and Lemeshow test, which shows model fitness when it is found not statistically significant (p-value > 0.05). Higher values of Negalkerke R2 were observed, which shows that adding the independent variables to the model significantly increased the ability to predict the outcome variable. In order to show any possible significant correlation between independent variables, Spearman’s correlation analysis was carried out. To identify the variables to be entered from bivariable logistic regression to multivariable logistic regression analysis, a p-value < 0.25 was used. Multivariable logistic regression analysis was done by using the backward likelihood ratio and variables whose p-value was less than 0.05 at a 95% confidence interval with the AOR of the predictor variables, which were declared the relationship of the dependent variable with independent variables in the model. The normality test was performed by Kolmogorov-Smirnov and Shapiro-Wilk, which showed a non-normal data distribution. The median with interquartile range (IQR), frequency, and percentages were calculated, and the results were presented by tables, statements, and graphs.

Socio-demographic characteristics of study participants

A total of 385 nurses were involved, which gives a response rate of 91%. The median age of nurses was 37 (IQR = 15) years. From the total nurses, 227 (59%) were female, and 20 (5.2%) had participated in the patient support groups in the hospital (Table  1 ).

Nurse related characteristics of study participants

The median score of nurses’ cooperation was s 61 (IQR = 32 and 165 (42.9%) of participants did not cooperate to avoid conflicts and reach the most possible agreement. The median score of knowledge about patient advocacy was 4 (IQR = 4). The median score of fatigue among nurses was 24 (IQR = 9). The median score of job satisfaction was 59 (IQR = 28). Of the total study participants, 183 (47.6%) were not satisfied with their job as nurses (Table  2 ).

Organization related characteristics of respondents

The median score of the working environment was 30 (IQR = 5) points. The median score for perceived supervision of work was 42 (IQR = 22). In this study, 188 (48.8%) of participants perceived poor supervision of work within their hospitals, and 100 (26%) of study participants had taken training on patient advocacy (such as trainings related to patient rights, empowerment, infection prevention, and patient safety) (Table  3 ).

Nurses’ attitude towards patient advocacy

The median score of nurses’ attitudes on the dimension of ‘Acting on Behalf of Patients’ was 29 (IQR = 19) points. The median score of nurses’ attitudes on the dimension of “safeguarding patients’ autonomy’ was 35 (IQR = 25) points. The median score of nurses’ attitudes on the dimension of championing social justice’ was 28 (IQR = 18) points. The unfavorable attitudes of nurses towards patient advocacy on the dimensions of acting on behalf of patients, safeguarding patients’ autonomy, and championing social justice in the provision of healthcare were 49.6%, 46.5%, and 47.3%, respectively (Fig.  2 ).

The median score of nurses’ attitude towards patient advocacy was 97 (IQR = 35) points. The overall magnitude of the unfavorable attitude of nurses towards patient advocacy was 49.9% [95% CI = (45.2-55.3%)].

Nurses’ Attitude score on dimensions of patient advocacy in East Gojjam Zone Public Hospitals, Northwest Ethiopia, 2023( n  = 385)

Factors Associated with attitude of nurses towards patient advocacy

In bivariable logistic regression, the twelve variables, including hospital level, marital status, work experience, level of education, working unit, current position, training on patient advocacy, cooperation of nurses, fatigue of nurses, job satisfaction of nurses, working environment of nurses, and perceived supervision of nurses’ work, were found to be significant at a P value < 0.25 and entered into multivariable logistic regression. In the multivariable logistic regression analysis, at p-value < 0.05, variables such as hospital level (primary), poor cooperation of nurses, being not satisfied with the job, and poor perceived supervision of nurses’ work were found to be significantly associated with the attitude of nurses towards patient advocacy.

Accordingly, those respondent nurses who were working in primary hospitals were two times more likely to have an unfavorable attitude towards patient advocacy as compared to nurses working in referral hospitals [AOR = 2.3; 95% CI: 1.4–3.8]. Those nurses who had poor cooperation with other health care providers were two times more likely to have an unfavorable attitude towards patient advocacy as compared to those who had good cooperation [AOR = 1.7; 95% CI: 1.1–2.8%]. Those nurses who were not satisfied with their job were two times more likely to have an unfavorable attitude towards patient advocacy as compared to those who were satisfied with their job [AOR = 1.7; 95% CI: 1.1–2.7)]. Those nurses who had poor perceived supervision of work were six times more likely to have an unfavorable attitude towards patient advocacy as compared to those who had good perceived supervision of work [AOR: 6.1; 95% CI: (3.7–9.8)] (Table  4 ).

Among nurses’ primary responsibilities is advocacy. Nurses who wish to discharge advocacy roles should be internally committed and have a positive attitude towards it. It is impossible to put into practice without having an optimistic view. Despite this fact, the level of nurses’ attitude towards patient advocacy in Ethiopia is not known. Understanding nurses’ attitudes is essential before encouraging them to take on the role of patient advocate. Thus, this study will give information about nurses’ attitudes and help stakeholders design interventions that improve nurses’ attitudes towards patient advocacy.

The result of this study showed that, the magnitude of unfavorable attitude of nurses towards patient advocacy was 49.9% [95% CI = (45.2-55.3%)]. This finding was higher than studies conducted in Saudi Arabia [ 5 ], United States of America [ 10 ] and Iran [ 13 ] where 18%, 3.6% and 27% of nurses respectively, having unfavorable attitude towards patient advocacy. The inconsistency might be due to cultural and socio-economic factors such as differences among nurses, differences in the level of health care services used for patient care, and differences in the economic status of the countries. In addition to this, this study included nurses from all departments, unlike the study done in Saudi Arabia, which included only nurses from the oncology department. The other possible justification could be that those nurses abhorring their profession with payment would not be eager to advocate for patients with consequences. These nurses are less likely to monitor medication faults with responsibilities and would be less protective for patients from incompetent healthcare providers. Due to this, they have a high score for unfavorable attitudes towards patient advocacy.

This study found that those nurses who were working in primary hospital were two times more likely to have unfavorable attitude towards patient advocacy as compared to nurses working in referral hospitals. This may happen because of the difference in the number of services delivered by higher institutions with new specialties and more consultations could be requested to different units. This would take longer to be a patient advocate with the increasing demands of patients. This could also be explained as those nurses working in primary hospitals were challenged by a higher number of patients due to the higher burden of chronic diseases, making stressful situations more stressful as compared to those nurses in referral hospitals. In addition to this, it may be due to the more options available for patients, such as different private clinics and drug stores near the hospital, that nurses are less concerned about advocating for patients. The other possible reason could be due to fear of conflicts with other members of the healthcare team and experiencing feelings of separation. All of these would lead nurses to be more likely to have an unfavorable attitude towards patient advocacy.

In this study those nurses who had poor cooperation were two times more likely to have unfavorable attitude towards patient advocacy as compared to those who had good cooperation. This finding was supported by a study conducted in Sweden [ 35 ], in which collaboration among nurses had a significant association with nurses attitudes towards patient advocacy. Additionally, this study could be justified by a study done in Jimma (48) in 2019, where the nurses’ perception of caring behavior was low, which would make nurses to have an unfavorable attitude towards patient care and advocacy. This may be explained by the fact that those participants who work in the absence of collaboration with other healthcare professionals could be troubled by conflicts and withdraw from patient care. As a result, nurses will have an unfavorable attitude towards patient advocacy.

Those nurses who were not satisfied with their job were two times more likely to have an unfavorable attitude towards patient advocacy as compared to satisfied nurses. This finding was supported by a study done in Eastern Ethiopia (34) in 2017, where 52% of nurses were dissatisfied and influenced patient safety, productivity, quality of care, and the intention to leave the job. This finding was also supported by a study done in Malawi in 2016 that found a link between job satisfaction and the attitude of nurses [ 23 ]. A study in Pakistan in 2021 also supports this finding, which showed that, strong relationship existed between nurses’ job satisfaction and patient safety attitudes [ 36 ]. In addition to this, this finding is strongly supported by a study in Turkey (49) in 2015 that found that being unsatisfied with a job among nurses made them more likely to leave the nursing profession. This is due to the fact that those nurses who were dissatisfied would search for other job opportunities, not be involved in patient care, and then have a strongly unfavorable attitude towards advocating for patients.

Those nurses with poor perceived supervision of work were six times more likely to have an unfavorable attitude towards patient advocacy as compared to those nurses who had good perceived supervision of work. This finding was supported by studies done in Sweden [ 35 ] and United States of America [ 20 ], where supervision of work was associated with nurses’ attitude towards patient advocacy. This may be explained by the fact that, when the activities of nurses were not adequately supervised, those hard-working nurses were not supported actively by their corresponding manager. This would result in more workloads for patient care imposed on a number of nurses. On the other hand, less interested nurses—a nearly higher number of nurses—would go away from hospitals and may be missed out of nursing care areas. This might lead to fatigue and burnout for actively working nurses, while others go searching for extra income or other jobs. On both sides, it will end up with a higher intention to leave the nursing profession (50). All these leads nurses to have unfavorable attitudes towards patient advocacy.

Limitation of the study

This study has its own limitations. Due to the fact that patient advocacy is the major role of nurses, study participants may underestimate and hide the presence of the problem. Furthermore, due to social desirability, study participants gave biased responses. Thus, it is difficult to generalize the finding. Moreover, methodologically, this study cannot show the cause-and-effect relationship since it is a cross-sectional study.

A significant number of nurses had an unfavorable attitude towards patient advocacy. Being working in a primary hospital, poor cooperation of nurses, not being satisfied with the job, and poor perceived supervision of work were the factors significantly associated with the unfavorable attitude of nurses towards patient advocacy.

Recommendations

Nurses had better put emphasis on cooperation with other healthcare professionals and other workers to enhance their shared experiences regarding patient advocacy and other nursing roles.

Hospitals should have a system of good supervision for nursing activities and support the nurses in different ways to increase their job satisfaction.

Amhara Regional Health Bureau and hospital managers should consider the rotation of nurses between primary, general, and referral hospitals.

Researchers should study the practice of patient advocacy among nursing staff for better interventions in solving the problem.

Data availability

The dataset will not be shared in order to protect the participants’ identities but is available from the corresponding author on reasonable request.

Abbreviations

Adult Health Nursing

Adjusted Odds Ratio

Bachelors of Science

Confidence Interval

Crude Odds Ratio

East Gojjam Zone Public Hospitals

Intensive Care Unit

Inter Quartile Range

Masters of Science

Statistical Product for Service Solution

United States of America

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Acknowledgements

We would like to forward our thank to Amhara National Regional Health Bureau and Debre Markos University, College of Medicine and Health Science their support. We also grateful to East Gojjam Zone Public Hospitals, data collectors and study participants for their timely collaboration and respected involvement in this study.

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AT conceived and designed the study, performed analysis and interpretation of data. AE and MM advised and supervised the design conception, analysis, interpretation of data and made critical comments at each step of research. AE and TL drafted the manuscript. All authors read and approved the final Manuscript. Confidentiality and anonymity were ensured throughout the execution of the study.

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Ethics approval and consent to participate

Data collection was started after the study was approved by the Institutional Research Ethics Review Committee of Debre Markos University, College of Medicine and Health Science. The ethical clearance was also taken from Amhara Public Health Institute to get secured permission letter from administrators of East Gojjam Zone Public hospitals. Informed consent was taken from all study participants, with full right to refuse participating in the study. The confidentiality of the records was preserved throughout the study. Respondents’ responses were excluding the names and identifiers of study.

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Tadie, A., Muche, M., Liknaw, T. et al. Nurses’ attitude towards patient advocacy and its associated factor in East Gojjam Zone Public hospitals, Northwest Ethiopia, 2023. BMC Nurs 23 , 561 (2024). https://doi.org/10.1186/s12912-024-02206-2

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Nursing Advocacy: The Role of Nurses Advocating for Patients

August 29, 2023

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The relationship of trust between nurses and their patients has long been recognized as a critical aspect of health care. Patients’ favorable assessments of that relationship are directly reflected in their opinions about the nursing profession: In a 2020 Gallup poll, Americans reported feeling that nurses were the most honest and ethical of 15 different occupational groups — the 19th consecutive year for the honor.

The trust that patients place in their nurses is well founded. Nurses spend a great deal of time with their patients, and fulfilling their obligation under the nursing code of ethics to advocate for their patients can make a significant difference in patient outcomes.

Nursing advocacy can come in many forms and at various levels in health care, and nurses need to have a clear understanding of their role in advocating for patients. This is particularly true for nurses who wish to advance in the profession or aspire to leadership positions. Nurses who complete online Master of Science in Nursing (MSN) to Doctor of Nursing Practice (DNP) programs may find themselves at the forefront of patient advocacy, and they’ll need to keep that aspect of the profession in mind as they go up the career ladder.

What Is Advocacy in Nursing?

Knowing exactly what advocacy in nursing is, how it fits into the profession, why it’s important, and its potential impairments are key elements in nurses’ understanding of their obligations to their patients.

The Concept of Nursing Advocacy

A 2019 study published in the journal Nursing Ethics identified several overarching characteristics of nursing advocacy. After reviewing 46 articles and two books on the subject published between 1850 and 2016, the study’s authors highlighted the following attributes that characterize the concept of nursing advocacy:

Apprising encompasses responsibilities such as providing patients with information regarding their diagnoses, prognoses, treatments, and discharge, as well as discussing health care alternatives with them.

Championing Social Justice in Health Care

Championing social justice in health care includes responsibilities such as facilitating patients’ access to health resources, addressing inequalities in health care delivery, and identifying and confronting rules or policies in a health care system that are inappropriate.

Mediating involves responsibilities such as serving as a patient’s voice when necessary, acting as a liaison for patients with other health care professionals or patients’ families, and relaying the cultural values and preferences of patients to other health care professionals.

Safeguarding

Safeguarding entails carrying out responsibilities such as tracking errors made in patient care and protecting patients if other health care professionals aren’t competent or have committed misconduct.

Valuing focuses on responsibilities such as facilitating patients’ ability to make decisions freely; maintaining patients’ right to privacy; and operating in accordance with patients’ preferences, beliefs, and culture.

The Innate Nature of Advocacy in Nursing

Being patient advocates is a natural fit for nurses and nurse leaders. The sheer amount of time that nurses spend with their patients affords nurses a unique opportunity to build trusting relationships and an open rapport.

The nursing code of ethics also establishes the fundamental obligation of nurses to advocate on behalf of their patients. Specifically, the provisions within the American Nurses Association (ANA) Code of Ethics for Nurses contain important requirements that are directly related to nursing advocacy. For example:

• Provision 2 establishes that nurses’ primary commitment is to their patients and requires nurses to provide patients with the opportunity to participate in the development of treatment plans that patients deem acceptable.
• Provision 3 obligates nurses to protect and advocate for patients’ safety, rights, and health.
• Provision 4 requires nurses to provide optimal care and promote patients’ health.
• Provision 7 calls for nurses to uphold patients’ rights across the continuum of care and while patients are involved in research projects.
• Provision 8 requires nurses to work with other health care professionals in areas such as protecting human rights and reducing disparities in health care.
• Provision 9 establishes nurses’ obligation to include social justice principles in health policies.

Why Is Nursing Advocacy Important?

Advocacy in nursing is important for many reasons. For example, the previously mentioned study in Nursing Ethics noted that nursing advocacy can:

• Improve public health
• Increase collaboration among health care professionals, patients, and patients families
• Enhance the quality of care
• Improve the safety of vulnerable patients
• Elevate patients’ sense of empowerment
• Improve patient access to health care

Nurses themselves can also get a morale boost from patient advocacy. Specifically, the study noted that nurses can strengthen their own self-concept, self-motivation, and job satisfaction by advocating on their patients’ behalf. However, the study also cautioned that health care organizations need to be supportive of nurses’ advocacy efforts; otherwise, nurses may experience feelings of isolation.

What Are the Barriers to Nursing Advocacy?

Certain barriers can impair nurses’ ability to advocate for their patients. A 2020 study published in the journal Nursing Open identified an overall lack of cooperation among patients, health care professionals, and health care organizations as the primary barrier to patient advocacy. As components of that overall lack of cooperation, the following more specific barriers to nursing advocacy were identified in the study:

• Health care organizations’ bureaucracy
• Working environment inadequacies, such as lack of support from doctors or limited supplies of medical equipment
• Inadequate communication and interpersonal skills among staff
• Lack of support from health care organizations’ legal teams
• Lack of support from patients’ families
• Limitations on patients’ financial resources
• Nurses’ fear of negative outcomes from advocacy, such as being fired or transferred
• Nurses’ lack of belief in patient advocacy
• Nurses’ limited knowledge regarding patient advocacy
• Patient-related factors or barriers, such as culture, limited literacy, or strongly held ideologies or religious beliefs

Nurses in leadership roles need to be aware of the barriers to nursing advocacy so that they can implement strategies to address them.

What Advocacy Strategies in Nursing Are Effective?

Several effective advocacy strategies in nursing exist at both the patient and the health care organization levels.

Nursing Advocacy Strategies at the Patient Level

A 2018 article in the journal Oncology Nursing News offered these strategies that nurses can implement to advocate for patients:

Give Patients a Voice

Simply remaining in a patient’s room while a physician discusses a diagnosis and options for treatment can make the patient feel more comfortable asking questions.

Educate Patients

Nurses can provide patients with important information regarding how to manage their health issues and improve their quality of life. For example, nurses can provide patients who are receiving chemotherapy with information about how to take anti-nausea medication most effectively.

Protect Patients’ Rights

Learning patients’ wishes and communicating them to others can be effective in protecting patients’ right to make choices about their health.

Review for Errors

Taking the time to review for and correct errors in patients’ health care information is critical in advocating for them. By conducting reviews, nurses can identify errors, conflicting orders, or oversights in a patient’s care.

Connect Patients to the Resources They Need

Developing an awareness of community resources, such as transportation, financial assistance, and support networks, and connecting patients with the resources are important elements of nursing advocacy.

Nursing Advocacy Strategies at the Organizational Level

Nurses who are in a position to influence policies and procedures or join committees where they work can promote advocacy strategies at the organizational level. For example, a 2021 article in ONS Voice suggests:

• Arranging patient care conferences
• Requesting ethics consultations
• Serving on an ethics committee
• Working with nurse mentors

A 2018 article in HealthLeaders explained that holding patient care conferences — in which health care professionals from different disciplines confer on patients’ health care — are particularly beneficial for patients with multiple morbidities. Holding these conferences can lead to enhanced collaboration and coordination and better prioritization of patients’ health goals.

The American Medical Association (AMA) notes that ethics consultations — in which parties such as patients, members of their health care teams, and ethics consultants confer to clarify ethical issues — can support informed decision-making about patient care. The AMA also notes that ethics committees can help facilitate decision-making regarding patient care, enhance organization-held ethics training, and help organizations develop ethics policies.

A study on in-service nurse mentoring published in the journal Global Health Action in 2020 noted the potential for the use of mentors in nursing to improve patient care. Particularly in rural areas, where there may be fewer opportunities for professional development, nurse mentoring can be beneficial in helping nurses develop their skills to enhance quality of care.

Advocacy in Action: Nursing Advocacy Examples

Patient advocacy happens in various contexts, and specific nursing advocacy examples exist at both the patient and the organizational levels.

Examples of Nursing Advocacy at the Patient Level

Look no further than the COVID-19 pandemic for some of the most tremendous examples of how nurses advocate for their patients. A 2021 article in Issues in Science and Technology highlights several examples of nurses’ innovations during the pandemic, such as the following:

• Nurses moved hospitalized COVID-19 patients’ infusion pumps (which dispense fluids and medicines) from patients’ bedsides to hallways. This enabled the nurses to tend to those pumps and replace the bags much more efficiently. Limiting close patient contact enabled the nurses to help more patients and reduce the risk of COVID-19 transmission.
• Nurses played a significant role in turning hospitalized COVID-19 patients on their stomachs, improving the patients’ blood oxygen levels.
• Nurses used their personal cellphones and iPads to enable hospitalized COVID-19 patients to communicate with their loved ones, who weren’t permitted to enter hospitals.
• A psychiatric-mental health nurse practitioner (PMHNP) in North Dakota was instrumental in swiftly creating a program to help a homeless shelter assist individuals who were experiencing alcohol withdrawal during quarantine.

Beyond the pandemic, examples of nursing advocacy at the patient level demonstrate nurses’ dedication to patient care. Nurse advocate firm Healthlink Advocates Inc. offers the following examples:

• Double-checking for errors helped a nurse determine that a patient’s dosage of blood thinner was too high, leading to the patient’s transfer to a facility to treat signs of internal bleeding.
• Proactively communicating with members of the patient’s health care team enabled a nurse advocate to help a patient avoid errors in treatment.

Nurse advocate firm Guardian Nurses Healthcare Advocates Inc. offers the following examples:

• Interpreting medical terms for the family of a hospitalized patient enabled a nurse advocate to fully inform the family of the patient’s condition.
• Facilitating medical appointments and treatment for a patient with a rare form of cancer helped a nurse advocate to reduce the patient’s anxiety and allow the patient to make informed decisions about treatment.

Medical staffing firm Premier Medical Staffing Services offers the following examples:

• Nurses can teach patients how to advocate for themselves through activities such as helping a patient create a list of concerns or questions to discuss with medical professionals.
• Nurses can tactfully protect patients’ privacy rights by requesting patients’ permission before discussing their care in the presence of people or periodically reminding other medical professionals about patients’ privacy rights.

Examples of Nursing Advocacy at the Organizational Level

Nurses can work toward organizational approaches for advocating on behalf of multiple patients. Nursing advocacy can be woven into an organization’s operations, as the following examples demonstrate:

Assigning Nurses as Care Coordinators

Cleveland Clinic Care Community reduced patient transmissions and trips to the emergency room by assigning registered nurses (RNs) as care coordinators for high-risk patients. After identifying high-risk patients using an algorithm based on claims information, demographics, and state of disease, the organization assigns RNs to those patients to assist them in managing their diseases.

The RNs also connect patients to resources in the community (such as social workers or exercise programs), ensure that patients receive routine health care (such as colonoscopies and eye exams), and encourage patients to participate in other health-related programs (such as smoking cessation or weight loss programs).

Using a Guided Care Model

Assisting patients with multiple chronic diseases through a guided care model that Johns Hopkins University developed can help patients follow a care plan that encompasses all their health challenges. In the guided care model, RNs assess patients’ needs and coordinate with primary care physicians to develop care plans. The nurses also teach patients and caregivers ways of managing their diseases. In addition to improving the chances for positive outcomes, this model has reduced patients’ health care expenditures.

Using a Transitional Care Model

A Vermont hospital improved patient service by implementing a transitional care model to continue to assist patients after they transfer from one health care setting to another. By assigning advanced practice nurses to patients transitioning to other health care settings, Southwestern Vermont Medical Center significantly improved service continuity. The nurses help patients better understand their medications and physicians’ instructions; visit patients’ homes when necessary; and connect patients with social services, such as housing or treatment for addiction. The program is free to the patients who participate.

What Is Patient Advocacy Nursing?

Nurses who have a strong affinity for nursing advocacy can consider working exclusively in patient advocacy nursing. Although nurses don’t need to follow any single career path to work solely in patient advocacy nursing, they need to know about certifications in the field. For example:

• The Academy of Oncology Nurse & Patient Navigators (AONN Plus) offers certification as an Oncology Nurse Navigator-Certified Generalist (ONN-CG). RNs who meet the eligibility requirements must pass an exam on topics such as community outreach, coordination of care, patient advocacy, psychosocial support services, survivorship, and ethics.
• The Patient Advocate Certification Board (PACB) offers certification as a Board Certified Patient Advocate (BCPA). The certification is available to individuals from many different backgrounds, including nursing. Candidates for certification must meet eligibility requirements and pass an exam on topics such as empowerment, autonomy, communication, interpersonal relationships, health care access, and ethics.

Nurses have also started establishing their own nursing advocacy businesses. Patients and families hire and pay these nurse advocates to help them through difficult health issues. Examples of their services are:

• Explaining a diagnosis
• Providing support when a patient makes medical decisions
• Coordinating medical care, such as medical appointments, hospitalizations, and surgeries
• Visiting patients in the hospital to ensure that their needs are being met
• Assisting patients in obtaining medical equipment
• Providing patients with health and wellness advice and coaching
• Assisting patients with health insurance billing and other insurance matters

According to the Alliance of Professional Health Advocates (APHA), independent advocates usually charge hourly rates of $125 to $350, depending on the advocate’s credentials, location, and services.

As with any endeavor to start a business, nurses who want to strike out on their own can benefit from studying the market for their services, creating a business plan, considering factors such as insurance, and pinpointing the precise services they intend to provide.

Finding a Role in Nursing Advocacy

Nursing advocacy is a critical and rewarding component of any nursing career. Nurses or prospective students who aspire to leadership positions and promote nursing advocacy can explore Hawai‘i Pacific University’s online MSN to DNP program to learn more about how the program may help them achieve their professional goals. Start expanding your knowledge on patient advocacy and nursing today.

Recommended Readings

The Benefits of Advanced Nursing: What Is the Expected MSN Salary Range?

Careers in Advanced Nursing: What Is a Family Nurse Practitioner?

How Family Nurse Practitioners Can Play a Major Role in Addressing the Growing Physician Shortage in the U.S.

Academy of Oncology Nurse & Patient Navigators, Oncology Nurse Navigator Certified

Generalist (ONN-CG) Candidate Handbook and Application

American Medical Association, Ethics Committees in Health Care Institutions

American Medical Association, Ethics Consultations

American Nurses Association, Code of Ethics for Nurses with Interpretive Statements

Cleveland Clinic, Care Coordinators Help High-Risk Patients

Gallup, "U.S. Ethics Ratings Rise for Medical Workers and Teachers"

Guardian Nurses Healthcare Advocates, Patient Advocacy

Guardian Nurses Healthcare Advocates, Testimonials

HealthLeaders , "4 Steps for Successful Complex Care Conferences"

Healthlink Advocates Inc., Our Services

Healthlink Advocates Inc., "The Patient Advocate Role and Patient Safety"

Issues in Science and Technology , "Innovating in the Here and Now"

Johns Hopkins Medicine, Guided Care Nursing

Medical Economics , "How to Close the Gaps in Care Coordination"

SAGE Journals, "Patient Advocacy in Nursing: A Concept Analysis"

National Center for Biotechnology Information, "Barriers to Practicing Patient Advocacy in Healthcare Setting"

Oncology Nursing News , "Six Ways Nurses Can Advocate for Patients"

ONS Voice , "Nurses Have an Ethical Responsibility to Speak Up and Advocate for Patients"

Premier Medical Staffing Services LLC, "4 Ways Nurses Can Advocate for Patients"

Taylor & Francis Online, "In-service Nurse Mentoring in 2020, the Year of the Nurse and the Midwife: Learning From Bihar, India"

The Alliance of Professional Health Advocates, "Burned Out? Leaving Medicine? Advocacy Might Be Right for You"

Wiley Online Library, "Registered Nurses’ Description of Patient Advocacy in the Clinical Setting"

VTDigger.org, "Bennington Hospital Doubles Down on Nursing Care; Fewer Patients Admitted"

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Lydia Rotondo Named Fellow of the American Academy of Nursing

  By Gianluca D'Elia   Thursday, August 15, 2024

Lydia Rotondo, DNP, RN, CNS, FNAP , the School of Nursing’s senior associate dean for graduate education and innovation has been named a 2024 Fellow of the American Academy of Nursing (FAAN). A major milestone in a nurse leader’s career, induction into the Academy recognizes contributions to nursing and the public's overall health.

Rotondo , who also serves as director of the Doctor of Nursing Practice program and a professor of clinical nursing, joins a cohort of Fellows that represents 37 states, the District of Columbia, Guam, and 14 countries. The American Academy of Nursing (AAN) comprises nearly 3,000 nursing leaders who are experts in policy, research, administration, practice, and academia who champion health and wellness, locally and globally.

“I am thrilled to welcome these impressive nurse leaders into our organization. With exceptional subject matter expertise, each new Fellow will be vital to achieve the Academy’s mission of improving health and achieving health equity by impacting policy through nursing leadership, innovation, and science,” said Academy President Linda D. Scott, PhD, RN, NEA-BC, FNAP, FAAN . “Induction into the Academy represents the highest honor in nursing. Earning the FAAN credential is a significant recognition of one’s accomplishments and signifies the future impact they will make in collaboration with their colleagues in the Academy.”

For Rotondo, recognition as a FAAN has offered a chance to pause and reflect on her contributions to the nursing profession as a leader, educator, and advocate.

“Nurses often start their careers wondering what they will contribute on a daily basis to improve health and support their colleagues. Induction into the Academy offers a longitudinal perspective, demonstrating that colleagues both within and outside of the nursing profession recognize your continued contributions over time,” Rotondo said.

Through her roles as an associate dean and program director, Rotondo has led efforts to promote interprofessional education and create innovative solutions to address workforce and community needs. Under Rotondo’s leadership in her previous role as associate dean for education and student affairs, the School of Nursing expanded its focus on academic innovation, implementing new educational technology and experiential learning to support competency-based education.

This transformation led the School of Nursing to earn designation as an Apple Distinguished School in 2021 and 2024, and receive endorsement from the International Nursing Association of Clinical Simulation and Learning (INACSL) for excellence in simulation education. The School also earned further recognition as the recipient of the American Association of Colleges of Nursing (AACN) Innovations in Professional Nursing Education Award (Academic Health Center). Most recently, UR Nursing was named a 2024 National League for Nursing Center of Excellence for enhancing student learning and professional development.

“We wanted to be intentional about continuing the School’s legacy as a leader in nursing education, and thinking about it in a way that prepares students for the future of healthcare,” Rotondo said. “Pivoting our philosophical and pedagogical foundations was critical in laying the groundwork for utilizing educational technology to prepare nurses as knowledge workers in a digital age practicing in complex healthcare environments.”

As DNP program director, Rotondo has helped UR Nursing stand out as an early leader in shaping DNP education. Over the past decade, Rotondo has had opportunities to add her expertise to DNP curriculum development and DNP scholarship through national presentations and publications.

Furthermore, through the establishment of the annual DNP Summit , Rotondo has positioned the School as a leader of national conversations on DNP education, career pathways, scholarship, and emerging topics. Now in its ninth year, the annual webinar series has welcomed thought leaders in nursing from across the country and attracted a growing national audience.

Her influence also extends beyond the university setting. Collaborating with New York State education leaders, she contributed to the passage of recent legislation that supports the integration of simulation in clinical nursing education. Earlier this summer, she helped lead the University of Rochester to become the first institution in New York to expand its DNP program entry point, a major milestone in expanding access and eligibility for master’s-prepared nurses to pursue a DNP.

Nationally, she has also served on the American Association of Colleges of Nursing (AACN) New Essentials Implementation Task Force, further advancing nursing education in the U.S.

Rotondo looks forward to continuing her advocacy work and furthering her impact as a Fellow. Becoming part of the Academy will provide an opportunity to “magnify your impact by expanding your advocacy platform," she shared.

“I’m looking forward to learning from my colleagues and participating in the Academy’s initiatives to advance health policy and practice.”

Get the latest UR Nursing news in your inbox.

Join us at our 2024 DNP Summit , "Innovation & Inspiration," Oct. 4, 11 and 18. 

Categories: DNP , Nursing Leadership

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NJ is still failing nursing home residents. Accountability and transparency are essential

3-minute read.

Just last year, the for-profit nursing home Princeton Care Center’s  abrupt and chaotic 24-hour shutdown  disrupted, displaced, and, in some cases, traumatized the lives of 72 nursing home residents and their families. Despite the closure being  months in the making , residents were given only hours to find a new home, with their belongings packed in garbage bags. The care being provided to these residents was so poor that weeks earlier, the New Jersey Department of Health had  suspended new admissions  to the facility. State regulators and local and state officials knew this taxpayer-funded facility was in financial and medical trouble. Yet, residents were unaware of the situation or why it was closing. 

This incident highlights why — despite millions of new state and federal taxpayer dollars being invested in New Jersey’s nursing homes since 2019 — a full, clear, and constant view into their workings is essential. Without transparency and accountability, more families may suffer through similar situations in other nursing homes.

This past budget season New Jersey's Legislature had an opportunity to include budget language that would enforce improved transparency and accountability tied to an increase in funding for nursing homes. Instead, nursing homes received an additional, last-minute $60 million appropriation — above and beyond what Gov. Phil Murphy proposed for this year — with no strings attached. 

After the tragic deaths of over 9,000 New Jersey long-term care residents during the COVID crisis, individuals living in nursing homes and their families deserve an independent audit of where our current dollars are going, what they are being spent on, and whether their money is improving the safety and quality of care of these centers.  

Business as usual simply will not do. Unfortunately, business as usual is what New Jersey keeps delivering. Nursing homes are primarily funded through Medicaid, and today, they receive more than $2 billion from taxpayers. In the final days and hours of last year’s state budget negotiations, a backroom deal quadrupled the proposed increase to the taxpayer-funded Medicaid reimbursement rate — a $120 million windfall. This increase was over and above basic Medicaid rates for nursing homes and is now embedded in their rates for the new fiscal year — along with the additional $60 million. 

Most concerning is there is no requirement to use these taxpayer dollars to improve quality care like infection control, to improve the wages and working conditions for direct care staff despite nursing homes being chronically understaffed, or to provide any information to consumers, policymakers, and regulators on how the additional money would be spent. Once again, this year’s state budget fails to require improved transparency on how our tax dollars are spent, information that is also very important to the residents and their families who call a nursing home home. Greater transparency would reveal where our dollars are flowing. For example, how much is being spent on residents’ direct care needs and personal care plans? How much is being spent on direct care staff salaries instead of nursing home profits? This vital information will help hold nursing homes accountable for how they are using taxpayer dollars and how they are providing care. Legislation  was reintroduced this year to revise reporting requirements for nursing homes’ financial disclosures and ownership structure. Rather than more backroom deals directing millions more of taxpayer dollars to an industry where stronger accountability and transparency are needed, the governor and Legislature should continue to work together to enact this bill to ensure that the billions in funding that nursing homes receive from New Jersey taxpayers goes toward improving the quality of care for residents.

Katie Squires is associate state director of advocacy for AARP New Jersey .

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Kamala Harris Had a Great Health Care Idea in 2019. She Should Embrace It.

By Jacob S. Hacker

Mr. Hacker is a political science professor at Yale who has researched and written extensively about health care.

From the moment Kamala Harris became the presumptive Democratic nominee, Republicans have sought to paint her as a far-left California liberal. After all, they argue, she supported getting rid of private health insurance in her 2019 presidential campaign.

But Ms. Harris didn’t seek to eliminate private insurance in 2019. The core of her previous campaign’s health plan was an intelligently designed and politically astute public option — a more robust version of the Democratic approach embraced that year by Joe Biden (but one he never pursued after he took office). Essentially, she wanted to encourage Americans to buy into a revamped Medicare program that would give people the choice of public or private coverage.

As the so-called father of the public option , I feel confident in saying that Ms. Harris’s 2019 plan for a public option was — and remains — the strongest ever put forth by a presidential candidate. She shouldn’t run away from it. She should embrace it as a central part of her 2024 campaign both because it is smart policy and because it is smart politics.

Health care is “unbelievably complex,” as President Donald Trump remarked in 2017, as his party’s drive to repeal and replace the Affordable Care Act headed for defeat. Americans hate a lot about the current semi-system — its high prices, its insecure coverage, its rapacious financial practices (and until 2017, they seemed fairly ambivalent about the A.C.A., too).

The G.O.P.’s repeal rout made clear that a majority of Americans don’t want to go back to a time before the Affordable Care Act. It also reinvigorated the Democratic Party. No issue has unified the party or dominated its messaging like health care. It’s where abortion, child and maternal health, the rural health crisis, paid medical and family leave, the health risks of climate change, the continuing threat of Covid and the economic security of working families all come together.

Still, the party does not quite agree on what the big health care policy goal should be. Progressives advocate a universal Medicare program financed by higher taxes, which is to say Medicare for all. Moderates call for upgrading the A.C.A. by adding a public option (which was stripped from the original legislation before its passage in 2010).

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Patient Advocacy in Nursing Practice

Related Papers

Scandinavian Journal of Caring Sciences

Tarja Suominen , Sanna Salanterä

Revista da Escola de Enfermagem da U S P

Edison Barlem

OBJECTIVEAnalyzing beliefs and actions of nurses in exercising patient advocacy in a hospital context.METHODA quantitative cross-sectional exploratory and descriptive study, conducted with 153 nurses from two hospitals in southern Brazil, one public and one philanthropic, by applying Protective Nursing Advocacy Scale - Brazilian version. Data were analyzed using descriptive statistics and analysis of variance.RESULTSNurses believe they are advocating for patients in their workplaces, and agree that they should advocate, especially when vulnerable patients need their protection. Personal values and professional skills have been identified as major sources of support for the practice of advocacy.CONCLUSIONNurses do not disagree nor agree that advocating for patients in their working environments can bring them negative consequences. It is necessary to recognize how the characteristics of public and private institutions have helped or not helped in exercising patient advocacy by nurses.

Contemporary Nurse

Katrina Ford

Journal of Health, Medicine and Nursing

Francesco Germini

Nursing Ethics

Nermin Ersoy

Journal ijmr.net.in(UGC Approved)

Patient advocacy is described as “Nursing activities aimed at securing patient’s legal and ethical rights and satisfying their existential needs, both on the level of the patient- nurse relationship and in the health care team or organization”. Nurse as a patient’s advocate helps patients communicate with other health care providers so they

International Journal of Nursing & Clinical Practices

Moath Saleh

BMC nursing

Prof. Lydia Aziato

Patient advocacy has been identified as a core duty of the nurse, and certain nurse characteristics influence the performance of the role. However, these characteristics have not been adequately explored in Ghana. This study aimed to explore the perspectives of nurses about the characteristics of nurses that influence their role as patient advocates. An exploratory descriptive qualitative study was conducted among 15 nurses from a regional hospital in Ghana. Purposive sampling was used to select participants and individual in-depth interviews were conducted in English using a semi-structured interview guide. The interviews were audio-taped and transcribed. Data analysis was done concurrently employing the principles of thematic analysis. Ethical approval was obtained for the study from the Noguchi Memorial Institute of Medical Research and the Ghana Health Service Ethical Review Committee. Themes generated revealed nurse traits which enhanced the advocacy role of nurses such as bein...

BMC Nursing

Fatemeh Oskouie , Mansoureh Yadavareh-nikravesh , Ingalill Hallberg

Journal of medical ethics and history of medicine

shirmohammad davoodvand

One of the advanced nursing care procedures emphasized by nursing organizations around the world is patient or nursing advocacy. In addition to illustrating the professional power of nursing, it helps to provide effective nursing care. The aim of the present study was to explain the concept of patient advocacy from the perspective of Iranian clinical nurses. This was a qualitative study that examined the viewpoint and experiences of 15 clinical nurses regarding patient advocacy in nursing. The nurses worked in intensive care units (ICUs), coronary care units (CCUs), and emergency units. The study participants were selected via purposeful sampling. The data was collected through semi-structured interviews and analyzed using content analysis. Data analysis showed that patient advocacy consisted of the two themes of empathy with the patient (including understanding, being sympathetic with, and feeling close to the patient) and protecting the patients (including patient care, prioritiza...

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