Patient, Subordinate, and Professional Advocacy in Nursing

Advocacy has been recognized as one of the most vital and basic roles of the nursing profession. The role of advocacy, though, is an intricate one. “Nurses may act as advocating by promoting informed decisions, by acting as liaisons or by interceding for another individual. The term advocacy in its simplest outline means standing up for what one believes in for both self and others. Nursing advocacy then is a form of representation that nurses do for patients and others when they are not able to speak up for themselves. The nurses who advocate for patients and others do so within a nurturing capability.” The objectives of the advocate are to notify, enhance independence and respect the decision of the patient (“Patient, Subordinate and Professional Advocacy, n.d.). Simply put, advocates are often the go between or mediator between the healthcare system and the patient.

Advocacy in daily nursing and advanced practice nursing is guided by ethical codes. These codes influence the profession on a global scale. While certain codes may vary from country to country, at their core are principles that are created for the relationship between the nurse and the patient. In nursing literature and research on the subject, the concept of advocacy has gotten many different perspectives. Advocacy is typically discussed within the area of patients' rights and the philosophy of nursing as a whole. It is important to recognize however, that nursing advocacy can also be interpreted as a professional strategy as well that falls outside of the nurse-patient relationship. This concept is rarely discussed or debated in nursing quarters. Since there seems to be a basis for criteria for nurses to be advocates, much emphasis has been placed on the emotional strength and willingness of nurses to perform the needs of patient advocacy. The existence of a relationship between the patient and nurse becomes the focus of advocacy when discussing patient advocacy. It is the foundational standard. Factors such as integrity and collegiality are examples of what are used in addition to other criteria in patient advocacy selection (Vaartio, 2008). Patient advocacy can be understood by reflecting on its aspects with a thorough examination. 

Patient Advocacy

The viewpoint of nursing requires that nurses in some ways advocate for patients. This principle central to the nurse-patient relationship and reflects an approach of admiration towards patients as individuals. Advocacy is recognized as a task of the professional nurse and as a basic aspect of good care. It has been recommended that if the nursing vocation fails to advocate for patients, it has little purpose beyond the standard definition. The idea of advocacy is simply an attempt to raise the certified status of nurses, some critics suggest (Vaartio, 2008).

 Advocacy has continued to draw an increasing amount of analysis and understanding because of the rights that patients have based on the Status and Rights of the Patients 1992. This increases the demands of both the business providing care and on the clinical and moral skill of those seeking to respond to the demands. In other words, valuable patient advocacy requires advocacy for the nursing line of work. It is important that nurses recognize and can show to the best of their ability a genuine care for patients. If nursing professionals are to aid clients, they must first of all give power to themselves. The theory and procedure of advocacy is typically explored within the framework of pain care and procedure. Pain is always one-sided and each patient's own evaluation should carry the most weight in valuable pain management (Vaartio, 2008). Nonetheless pain care often involves dilemmas which need to be examined within the area of patient advocacy and advocacy in general.

Pain management is an area important within patient advocacy. Both nursing and medical expertise overlap and this allows nurses to make judgments where necessary about a patient or for them. Nursing professionals must fulfill their obligation as an advocate to the patient. This can often times create an ethical dilemma due to the overlapping. The ethics of nursing has allowed for many negotiations to take place to keep the balance of any conflict that may arise as a result of pain management within patient advocacy (Vaartio, 2008).

The majority of patient advocacy literature has recommended that the patient communication with someone they trust. It is essential to select an individual who has good communication skills and to ensure that person will be the type of advocate needed. The patient must choose what they need help with and what they can handle on their own when they are assessing their particular needs. This including describing options for hospitals, doctors and specific types of procedures and treatment choices. Getting as much information as possible and asking specific questions is also essential during the start of the advocacy process. Patients should also decide if they would like their advocate to accompany them to appointments, procedures and treatments ("Role of the Patient Advocate," 2013).  It is equally important for the patient advocate to take into consideration the morals of the patient. While it is part of the duty of health care professionals to provide the necessary skills and know-how to the patient, ultimately the patient makes the decisions. This serves as the foundation of empowerment that nurse advocates provide. Advocates serve as sounding boards for the patients and they provide the patient with the necessary answers they need with regard to risks or injury that may result from a decision they themselves make. Despite the fact that patients make their own decisions, there can be negotiations that take place as well. Patients have hopes and aspirations to the people they love and those that love them. Competing viewpoints may need to be taken into weighed by a mediator if the nurse advocate and patient differ on something. While this does not happen most of time, it can arise in certain healthcare situations. Nurses in the end have to be willing to compromise if need be rather than using their personal interests as a vehicle. The way forward is therefore to enhance the patient and place the reigns of control over to them once the pivotal decisions have been made (Bird, 1994). The goal is to make certain that the advocate that is chosen is the right fit for the patient as they will more than likely be an advocate for an extended period of time.

The case for nurses as advocates when examined in further detail is based on two considerations. First, there is a fundamental existence in the healthcare system for such a person and two, as people are a combination of mind and body, the nursing occupation regards each patient as a human being with an intelligence that requires as much consideration as the body does. Arguments in support of nurses as patient advocates can be elaborated by clearing up not only what nurses do to aid patients in suffering but also what they do for patients who need extended periods of care. There is reason to believe that unequal relationships exist among doctors and patients, therefore, nurses are often the ones who take on the responsibilities and the challenges of being an advocate for the patient. While this may result in disagreement within the particular health care team, in the long-run, the patient benefits from such practice. It is important to appreciate, however, that the nurses owes a certain amount of trust to the other members of his/her team, but owes just as much trust to the patient as well. It could very well be difficult to balance these loyalties if the surroundings the nurse is in is not one of shared care and support of the patients. The patient advocate is often considered a kind, sensible friend to the patient who understands the patient's belief systems and aspirations. These individuals are those that are trusted by the patients to do what is required and needed when necessary (Bird, 1994).  

 There appears to be an ethical code that runs within the parameters of patient advocacy. Literature has argued that nurses who are advocates to patients must put the needs of the patients above their own in certain cases. Reasoning suggests that there will be gains for the patient, but not necessarily other areas of the nursing occupation. It can be argued, however, that nurses who get rid of the notion that they do this for themselves are more competent of being better advocates for the patients. Kohnke, a prominent professional, within the nursing system, argues that certified nurses should adopt “emotional neutrality towards their client." By doing this, the patient-advocate relationship is formed, but there are not other interests taken into consideration in the association. This keeps out any form of injustices on behalf of the advocate or the patient (Bird, 1994).  Essentially, nurses should try to remain neutral throughout their working as an advocate.

There are common areas where patient advocacy is required such as “end of life decisions, technological advances, health care reimbursements, medical errors, cultural and ethnic diversity, respect for patient dignity, incompetence among health care provides, the aging population, social issues such as poverty, violence or sexually transmitted diseases and insurance authorizations and denials.” As a result, advocacy becomes the fundamental nature of nursing as these are often issues that the healthcare field deals with frequently. It is noteworthy however, for the patient advocate to recognize the difference between controlling patient choices and assisting patients in choosing the best decisions for care and wellbeing. A nursing advocate acts for the patient even when the decisions may change from those of the nurse (“Patient, Subordinate and Professional Advocacy, n.d.). The legislative controls of nursing practice primarily protect the rights of patients. Until the 1960s, patients have minimal rights and were pretty much denied the basic rights as humans. In today's culture, patients are more involved in their own wellbeing. They have more information to evaluate and can make the essential decisions needed regarding their own care, and they have support systems in place to assist in this process as well (“Patient, Subordinate and Professional Advocacy, n.d.). This makes the patient-advocate relationship operate smoother as a result because of the legislative changes. 

Subordinate Advocacy

The definition of subordinate advocacy is often a difficult one, partly because of it being an abandoned idea within management theory. Within this particular area of advocacy, the manager seeks to help subordinates resolve ethical problems and provide solutions at the team level. Organizations and leadership roles that create the need for subordinate advocacy are frequent. Managers have to be aware of what subordinates are seeking within their respected careers, the overall goals of their employees and the values that may be appropriate for their positions (“Patient, Subordinate and Professional Advocacy, n.d.).

A manager utilizing subordinate advocacy has to be attentive to their staff by listening, getting to know the staff, taking the time to be polite of challenges that the staff may be facing, empowering the staff to perform their tasks and duties to the best of the ability and promoting self-sufficiency. Without these proper measures put into place, subordinate advocacy is unneeded. Subordinate advocacy also includes “workplace advocacy, where the manager sees a need to make the workplace a safe and conducive environment for personal and professional growth among the staff. Different from subordinate advocacy, workplace advocacy requires that managers advocate to higher levels of an organization for reasonable expectations and assurances needed for safety at the workplace” (“Patient, Subordinate and Professional Advocacy, n.d.). This ensures that everyone is reasonable or can be reasonably happy while they are performing their tasks.

Workplace advocacy can exist at an organizational, local, state or national level to competently provide nurses with a wide ranging quantity of strategies that strengthen their contribution in the workplace. Developing a successful workplace strategy is a task that managers have to understand. The task is multifaceted in that it involves the cooperation of both management and the individual nurses themselves. Macro level strategies, also known as external ones, are usually started by state or national nursing practices and are aligned with different types of initiatives that typically result in legislation of health policies. Individual nurses often see that they have a professional obligation to participate in these macro level strategies. Micro level strategies typically happen where the nurse is employed and are more in line with improvements being made to the workplace to prevent injury and overall workplace protection (Green, 2004). Workplace advocacy in nursing is a vital necessity in making sure nurses are involved in the daily operation of the workplace through feedback they give to managers about the workplace.

Workplace advocacy is more in line with collaborative advocacy. Advocates must be able to establish positive and supportive relationships with others to garner the support necessary to address the issue. This is why is important that managers get to know their staff. Collaboration amongst staff has to be built on trust. Successful collaboration requires careful consideration with groups involved in the advocacy process so that the end goal is reach. It is often necessary for a manager to collaborate with multiple people in an organization such as other managers and staff before approaching higher levels of management to get something changed or considered. In doing so, managers strengthen the morale of the workplace and become an invaluable form of support in the advocacy process (Tomajan, 2012). This takes the complexity out of the subordinate advocacy process and makes solutions easier to be achieved.

With today's working atmosphere becoming more demanding for many, advocacy is enhanced when staffing are in cooperation with planning a variety of solutions to ensure that unforeseen situations are handled when they occur. Leaders have a role in designing the workflow process to ensure that the staff is reasonably content. Increased staff familiarity of costs associated with certain procedures, along with any workflow changes makes the advocacy process simpler and more resourceful. This also allows for better maintenance of budgets and resources being allocated towards any type of proposal. Staff participation may be asked on certain decisions that are made with regard to product decisions. Managers must also be forward looking in future improvements to healthcare. By fully engaging all levels of an organization, the managers can help to make the necessary changes when they arise (Tomajan, 2012).  Changing the dynamics of an environment are the means of subordinate advocacy and it is important that managers are committed to this process.

Professional Advocacy

Professional nursing organizations tend to support the role of nurses as advocates at all levels. The nursing profession has for many years suffered as a result of politics within organizations. This has resulted in powerlessness among nurses in both behavior and morale. In nursing philosophy, nurses should be involved in the process of both professional and personal levels in understanding the laws and regulations that govern certain acts in the creation of nursing policy. This is why professional advocacy is an essential area within the realm of advocacy. Advocacy and health care policy go hand in hand at most professional nursing associations and organizations. The professional nursing organization is the voice of reason within the conflict and struggle that comes as a result of the legislative process. It is through professional nursing advocacy that many novice nurses even consider being advocates (Sheehan, 2010). Professional advocacy can be defined then as the foundational groundwork of advocacy as a whole. 

Professional advocacy is therefore a tone setter for advocacy at all levels of nursing and even at the federal level. It can be said that professional advocacy at the federal level is a bottom up approach to advocacy in that it encourages collaboration from state and chapter level leaders and widens the amount of participation of nurses in advocacy measures and proposals. Professional nursing organizations seek to facilitate grassroots efforts as a way of building awareness and the need for spreading the message of a shared responsibility that nurses have as advocates to patients. Effective professional advocacy involves having a certain strategy that addresses specific issues that are significant to the nursing profession (Sheehan, 2010). Professional advocacy then is what gives advocacy its meaning and voice.

Professional advocacy has long been discussed in the profession of nursing. Nurses have been pushing for accountability of some kind for decades. While professional issues are always on the side of ethics, many nurses have often perceived a gap in the roles they have versus societal expectations. Nurses understand that they have a responsibility to advocate for their profession and that their commitment to their profession is one that will inevitably make the difference in whether changes happen. If nursing then is to advance as a profession, managers have to broaden their understanding of consumer issues and health care policy making. This will hopefully alleviate some of the issues that are plaguing society today. Managers must do this in order for professional advocacy to work successfully (“Patient, Subordinate and Professional Advocacy, n.d.).

As it currently stands, there are nursing lobbyists that influence legislation regarding many different issues. The nursing profession unfortunately in spite of the professional advocacy process has not recognized the powerful influence they have on political and legislative initiatives. The nursing profession as a collective has often been too reluctant to become involved and therefore have failed to join in to create or expand the roles nursing plays as a vocation. Active participation is necessary for professional advocacy to be a verifiable practice. There are nurses that do become involved by writing letters or talking to the media in order to influence certain decision making that affects their professions (“Patient, Subordinate and Professional Advocacy, n.d.). While there has been some participation on behalf of nursing and nursing organizations with regard to influencing legislation, assessments have stated that more support is needed.

Conclusion

While advocacy is regarded as an essential role within the profession of nursing, there is no clear-cut definition of advocacy and what it means to be an advocate. This means that nurses cannot be certain as to the specific definition of advocacy within their line of work. Where nurses act as an advocate, they might be acting outside the realm of their vocation. Managers who act as subordinate advocates also have to be careful with their actions and empowerment of workers. Professional organizations should maintain their rights within their support systems in order to keep within the ethical codes of nursing (Wheeler, 2000).  This allows for a better and more disciplined advocacy process in the long run.

The role of the nurse advocate is to empower the patient (patient advocacy); while the role of the manager is to assess specifically the needs of his/her staff (subordinate advocacy) and professional advocacy aims to further the profession of nursing through organizational efforts to affect legislation and other policies that affect it. Advocacy is an important product that should be understood and taken advantage of given the benefits that outweigh the negatives. The nursing profession has and continues to benefit from advocacy.

References

Bird, A. W. (1994). Enhancing patient well-being: advocacy or negotiation? Journal of medical ethics, 20, 152-156. Retrieved from http://jme.bmj.com/content/20/3/152.full.pdf

Green, A. (2004). Common Denominators: Shared Governance and Work Place Advocacy – Strategies for Nurses To Gain Control Over Their Practice. Retrieved from http://www.medscape.com/viewarticle/490770_3

Patient, Subordinate and Professional Advocacy. (n.d.). In Leadership Roles and Management Functions in Nursing Theory and Application. (Reprinted from Leadership Roles and Management Functions in Nursing Theory and Application, 6th ed.

Role of the Patient Advocate. (2013). Retrieved from http://www.npsf.org/for-patients-consumers/tools-and-resources-for-patients-and-consumers/role-of-the-patient-advocate/

Sheehan , A. (2010). The Value of Health Care Advocacy for Nurse Practitioners. Retrieved from http://www.medscape.com/viewarticle/726510_3

Tomajan, K., (January 31, 2012) "Advocating for Nurses and Nursing" OJIN: The Online Journal of Issues in Nursing, 17(1), Manuscript 4.

Vaartio, H. (2008). Nursing Advocacy: A concept clarification in context of procedural pain care [Report]. Retrieved from http://www.doria.fi/bitstream/handle/10024/42558/D826.pdf?sequence=1

Wheeler, P. (2000). Is advocacy at the heart of professional practice? Nursing Standard, 14(36), 39-41. Retrieved from http://nursingstandard.rcnpublishing.co.uk/archive/article-is-advocacy-at-the-heart-of-professional-practice