ACTIONS OF NURSES IN THE EXERCISE OF PATIENT ADVOCACY: AN INTEGRATIVE REVIEW¹

ABSTRACT

Objective:

to identify the actions of nurses when advocating for patients as reported by the international scientific literature published in the last ten years.

Method:

integrative literature review with data collected from the Cumulative Index to Nursing and Allied Health Literature database and SAGE Journals Online, using the key words "patient advocacy" and "nursing"; 27 papers were identified.

Results:

two categories emerged: advocacy actions performed by nurses from different countries and cultures; and advocacy actions performed by nurses in different healthcare settings.

Conclusion:

this study's findings are expected to contribute to research and knowledge in the field of nursing, broadening understanding of patient advocacy as an ethical component of the nursing practice.

DESCRIPTORS:
Health advocacy; Nursing; Ethics, Nursing; Review

RESUMO:

Objetivo:

identificar as ações dos enfermeiros no exercício da advocacia do paciente, na literatura científica internacional publicada nos últimos dez anos.

Método:

revisão integrativa da literatura, cujos dados foram coletados na base de dados Cumulative Index to Nursing and Allied Health Literature e SAGE Journals Online, utilizando-se os descritores "patient advocacy" e "nursing", sendo encontrados 27 artigos.

Resultados:

como resultados, emergiram duas categorias: ações de advocacia exercidas por enfermeiros em diferentes nações e culturas; e ações de advocacia nos diferentes ambientes de atuação dos enfermeiros.

Conclusão:

acredita-se que os achados deste estudo poderão contribuir para a produção de pesquisas e conhecimentos em enfermagem, ampliando a compreensão da advocacia do paciente como um componente ético da prática dos enfermeiros.

DESCRITORES:
Advocacia em saúde; Enfermagem; Ética em enfermagem; Revisão

RESUMEN

Objetivo:

identificar las acciones de los enfermeros en ejercicio de defensa de los pacientes en la literatura científica internacional publicada en los últimos diez años.

Método:

revisión integrativa de literatura, y los datos fueron recogidos en la base de datos Cumulative Index to Nursing and Allied Health Literature y SAGE Journals Online, utilizando los descriptores "patient advocacy" y "nursing", siendo encontrado 27 artículos.

Resultados:

como resultado, emergieron dos categorías: las acciones de defensa ejercitadas por enfermeros e n diferentes naciones y culturas; las acciones de defensa en los distintos ámbitos de acción de los las enfermeros.

Conclusión:

se considera que los resultados de este estudio pueden contribuir a la producción de la investigación y el conocimiento en la enfermería, la ampliación de la comprensión de la defensa de los pacientes como un componente ético de la práctica de enfermería.

DESCRIPTORES:
Defensa de la salud; Enfermería; Ética en enfermería; Revisión

INTRODUCTION

Discussions concerning patient advocacy emerged in the 1970s from social circumstances that led consumers of health care services to reject paternalistic health practices and demand autonomy and freedom to make clinical decisions concerning their own health and disease situation.^1-2 This movement in favor of patient rights gave rise to a greater emphasis on the role of nurses as the advocates of patients,³ considering the close relationship nurses can establish with patients and their constant presence in healthcare settings.⁴

In 1973, the International Council of Nurses introduced the term advocacy into their professional code, evidencing a fundamental principle of nursing ethics.⁵ Nonetheless, only in the 1980s, in the United States, was patient advocacy openly acknowledged in nursing practice, while it is still considered a relatively new role for nurses,⁶ especially in some countries, such as Brazil.

Even though patient advocacy is not an activity exclusive to nurses, with other health workers also advocating for patients, patient advocacy is clearly an important role within nursing practice, evidenced in the philosophical and scientific literature and ethical codes, such as the Code of Ethics of the American Nurses Association, and in teaching competencies.^2,7

Patient advocacy has been increasingly discussed as an essential component and moral obligation in the practice of nursing. Since its emergence, however, many definitions have been proposed in the literature for nursing,^2,7-8 which may lead to ambiguities and hinder its implementation in different health settings.

The first attempts to conceptualize and provide models for patient advocacy derive from philosophical definitions, emphasizing the nature and purpose of the nurse-patient relationship at the expense of a specific set of actions and behaviors.⁹ The philosophical models of advocacy most frequently discussed in the literature include: the human advocacy model,¹⁰ the existential advocacy model,¹¹ the functional model of patient advocacy,¹² and the social advocacy model.¹³

These models are widely used and discussed in the literature but do not seem to reflect the role of nurses in terms of patient advocacy, hindering the recognition of actions that should be implemented by this professional. Contradictions that involve the concept of advocacy within nursing, however, have been widely addressed by different studies seeking to describe nursing actions applicable to different contexts and clinical situations.^8,14

There is a lack of Brazilian studies investigating patient advocacy in the nursing sphere, while in the international literature this topic has been widely addressed. Thus, a literature review including internationally published scientific papers addressing the role of nurses in regard to patient advocacy is justified. The following question guided this review: "what are the actions of nurses in regard to patient advocacy?" The objective of the question was to identify the actions performed by nurses when they advocate for patients, as reported in the international scientific literature in the last ten years.

METHOD

This integrative literature review consists of organizing, cataloguing, and synthesizing the results presented in the papers selected for analysis, facilitating interpretation. Five stages were implemented to establish methodological rigor, namely: establishment and identification of the problem; data collection; data assessment; data analysis and interpretation; and the presentation of results.⁹

The first stage, establishment and identification of the problem, included acquiring theoretical depth regarding the topic of patient advocacy within the nursing sphere, which enabled more precisely identifying the variables loaded with greater meaning, according to the existing literature. At the end of this first stage, the guiding question was "what are the actions of nurses when advocating for patients?"

In the data collection stage, papers indexed in the following sources were identified in the CINAHL (Cumulative Index to Nursing and Allied Health Literature) database and SAGE Journals Online, using the descriptors listed by the Medical Subject Headings (MeSH): "patient advocacy" and "nursing", with the Boolean operator AND. The search was performed online in December 2013. The inclusion criteria established for this integrative review were: full texts; published between 2003 and 2013; written in English; presenting the abstract, so an initial analysis could be performed; and having patient advocacy as the main subject.

A total of 13 papers that met inclusion criteria were selected from the SAGE database and another 31 were identified in the CINAHL database. In the third stage, data assessment, 44 papers were assessed to verify whether they focused on the topic and were aligned with the research question, and 33 papers remained (Table 1). Note that six papers appeared in both databases so that 27 papers remained in the sample.

Table 1
Papers selected from the databases in December 2013

Database	CINAHL	SAGE	Total
Descriptors	Patient advocacy AND nursing	Patient advocacy AND nursing
Papers identified	194	382	576
Papers that met inclusion criteria	31	13	44
Papers that focused on the topic and were aligned with the research question	22	11	33
Papers that appeared in both databases			6
Sample			27

The fourth stage, analysis and interpretation of data, included reducing, visualizing and comparing data in addition to drawing and writing conclusions. During the reduction process, the data were organized according to the following variables: authors' names; periodical; title; year of publication; objectives; study design; subjects; and main results. In the visualization, the data were grouped in a table and comparison of data included analysis in which the themes and specificities of each paper were identified. The stage concerning drawing and writing conclusions required an interpretative effort to gather and then synthesize data to facilitate the presentation of results in categories. Finally, the last stage, that of presenting the data, included establishing conclusions and a discussion regarding concerns and reflections that accumulated over the process.

This study was not submitted to the Institutional Review Board because it is an integrative literature review using sources in the public domain, though ethical guidelines concerning the search for, analysis, discussion and presentation of results were rigorously followed.

RESULTS AND DISCUSSION

Analysis of the 27 papers reveals that the periodical with the largest number of papers addressing the topic was Nursing Ethics (ten papers). In terms of year of publication, the largest number of papers was published in 2007 and 2008 (five papers each). In the analysis of methods, quantitative (11 papers) and qualitative studies (11 papers) predominated, followed by theoretical studies (three papers) and a combination of quantitative and qualitative designs (two papers). Some of the variables addressed in the papers are presented in Table 2.

Table 2
Papers' titles, authors, periodicals, and year of publication.

Papers' title	Authors	Periodical	Year
Undertaking the role of the patient advocate: a longitudinal study of nursing students	Altun I, Ersoy N.	Nursing Ethics	2003
A pilot study of selected Japanese nurses' ideas on patient advocacy	Davis AJ, Konishi E, Tashiro M.	Nursing Ethics	2003
Nurses' Advocacy in an Australian Operating Department	Bull R, Fitzgerald M.	AORN Journal	2004
Patient advocacy in the perioperative setting	Boyle HJ.	AORN Journal	2005
Bridging the gap: a study of general nurses' perceptions of patient advocacy in Ireland	O'Connor T, Kelly B.	Nursing Ethics	2005
Advocating for the Rights of the Mentally III: A Global Issue	Rossetti J, Fox PG, Burns K.	The International Journal of Psychiatric Nursing Research	2005
Nursing advocacy in an Australian multidisciplinary context: findings on medico-centrism	McGrath P, Holewa H, Mcgrath Z.	Scandinavian Journal of Caring Sciences	2006
The role of the nurse as advocate in ethically difficult care situations with dying patients	McSteen K, Peden-McAlpine C.	Journal of Hospice and Palliative Nursing	2006
The road less traveled: nursing advocacy at the policy level	Spenceley SM, Reutter L, Allen MN.	Policy, Politics and Nursing Practice	2006
Nursing advocacy: how is it defined by patients and nurses, what does it involve and how is it experienced?	Vaartio, H. Leino-Kilpi H, Salantera S, Suominen T.	Scandinavian Journal of Caring Sciences	2006
Nursing advocacy in North Carolina	Gosselin-Acomb T, Schneider, Robert W, Veenstra BV.	Oncology Nursing Forum	2007
An investigation into the advocacy role of the learning disability nurse	Llewellyn P, Northway R.	Journal of Research in Nursing	2007a
The views and experiences of learning disability nurses concerning their advocacy education	Llewellyn P, Northway R.	Nurse Education Today	2007b
Patient advocacy and advance care planning in the acute hospital setting	Seal M.	Australian Journal of Advanced Nursing	2007
Advocacy at end-of-life research design: an ethnographic study of an ICU	Sorensen R, Iedema R.	International Journal of Nursing Studies	2007
The lived experience of nursing advocacy	Hanks RG.	Nursing Ethics	2008
The meaning of patient advocacy for Iranian nurses	Negarandeh R, Oskouie F, Ahmadi F, Nikravesh M	Nursing Ethics	2008
Autonomy and advocacy in perinatal nursing practice	Simmonds AH.	Nursing Ethics	2008
Nurses' advocacy behaviors in end-of-life nursing care	Thacker KS.	Nursing Ethics	2008
The content of advocacy in procedural pain care - patients' and nurses' perspectives	Vaartio H, Leino-Kilpi H, Suominen T, Puukka P.	Journal of Advanced Nursing	2008
Nursing Advocacy in procedural pain care	Vaartio H, Leino-Kilpi H, Suominen T, Puukka P.	Nursing Ethics	2009a
Measuring nursing advocacy in procedural pain care. Development and validation of an instrument	Vaartio H, Leino-Kilpi H, Suominen T, Puukka P.	Pain Management Nursing	2009b
The medical-surgical nurse perspective of advocate role	Hanks RG.	Nursing Forum	2010a
Development and testing of an instrument to measure protective nursing advocacy	Hanks RG.	Nursing Ethics	2010b
Public health nurse perceptions of empowerment and advocacy in child health surveillance in West Ireland	Cawley T, Mcnamara PM.	Public Health Nursing	2011
Factors that influence the patient advocacy of pain management nurses: results of the American society for pain management nursing survey	Ware LJ, Bruckenthal P, Davis GC, O'Conner-Von SK.	Pain Management Nursing	2011
Health and human rights advocacy: perspectives from a Rwandan refugee camp	Pavlish C, Ho A, Rounkle A.	Nursing Ethics	2012

Some study variables are presented (Table 2).

Data analysis enabled the identification of guiding axes in terms of knowledge produced internationally and focused on the actions of nurses in the advocacy of patients. Thus, two categories emerged: Advocacy actions performed by nurses in different countries and cultures and Advocacy actions performed by nurses in different health settings.

Advocacy actions performed by nurses in different countries and cultures

Patient advocacy has been the object of various studies conducted in different countries and cultures such as: the United States,^15-21 Filand,^22-25 Ireland,^26-27 United Kingdom,^28-29 Republic of Rwanda,³⁰ Australia,^31-34 Iran,³⁵ Turkey,³⁶ and Japan.³⁷ Some of these studies investigated the meaning of patient advocacy from the perceptions of nurses according to their cultural contexts, clarifying important aspects both for the concept of patient advocacy and its implementation into practice.

In Japan, patient advocacy derived from Western concepts and became an ethical ideal for Japanese nurses, who often face difficulties putting it into practice due to power relationships existing among health workers. Japanese nurses believe they are advocating in favor of patients when they provide information to patients and their families, when they provide information regarding patients to other health workers, and when they put themselves at risk to defend patients in anti-ethical situations.³⁷

The meaning of patient advocacy for Iranian nurses is translated into actions like providing information and education, valuing and respecting, and supporting and promoting the continuity of care. Likewise, nurses are supposed to protect patients from the malpractice of other health workers. These actions can only be implemented when the individuality and dignity of patients are acknowledged and respected.³⁵

In Ireland, the main role of nurses as patient advocates lies in acting as the middle person between the patient and healthcare settings, while there is a distinction between clinical and organizational advocacy. Clinical advocacy comprises specific actions to act on behalf of a patient, while organizational advocacy involves actions intended to implement change and improvements at an institutional level, benefitting patients in general.²⁶

According to Finnish nurses, patient advocacy cannot be considered a random and single event, but a process of analysis of clinical situations, counseling, protection and complaints, which is a result of the continual assessment of patients' needs and desires. When such an assessment is not performed, advocacy actions may be distorted and easily interpreted as paternalist in nature.²²

In the context of the healthcare field in the United States, the precursor of recognition of advocacy actions within the practice of nursing, medical-surgical nurses play the role of advocates, especially when they speak and act on the behalf of patients and work to meet unmet needs.^19-20 Other actions in the exercise of patient advocacy include: educate patients and their families; communicate their wishes to other members of the health staff; ensure proper care is provided; identify the patients' wishes; and ensure their safety.²⁰

Looking for similarities and differences among the various countries in which advocacy actions were investigated in their cultural contexts, we find that patient orientation was a common element, showing that advocacy actions specifically aim to inform patients and provide clarification to them in order to ensure their right to autonomy. Such an aspect is similar in Brazil, where nurses practice patient advocacy when they inform patients of their rights and ensure they are autonomous in making decisions; a patient has difficulties being sufficiently informed when facing restrictive practices and policies established by health institutions.³⁸

These findings indicate that advocacy actions implemented in the different countries and cultures are strongly associated with human,¹⁰ existencial,¹¹ and functional¹² advocacy models, as such models are based on the common belief that individuals need to be sufficiently informed in order to exert their freedom, autonomy, and make their own choices and decisions. Note, however, that the social advocacy model,¹³ which maintains the concerns of nurses with the advocacy of individual patients and then goes beyond the scope of health settings, provoking participation in criticism and social change, was not evidenced in the actions implemented by nurses in the different countries and cultures.

From this perspective, considering the need for a reference for advocacy actions implemented in the different countries and cultures, the Mid-Range Theory of Patient Advocacy⁸ seems to be the most applicable and comprehensive model, comprising three fundamental principles: safeguard the autonomy of patients; act on the behalf of patients; and defend social justice in the provision of health care. For that, nurses need to recognize situations in which patients need an advocate, what the interests of patients are, and what actions should be taken to preserve, represent or protect them.

It also should be noted that countries such as Japan and Iran place a greater emphasis on actions intended to protect patients in morally inappropriate situations. Hence, it is clear that advocacy for patients involves constantly making ethical judgments, and often questions and confronts values, standards and practices in order to ensure that the rights of patients are respected. In this sense, we highlight that the exercise of patient advocacy, in situations in which there are ethical conflicts, may lead nursing workers to feel relieved, or on the contrary, to experience greater moral distress when they are unable to play this role in a way that corresponds to their ideals, as identified by Brazilian studies addressing moral distress.³⁹

Advocacy actions performed by nurses in different healthcare settings

In regard to the healthcare settings where nurses work, there are investigations and reflections addressing the exercise of patient advocacy, especially in medical-surgical units,^19-20 oncological,¹⁷ perioperative,^15,31 and perinatal units,⁴⁰ settings in which palliative care is provided,^16,18,33-34 mental health facilities,⁴¹ community health,^27,30 settings where care is provided to patients with pain,^23-25,42 to patients with cognitive disabilities,^28-29 and when patient advocacy is addressed at a political level.⁴³

Nurses providing oncological care often exercise patient advocacy motivated by the complexity of patients' needs. Oncological nurses believe they are exercising advocacy especially when they teach self-care to patients and families and communicate necessary care procedures to other staff members.¹⁷

In regard to palliative care, ethical situations concerning the process of death and dying, such as the provision of non-curative treatments that do not benefit patients, raise a need for advocacy.³⁴ Patient advocacy in the context of palliative care can be considered from an emancipatory perspective, defined as a way to remove unnecessary suffering through the transformation of practices and people.³³

Furthermore, advocacy concerning palliative care in the sphere of nursing can be defined as support provided to patients and families to overcome barriers that impede access to care¹⁸ and defend the individual desires of patients in regard to their death.³³ A phenomenological study addressing the activities of nurses working with palliative care and dealing with ethical issues identified three major actions that portray the role of nurses: act as a guide, informing, educating and providing clarification to patients and family members; acting as a link between the health staff and the patient's family, reporting and defending the goals and desires of the patient to the health staff; supporting the meaning assigned to the disease by the patient and family members, defending patient choices according to their values.³²

Patients with pain represent another group who often need nurses to advocate on their behalf to improve pain management, as they do not know what therapeutic measures are available or what their rights are. Thus, providing education to patients so they can ask for pain medication and fulfill their unmet needs are important responsibilities of nurses.⁴²

In some situations, nurses have to act on the behalf of patients who need better treatment to manage pain, while in other situations, there is a need to establish a partnership between nurse and patient to achieve goals concerning pain management. Note that when patients opt for a nurse to act on their behalf, they are exerting their autonomy and right to choose. For this reason, it is necessary to analyze and heed the patients' preferences concerning care provided to their pain and provide clarification concerning such care.^23-25

In perioperative care settings, even if nurses get involved with patients only briefly, patient advocacy should be implemented, as patients are often unconscious or in a particularly strange environment. Even if they are physically prepared for procedures, patients may not have provided an informed consent form for surgical procedures.³¹ Advocacy actions implemented in perioperative contexts mainly comprise aiding uninformed patients or patients who did not provide proper consent for surgical procedures, and to protect patients from malpractice.¹⁵

One study with a phenomenological approach determined that nurses providing perioperative care define patient advocacy as protecting the rights of patients, ensuring they are properly cared for and safe; reporting their rights to patients and families; providing information regarding health care; acting on their behalf, intervening and supporting them in achieving optimized results. Hence, some actions under the responsibility of nurses include: checking information in the patient's medical file; checking whether the patient is correctly positioned during an anesthetic procedure; providing information regarding patients to the staff members; providing orientation to patients and family members in regard to surgical procedures, as well as informing them of its risks and benefits; damage prevention; and promoting a safe environment.¹⁵

Advocacy actions implemented in perinatal nursing care depend on the relationship established between nurse and patient, promoting the autonomy of pregnant women and ensuring their choices are respected. Nurses should be willing to remove obstacles that may prevent women from acting according to their values and provide the resources necessary to ensure their decisions are acknowledged and taken into account. Note, however, that sometimes nurses are aware of and understand the desires of women but are not able to advocate on their behalf because of restrictive practices and policies established by healthcare institutions.⁴⁰

In issues that concern mental health, patient advocacy is linked to human rights, requiring nurses to understand clearly and completely how they can advocate for their patients by providing health education, supporting their autonomy to make decisions, and participating in the establishment of policies.⁴¹ Advocacy actions implemented in the context of people with cognitive disabilities may also include acting on the behalf of patients when they cannot properly communicate verbally or support self-defense, whenever possible.^28-29

Similar to the context of mental health, patient advocacy in the context of community health also emphasizes human rights, seeking to establish conditions for autonomy, equality, and justice in social relationships, equal access to opportunities,³⁰ as well as training and empowering patients.²⁷ Advocacy at a political level, which does not exist, or at least is invisible in nursing practice, consists of influencing political decisions in order to improve the population's health and life conditions.⁴³

When discussing and reflecting upon the actions of nurses as they advocate for patients, some questions may emerge when we consider the different contexts and situations: why is it necessary to advocate for patients? Why do patients need nurses to advocate for them? What precedes patient advocacy in nursing practice?

Note that antecedents of patient advocacy in the nursing practice may take place at microsocial and macrosocial levels in the healthcare system. At a microsocial level, the clinical conditions of patients constitute the main antecedents of patient advocacy; the primary of these is the vulnerability of patients.⁸ At the macrosocial level, differences in health conditions motivated by factors such as poverty and poor access to health services, are the main reasons for advocating on the behalf of patients. Hospital settings may also present an important macrosocial antecedent considering that the use of advanced technology and the costs of health services lead workers to disregard the autonomy and values of patients.²

Therefore, the task of establishing and describing the actions of nurses when advocating for patients is a challenge, because such actions are not static or fixed, but are rather influenced by the characteristics of individuals, organizations, relationships, clinical situations and working settings.² Thus, the concept of patient advocacy in the sphere of nursing should always be considered from different perspectives and different clinical and cultural contexts taking into account the meanings nurses and patients assign to advocacy actions.

Thus, considering the different clinical conditions and health settings, advocacy actions performed by nurses should primarily aim to ensure the autonomy of patients, considering their beliefs and values in decision-making, protecting them from malpractice on the part of other health workers, and ensuring the quality of care delivery. Such actions contribute to the construction for nurse autonomy, as they allow these professionals to deal with situations that seem to be perceived as unquestionable in their work environments.

There are no Brazilian studies addressing patient advocacy in specific situations or clinical contexts. The Brazilian Association of Nursing (ABEn), however, has attempted to sensitize nurses to their political role. For that, patient advocacy is acknowledged as a process that uses strategic policies in order to promote the rights of patients, contribute to empowering them, as well as sensitize authorities in regard to the population's needs and deficiencies.⁴⁴

This initiative shows there is a concern in the Brazilian context for promoting political advocacy among nurses, which is an aspect seldom explored in international studies. In this sense, the objective of patient advocacy mainly accrues from the purpose of nursing and its commitment to society to improve the level of health at both the individual and collective levels.⁹

CONCLUSION

The papers analyzed here show that the actions of nurses focused on patient advocacy are permeated with many possibilities and are associated with recognition of what nurses believe to be necessary to advocate for the rights of patients. Nonetheless, the conclusion is that patient advocacy actions may vary depending on the culture, clinical situations, and the different health settings where nurses work.

All the papers converge on some specific actions, such as: inform and educate patients and families; identify and respect the rights of patients; ask for and ensure appropriate care is provided to patients, as well as ensure their safety and privacy; and speak and act on their behalf, supporting their decisions and promoting their autonomy.

It is also important to emphasize that patient advocacy is more than an isolated and random action; rather, it is an ethical component of nursing practice, involving the ways in which nurses face moral problems in their working environments. Hence, new studies are needed to investigate how patient advocacy can minimize the consequences of moral issues that arise in the environment of nursing practice, as it is necessary to investigate patient advocacy in different clinical contexts.

Acknowledging the actions of nurses when advocating for patients can orient practice, education and research in the nursing field, supporting nurses so they can more efficiently advocate on the behalf of their patients. We expect this study's findings to contribute to the development of research and nursing knowledge, broadening understanding of patient advocacy as an ethical component of nurses' practice.

• 1
  Paper extracted from the dissertation - The practice of patient advocacy by nurses: a Foucauldian perspective presented to the Programa de Pós-Graduação em Enfermagem (PPGEnf) at the Universidade Federal do Rio Grande (FURG), in 2014.

REFERÊNCIAS

• ¹
  Annas GJ, Healey J. The patient rights advocate. J Nurs Adm. 1974 May-Jun; 4(3): 25-31.
• ²
  Cole C, Wellard S, Mummery J. Problematising autonomy and advocacy in nursing. Nurs Ethics. 2014 Jan; 21(5):576-82.
• ³
  Annas GJ. The patient rights advocate: can nurses effectively fill the role? Superv Nurse. 1974 Jul; 5(7): 20-5.
• ⁴
  Josse-Eklund A, Jossebo M, Sandin-Bojo AK, WildeLarsson B, Petzall K. Swedish nurses' perceptions of influencers on patient advocacy. Nurs Ethics. 2014 Sep; 21(6):673-83.
• ⁵
  Vaartio H, Leino-kilpi H. Nursing advocacy: a review of the empirical research 1990-2003. Int J Nurs Stud. 2005 Aug; 42(6): 705-14.
• ⁶
  Hamric AB. What is happening to advocacy? Nurs Outlook. 2000 May-Jun; 48(3): 103-4.
• ⁷
  Bu X, Wu YB. Development and psychometric evaluation of the instrument: attitude toward patient advocacy. Res Nurs Health. 2008 Feb; 31(1): 63-75.
• ⁸
  Josse-Eklund A, Petzall K, Sandin-Bojo AK, WildeLarsson B. Swedish registered nurses' and nurse managers' attitudes towards patient advocacy in community care of older patients. J Nurs Manag. 2013 Jul; 21(5):753-61.
• ⁹
  Reed FM, Fitzgerald L, Bish MR. District nurse advocacy for choice to live and die at home in rural Australia: a scoping study. Nurs Ethics. 2015 Jun; 22(4):479-92.
• ¹⁰
  Curtin LL. The nurse as advocate: a philosophical foundation for nursing. ANS Adv Nurs Sci. 1979 Apr; 1(3): 1-10.
• ¹¹
  Choi PP. Patient advocacy: the role of the nurse. Nurs Stand. 2015 Feb; 29(41):52-8.
• ¹²
  Toda Y, Sakamoto M, Tagaya A, Takahashi M, Davis AJ. Patient advocacy: Japanese psychiatric nurses recognizing necessity for intervention. Nurs Ethics. 2015 Nov; 22(7):765-77.
• ¹³
  Fowler MD. Social advocacy: ethical issues in critical care. Heart Lung. 1989; 18 (1): 97-9.
• ¹⁴
  Hanks RG. Social Advocacy: a call for nursing action. Pastor Psychol. 2013 April; 62(2):163-73.
• ¹⁵
  Boyle HJ. Patient advocacy in the perioperative setting. AORN J. 2005 Aug; 82(2): 250-62.
• ¹⁶
  McSteen K, Peden-mc Alpine C. The role of the nurse as advocate in ethically difficult care situations with dying patients. J Hosp Palliat Nurs. 2006 Oct; 8 (5): 259-68.
• ¹⁷
  Gosselin-Acomb T, Schneider, Robert W, Veenstra BV. Nursing advocacy in North Carolina. Oncol Nurs Forum. 2007 Sep; 34(5): 1070-4.
• ¹⁸
  Thacker KS. Nurses' advocacy behaviors in end-of-life nursing care. Nurs Ethics. 2008 Mar; 15(2): 174-85.
• ¹⁹
  Hanks RG. The lived experience of nursing advocacy. Nurs Ethics. 2008 Jul; 15(4): 468-77.
• ²⁰
  Hanks RG. The medical-surgical nurse perspective of advocate role. Nurs Forum. 2010 Apr-Jun; 45 (2): 97-107.
• ²¹
  Hanks RG. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics. 2010 Mar; 17(2): 255-67.
• ²²
  Vaartio, H. Leino-Kilpi H, Salantera S, Suominen T. Nursing advocacy: how is it defined by patients and nurses, what does it involve and how is it experienced? Scand J Caring Sci. 2006 Sep; 20(3): 282-92.
• ²³
  Vaartio H, Leino-Kilpi H, Suominen T, Puukka P. The content of advocacy in procedural pain care - patients' and nurses' perspectives. J Adv Nurs. 2008 Dec; 64(5): 504-13.
• ²⁴
  Vaartio H, Leino-Kilpi H, Suominen T, Puukka P. Nursing advocacy in procedural pain care. Nurs Ethics. 2009 May; 16(3): 340-62.
• ²⁵
  Vaartio H, Leino-Kilpi H, Suominen T, Puukka P. Measuring nursing advocacy in procedural pain care. Development and validation of an instrument. Pain Manag Nurs. 2009 Dec;10(4):206-19.
• ²⁶
  O'Connor T, Kelly B. Bridging the gap: a study of general nurses' perceptions of patient advocacy in Ireland. Nurs Ethics. 2005 Sep; 12(5): 453-67.
• ²⁷
  Cawley T, Mcnamara PM. Public health nurse perceptions of empowerment and advocacy in child health surveillance in West Ireland. Public Health Nurs. 2011 Mar-Apr; 28(2): 150-8.
• ²⁸
  Llewellyn P, Northway R. An investigation into the advocacy role of the learning disability nurse. Nurse Educ Today. 2007 Nov; 27(8): 955-63.
• ²⁹
  Llewellyn P, Northway R. The views and experiences of learning disability nurses concerning their advocacy education. Nurse Educ Today. 2007 Nov; 27(8): 955-63.
• ³⁰
  Pavlish C, Ho A, Rounkle A. Health and human rights advocacy: perspectives from a Rwandan refugee camp. Nurs Ethics. 2012 Jul; 19(4): 538-49.
• ³¹
  Bull R, Fitzgerald M. Nurses' advocacy in an Australian Operating Department. AORN J. 2004 Jun; 79(6): 1265-74.
• ³²
  McGrath P, Holewa H, Mcgrath Z. Nursing advocacy in an Australian multidisciplinar context: findings on medico-centrism. Scand J Caring Sci. 2006 Dec; 20(4): 394-402.
• ³³
  Sorensen R, Iedema R. Advocacy at end-of-life research design: an ethnographic study of an ICU. Int J Nurs Stud. 2007 Nov; 44(8): 1343-53.
• ³⁴
  Seal M. Patient advocacy and advance care planning in the acute hospital setting. Aust J Adv Nurs. 2007 Jun-Aug; 24(4):29-36.
• ³⁵
  Negarandeh R, Oskouie F, Ahmadi F, Nikravesh M.. The meaning of patient advocacy for Iranian nurses. Nurs Ethics. 2008 Jul; 15(4): 457-67.
• ³⁶
  Altun I, Ersoy N. Undertaking the role of patient advocate: a longitudinal study of nursing students. Nurs Ethics. 2003 Sep; 10(5): 462-71.
• ³⁷
  Davis AJ, Konishi E, Tashiro M. A pilot study of selected japanese nurses' ideas on patient advocacy. Nurs Ethics. 2003 Jul; 10(4): 404-13.
• ³⁸
  Tomaschewski-Barlem JG, Lunardi VL, Barlem ELD, Ramos AM, Silveira RS, Vargas MAO. How have nurses practiced patient advocacy in the hospital context? - a foucaultian perspective. Texto & contexto enferm. 2016 Mai; 25(1): 256-65.
• ³⁹
  Barlem ELD, Ramos FRS. Constructing a theoretical model of moral distress. Nurs Ethics. 2015. Aug; 22(5): 608-15.
• ⁴⁰
  Simmonds AH. Autonomy and advocacy in perinatal nursing practice. Nurs Ethics. 2008 May; 15(3): 360-70.
• ⁴¹
  Rossetti J, Fox PG, Burns K. Advocating for the rights of the mentally III: a global issue. Int J Psychiatr Nurs Res. 2005 Sep; 11(1): 1211-7.
• ⁴²
  Ware LJ, Bruckenthal P, Davis GC, O'Conner-Von SK. Factors that influence patient advocacy by pain management nurses: results of the American society for pain management nursing survey. Pain Manag Nurs. 2011 Mar; 12(1): 25-32.
• ⁴³
  Spenceley SM, Reutter L, Allen MN. The road less traveled: nursing advocacy at the policy level. Policy Polit Nurs Pract. 2006 Aug;7(3): 180-94.
• ⁴⁴
  Ventura CAA, Mello DF, Andrade RD, Mendes IAC. Nursing partnership with users in the defense of SUS. Rev Bras Enferm. 2012 Dec; 65(6): 893-8.

Publication Dates

• Publication in this collection
  2018

History

• Received
  19 June 2014
• Accepted
  03 Dec 2014