PATIENT ADVOCACY IN NURSING: BARRIERS, FACILITATORS AND POTENTIAL IMPLICATIONS¹

ABSTRACT

Objective:

to promote reflection upon the barriers, facilitators and potential implications of patient advocacy on the part of nurses.

Results:

this reflection results from a thorough reading of the international literature addressing patient advocacy along with Brazilian and international studies addressing moral distress and its relationship with patient advocacy.

Conclusion:

the barriers imposed on patient advocacy are well-known and such constraints are based on the organizational structure of health institutions and power relationships established between doctors and nurses, challenging and discouraging nurses from acting in accordance with their knowledge and conscience, often leading to a condition known as moral distress.

DESCRIPTORS:
Health advocacy; Nursing; Nursing ethics

RESUMO

Objetivo:

realizar uma reflexão acerca das barreiras, facilitadores e possíveis implicações do exercício da advocacia do paciente pelos enfermeiros.

Resultados:

essa reflexão resulta de uma leitura minuciosa da literatura internacional acerca da advocacia do paciente, acrescida de estudos nacionais e internacionais acerca do sofrimento moral e suas relações com o exercício da advocacia.

Conclusão:

as barreiras diante do exercício da advocacia do paciente são notórias, pautando-se na própria estrutura organizacional das instituições de saúde e nas relações de poder entre equipes médica e de enfermagem, desafiando e desencorajando os enfermeiros a agirem de acordo com seus conhecimentos e consciências, implicando, muitas vezes, em situações reconhecidas como de sofrimento moral.

DESCRITORES:
Advocacia em saúde; Enfermagem; Ética em enfermagem

RESUMEN

Objetivo:

realizar una reflexión sobre las barreras, facilitadores y las posibles consecuencias del ejercicio de la defensa de los pacientes por enfermeras.

Resultados:

esta reflexión resulta de una lectura exhaustiva de la literatura internacional en defensa de los pacientes, como estudios nacionales e internacionales acerca de la angustia moral y su relación con la práctica de la defensa de los pacientes.

Conclusión:

los obstáculos al ejercicio de la defensa de los pacientes son notorios, basándose en la estructura organizativa de las instituciones de salud y de las relaciones de poder entre los equipos de médicos y enfermeros, desafiando y desencorajando los enfermeras para actuar de acuerdo con sus conocimientos y conciencia, resultando a menudo en situaciones consideradas como sufrimiento moral.

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

INTRODUCTION

Patient advocacy has been an intensively debated topic in the field of nursing in recent years, as it is considered an essential ethical component of the practice of nurses.¹ Even though patient advocacy is described as an ideal for nursing practice, its meaning, reach and implications are not yet clearly defined, which leads to ambiguities that hinder its exercise in the various health settings.^1-2

Patient advocacy has a broad conception in the nursing field and the actions of nurses, applicable to different situations and contexts related to patient advocacy, have been explored in the literature.^2-4 Therefore, the actions of nurses related to patient advocacy can be defined as an integral part of their effort to promote the interests of patients, ensuring they are aware of their rights and have access to information when making decisions, as well as defending their rights, and helping them to access health care and ensuring quality health care.^1,5-9

Moreover, the role of nursing in patient advocacy reveals in its essence a direct relationship with the moral sphere; patient advocacy is an essential activity of the nursing field. Many barriers, however, are faced by nurses, impeding them from satisfactorily fulfilling this role in accordance with their ideals.^10-11

Both Brazilian and international studies have identified that the practice of patient advocacy in the face of ethical conflicts can either generate relief or intensify moral distress if nursing workers are prevented from performing the role that corresponds to their ideals.^5,11-14 Therefore, nurses experience moral distress when they recognize a need to advocate in favor of their patients but, due to external pressure, are prevented from proceeding with such an action.¹⁵

Therefore, patient advocacy may be a response to the constant moral problems experienced by nurses in healthcare settings, especially given the possibility of nurses, in the face of situations arising in their work environment, taking a stand that can potentially benefit patients and contribute to the profession.

Therefore, considering that nurses often do not take a stand in their work environments, which compromises the practice of patient advocacy, we propose reflecting upon the barriers, facilitators and potential implications of exercising patient advocacy in order to support the development of strategies that contribute to the exercise of such advocacy in different settings where nurses work. Therefore, the objective is to reflect upon barriers, facilitators and potential implications of the practice of patient advocacy on the part of nurses.

This reflection results from a through reading of the international literature concerning patient advocacy, along with Brazilian and international studies addressing moral distress and its relationship to patient advocacy. To facilitate reflection upon the barriers and facilitators of patient advocacy, we present the main constraints impeding nurses from performing the role of advocate, as well as the main elements supporting nurses in the practice of patient advocacy.

PATIENT ADVOCACY BARRIERS AND FACILITATORS

The practice of patient advocacy faces numerous barriers that may prevent nurses from fulfilling their roles as patient advocates. These barriers also prevent nurses from realizing they have a responsibility as defenders, which in turn hinders decision-making in their work.^16-17 The main barriers to patient advocacy in the field of nursing include: the medical staff, lack of time, work overload, difficulties communicating with patients or healthcare staff, lack of knowledge, powerlessness, fear of taking risks, fear of conflict, lack of autonomy, lack of power to make decisions, and lack of support on the part of the institution.^1,17-26

In regard to the constraints imposed by the medical staff, nurses often need to question and challenge decisions based on established medical authority in order to efficiently practice patient advocacy. Even though the medical staff is known for being one barrier to patient advocacy, the nurses themselves do not question or challenge unacceptable decisions nor seek to establish alliances with physicians in order to jointly develop strategies to defend patients, despite potential negative implications for patients when they fail to do so.²³

Nurses often avoid scrutinizing the decisions or actions of physicians, abdicating their responsibilities as healthcare professionals, reinforcing the conception that barriers to advocacy do not reside only in physicians' disregard for nursing knowledge, but also in the attitudes and practices of the nursing professionals themselves. Hence, helplessness, lack of autonomy, and poor exercise of power when nurses make decisions reinforce an imbalance of forces with physicians.²³

Note that patient advocacy implies taking a stand that may lead to conflicts between nurses and the remaining health workers. Due to its nature, advocacy may trigger differences of opinion concerning what is in the patient's best interest, leading to imbalance in power relationships, especially between doctors and nurses. When these differences are left unresolved, they may lead to conflicts that become obstacles to patient advocacy.²³

These conflicts pose some risk to nurses, such as that of losing their jobs or being labeled negatively, which may inhibit their attempts to exercise their power and defend the rights of patients in healthcare settings.^1,20 Nurses seem to be risk-averse, as there is a culture of silence and conformity at the expense of conflict or confrontation, a culture that reinforces constraints that need to be overcome for nursing advocacy to be implemented.²⁰

Nurses can overcome these barriers, especially by seeking and improving their knowledge, which can be acquired through training, professional qualification and continuing education, enhancing the autonomy of nurses to advocate for their patients. In the same way, nurses can establish alliances with physicians, and share the same values and goals focusing on the care provided to patients and jointly promote advocacy, which can minimize potential conflicts. Therefore, for nurses to play an efficacious role as advocates, they need to recognize themselves to be at the same level of the other members of the staff and seek the support of their employers and the institutions at which they work.^27-28

Hence, the adoption of patient advocacy as an element of an institutional nature can be an important strategy for nurses to feel supported when advocating for their patients, as their fears concerning the risk of losing their jobs or having a negative image among colleagues are minimized. Hence, support from health institutions may give nurses greater autonomy to advocate for the rights of their patients and encourage them to seek qualification to make better decisions.^4,17,29

In regard to constraints, such as a lack of time and an excessive work load, nurses are indirectly advocating for their patients when they demand better working conditions.30 Therefore, when they demand that the health institution at which they work provide support so they can fulfill their ethical and professional responsibilities, they are taking actions that translate into patient advocacy.²⁷

Demanding better working conditions based on appropriate staffing levels, on the availability of material resources, and on the development of standards and routine protocols, can change and improve settings in which nurses work and contribute to patient advocacy, ensuring quality care and overcoming barriers that impede patient advocacy, such as work overload.

Nurses are usually apt and prepared to advocate for their patients but are prevented from defending them because of the way health institutions are organized, often based on the quantity rather than on the quality of care, possibly as a result of an imbalance in power experienced in work places and within the nursing staff itself.^11,31 Therefore, the work environment has been considered the factor that most influences the efficacy of nursing actions related to patient advocacy.^4,6,29,32

The efficacy of patient advocacy efforts does not depend only on the nurses' traits, skills, and the knowledge they hold as advocates, but also on a receptive environment.29 Therefore, it is important to note that advocacy always occurs in a social environment so that the identification of the characteristics of such an environment that can facilitate patient advocacy is essential.^4,6,29,32

Among the elements that facilitate the practice of patient advocacy, the following are highlighted: nurses' knowledge and competencies, as well as their personal traits; the physician, as a member of the staff; the multidisciplinary teams; communication; the relationship with patients and families; a recognition of patient needs and desires; the nursing staff; and the head nurse.^{4,6,18-19,24,26,29,32}

Nurses' traits can directly and positively influence patient advocacy, such as when nurses have confidence in their professional self-worth.^1,4,18,24 Note that nurses' traits like confidence, competence, autonomy and moral sensitivity are important elements supporting and orienting patient advocacy. These characteristics are mainly developed through a sensitive and dynamic attitude over the course of one's professional experience, going beyond theoretical knowledge.

The knowledge and competencies of nurses, however, are also considered to be determinants for the exercise of patient advocacy and can be developed during formal education and/or during professional experience through continuing education so that nurses acquire proper training to deal with situations that require patient advocacy.^19,24 Hence, the effective implementation of continuing education in health institutions is an important strategy to encourage the exercise of patient advocacy on the part of nurses.

The nursing staff and head nurse are also considered important elements facilitating patient advocacy, to the extent they reinforce and support the actions developed by nurses seeking to practice patient advocacy.^24,32 Therefore, the nature of the relationship with other members within the health staff is a powerful influence on the role nurses play as advocates, especially when values and goals concerning care delivery are shared, which imposes limitations on the medico-centric model and promotes patient-driven care, reinforcing the importance of multidisciplinary teams and effective communication.^24,33

Finally, the relationship between nurse and patient, effective communication, and the recognition of patients' needs, are essential for the effective practice of advocacy. The establishment of a proper relationship with patients enables nurses to understand more broadly the patients' real needs and become more efficacious when defending the patients' desires and interests while, at the same time, aids nurses in avoiding paternalism.^1,17,24 Hence, an important strategy for implementing patient advocacy consists of establishing bonds between nurses and patients so that nurses become familiar with their patients' situations and become comfortable and self-assured when advocating for them.

The successful implementation of patient advocacy results in many benefits for both patients and nurses; however, nurses may still fail, even when they seek to overcome barriers and recognize the factors that facilitate this process in their workplaces, which triggers feelings such as frustration, anger, helplessness, and possibly moral distress. Such circumstances should be properly managed to avoid potential consequences for nurses and patients.³⁴

ADVOCATE OR NOT? - POTENTIALS IMPLICATIONS

There are practical reasons for patient advocacy to be an exception rather than the rule in health institutions. Even though the positive results of patient advocacy are widely known, as they ensure that the rights, values and interests of patients are protected and preserved, nurses may face different consequences when they challenge the health system.³⁵

The implications of patient advocacy can be positive or negative both at the macro-social and micro-social levels. Various studies show that the outcomes for patients after interventions that comprise advocacy actions are always positive. At the micro-social level, patients have the freedom of self-determination and their autonomy ensured, receive proper information regarding their clinical condition, and become more competent to make decisions, in addition to receiving timely and proper treatment. At the macro-social level, advocacy action may further changes in policies and in the way health institutions are organized, resulting in improved care delivery for society as a whole.19,35-38

From the nurses' perspective, they are at risk of being accused of insubordination, tarnishing their professional reputations, being labeled as poor co-workers, losing their jobs, or having their personal lives disturbed. Sometimes, they may face extreme conflicts that manifest in the form of moral distress, and feel impotent pursuing the right course of action.^11-14 Considering all these implications, why do nurses accept the burden of advocacy if it is potentially troublesome or risky for them?³⁵

There are always personal implications for any nurse advocating for a patient, questioning the practice of other workers or even the policy of a health institution.^35,37 Nonetheless, nurses improve their satisfaction at work, self-confidence, and the credibility and visibility of the nursing field when they successfully exercise patient advocacy.³⁵ For this reason, encouraging and promoting patient advocacy potentially impacts these workers' level of satisfaction at work and strengthens their professional identity.³⁶

Moral distress experienced after failed attempts to practice patient advocacy is one of the main reason nurses abandon the profession, a result of dissatisfaction with their work and the profession they have chosen. Moral distress may be seen as a psychological imbalance caused by painful feelings that arise when nursing workers are unable to provide a morally appropriate response to a situation, that is, in accordance with their conscience.¹⁵

In the Brazilian context, studies conducted by the Center for Nursing and Health Studies and Research^11-14,39-40 reveal that when nursing workers decide not to confront situations that have the potential to generate moral distress, they opt not to abandon the profession but to abandon their values, beliefs and, finally, their own professional ideals.

The Moral Distress Scale was applied to determine the experience of distress among nurses in the Brazilian context and resulted in the identification and validation of four constructs related to the perception of moral distress, such as: denial of a nurse's role as a patient advocate; lack of competence in the work team; disregard for patient autonomy; and therapeutic obstinacy. Lack of competence on the part of the staff was the construct that most influenced the perception of moral distress, followed by denial of a nurse's role as patient advocate.¹² Subsequent studies identified that denying a nurse's role as a patient advocate, which is defined as the potential to claim the rights of patients that was unused by nurses, was an important source of moral distress.^13,41

Nurses can individually recognize the problems of patients in the routine of their work and advocate in their favor, but it is virtually impossible for them to confront and change systemic problems affecting their patients, which may cause them unnecessary distress. Understanding advocacy as an individual responsibility of nurses seems to discourage nursing associations from playing their most important leadership roles, abandoning nurses and their patients.^34-35

Nonetheless, recognizing that nursing as a profession is collectively responsible for patient advocacy does not mean denying nurses their individual role in promoting systemic changes. Expressing advocacy as a collective responsibility, supported by professional bodies and nursing representatives, rather than being a duty of nurses individually, can promote patient advocacy where nurses work, benefiting both patients and professionals and avoiding implications such as moral distress.^34-35,42

CHALLENGES AND POSSIBILITIES

The need to advocate for patients inevitably carries with it a risk of failure and a need for nurses to be brave when seeking to perform this important component of the nursing profession, considering its multiple ethical interfaces. The barriers posed to patient advocacy are well-known, such as the organizational structure of health institutions and power relationships established between medical and nursing teams, which challenge and discourage professionals in terms of acting in accordance with their knowledge and conscience, often leading to a condition known as moral distress.

Important elements stand out as facilitators of patient advocacy in multiple health contexts, among which is the importance of the workplace in all its dimensions. Strengthening professional relationships in these environments, establishing an ethical climate compatible with autonomy, having the support of management, establishing a candid and open dialogue, clinical knowledge, continuing education, and progressively developing moral competencies, can be considered factors that are associated with the effective implementation of patient advocacy.

Patient advocacy seems to manifest in a silent, isolated and fragmented way in the micro-spaces of nursing practice, hindering its dissemination and acknowledgement. Assuming patient advocacy as a collective element of institutional nature, concrete and inseparable from nurses' professional practice, can facilitate overcoming barriers that currently impede nurses from actually making a difference in the context of health, culminating in potential benefits for patients and the profession.

Finally, it is worth noting that the reflections proposed here result from pieces of information and data reported in both Brazilian and international studies and do not allow for generalization based on the results.

• 1
  Paper extracted from the dissertation entitled The exercise of patient advocacy on the part of nurses: from a Foucauldian perspective, defended in the Graduate Program in Nursing, Universidade Federal de Rio Grande (FURG), in 2014.

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Publication Dates

• Publication in this collection
  28 Sept 2017

History

• Received
  24 Mar 2015
• Accepted
  03 Dec 2015