Nurses as Advocates: Is It Worth It?

The patient is a 92-year-old male with colon cancer admitted for abdominal pain. He lives alone and cares for himself.

He rates his pain a “nine” on a scale of zero to 10. His pain regimen includes Oxycontin 40mg po bid with Oxy IR 10mg

po Q 2h prn. During the last 24 hours, he has taken 60mg of the Oxy IR with little relief. CT scans reveal metastasis to

the lung and liver; treatment planned includes oxaliplatin, 5-fl uorouracil, and leucovorin. For pain, he will receive Oxycontin 40mg po bid hydromorphone 4mg IV Q 2h. Prn are ordered, and he is requesting pain medication every hour with little relief.

The nurses discussing the chemotherapy plan for this patient find it hard to believe that they would be giving chemotherapy to a man of his age. The patient has asked about his chemotherapy, saying that he did well with previous treatment. A nurse reviews what he was taking for pain relief at home and compares it to his current orders; she finds that he was actually taking more medication at home. She speaks with the physician about the pain regimen, suggesting an increase in the IV hydromorphone and Oxycontin the following day after assessing the total amount of pain medication needed for adequate pain control. The physician agrees.

The nurse then prepares educational tools for the patient on his chemotherapy regimen. When speaking with the patient,

she emphasizes the potential for peripheral neuropathies, parasthesias, mucositis, and diarrhea. She speaks to the medical team about the appropriateness of treating this patient, who continue to voice their concerns over administering chemotherapy to this patient. The patient’s pain is ultimately controlled on Oxycontin 60mg po bid and Oxy IR 10mg po Q 2h prn. He receives his chemotherapy on schedule. His oxaliplatin is reduced after the initial dose related to

peripheral neuropathy. No other significant side effects are noted.

The Meaning of Advocacy

According to the Merriam Webster Dictionary, an advocate is “one that pleads the cause of another” or “one that supports or promotes the interests of another.” Author Constance L. Milton describes an advocate as someone who speaks for or defends another. The United Kingdom Central Council for Nursing, Midwifery and Health (UKCC) maintains that advocacy is concerned with promoting and protecting the interests of patients. The UKCC identifies advocacy on behalf of patients as a requirement of the nursing role in the introductory paragraphs of its Code of Professional Conduct. The International Council of Nurses also included nurse advocacy in its code. Advocacy is addressed in nursing literature related to ethics and has become linked with concepts of morality, autonomy, and patient empowerment. From Florence Nightingale to Virginia Henderson, the idea of advocacy has been promoted.

Nightingale was concerned that the world was unsafe, requiring that patients be protected from their surroundings. Henderson’s model began to define nursing as a separate entity with skills not included in the medical model of care. Advocacy then became entwined with the “art of nursing,” which was based more on ethics than on task completion.

Nursing should not be defined by its role and function, but rather its philosophical approach to healthcare. The nurse fulfills an advocacy role by creating an atmosphere that supports individual patient decision making. As advocates, nurses assist patients with finding meaning in their living and dying. Building on a humanistic theory of nursing, author Sally Gadow’s model of advocacy asserts that it is the patient and not the nurse who must define what is in the best interest of the patient. Patient choice is primary and it is the nurse’s role to help patients understand the situation and then decide for themselves what to do.

It is the nurse’s role to help the patient exercise autonomy and discern his or her own values, thus finding meaning in his or her own experience. There are also less philosophical models of advocacy. In order to practice self-determination, a patient must be able to make informed choices. It is the role of the advocate to inform the patient. The nurse must support the decisions made by the patient, as well as the patient's right to make them. Further, the nurse must first develop knowledge of her patient. Once interventions have been identified for the patient, it is the nurse who articulates the patient’s unique needs to the multidisciplinary team in order to adapt the interventions.

What’s at Stake?

Advocacy is generally thought to be a helpful and other-serving act. But are there times when the nurse advocate is really harmful and self-serving? Even when nurses believe they are acting with the intent to respect and protect people, assumptions about patients and their health infl uence the nurse’s actions in ways that may not, in reality, respect the person. Clearly, when a nurse sees a patient as weak and vulnerable, the patient may need an advocate who can protect his or her interests. This view assumes a paternalistic stance with the patient. The advocate’s role includes counseling patients, alleviating patients’ fears, helping them reach decisions about healthcare, representing them when they cannot represent themselves, monitoring quality of care, and ensuring that their rights are respected. These actions may or may not be consistent with the nurse’s primary responsibility to practice in ways the patient finds helpful. Health professionals cannot live the lives of others.

Although nurses can offer advice, it is the patient who must choose to act. Activities we call “advocacy” outside of a patient’s desire for help can be dangerous and disrespectful. The nurse can also be vulnerable in his or her role. The nurse must be aware of her own needs to be an advocate and the rationale behind those needs. Acknowledging that there may be some sense of paternalism embedded in this role can be difficult for the nurse. Being aware of the vulnerability and potential risks to advocacy is imperative.

Breaking Down Barriers

Despite the risks associated with advocacy, many nurses still take on the role effectively. The benefits of helpful advocacy based on patient-centered healthcare cannot be diminished. Even in the best of circumstances, barriers have been identified that keep nurses from advocating for their patients. Advocacy may not be inherent to all nurses, but requires knowledge and skill. The professional nurse must realize that patient preference is an important component to evidence-based care. Educating nurses on ways to determine patient preference and honoring those decisions is imperative to effective advocacy.

Time constraints are another barrier to advocacy. The routine built into the daily work of nurses is a type of ritual that can limit interpersonal relationships with patients. Nurses are restricted by the tasks that they need to perform on a daily basis and often have limited time for additional efforts.

A study that looked at barriers to the nurse acting as an advocate found one main emerging theme that focused on the established hierarchies of medicine and nursing and the inherent power of the physicians. Often nurses felt pressure to accept the status quo and that the physicians did not respect their views.

Why Advocate?

In order for nurses to empower patients, it is necessary for the nurse to first be empowered. One way to do this is to re-evaluate the distribution of power so that nurses participate fully in action and decision making. Nurses need to also realize that they are subordinate to others to the extent that they allow themselves to be oppressed. Changing the culture will help nurses feel confident in their ability to advocate for their patients. Despite the barriers and risks, there are many benefits to advocacy. Advocacy has the power to preserve dignity and make patients feel they are valued; it paves the way for both patients and nurses to increase their understanding of life. The essence of advocacy includes seeing the whole person, acknowledging and being touched by the other person’s situation, power in genuine commitment and interest, healing power of compassion, and respect for “small” things. Being an advocate bridges the gap between human beings and has the power to open up both patients and caregivers to development and growth in understanding life.

Advocacy can be looked at philosophically as promoting humanity and basic needs. Pragmatically, advocacy is seen as providing information. In either case, for advocacy to be effective, it has to be based on the patients’ desire for assistance and their input into what would be most helpful to them. In order to be the voice of the patient, one must first hear that patient’s voice. Being able to discern one’s own rationale for advocacy can be an invaluable tool. Educating nurses about the skills needed to advocate includes teaching about communication with patients and other healthcare professionals. Effective communication with patients will ensure that their needs are being addressed. Open communication with physicians and other members of the healthcare team will foster a collaborative practice for unsurpassed patient care. Nurses who advocate for their patients will find a greater sense of satisfaction in being aware of patients’ humanity as well as their own.

Colleen O’Leary, RN, BSN, OCN^®, is a staff educator of Medical Oncology at Northwestern Memorial Hospital in Chicago, IL.