The word advocacy is derived from the Latin word advocatus, meaning to plead the cause of another (Advocate, n.d.). While the word advocacy is most frequently associated with legal and political settings, the definition has expanded to encompass a wide range of activities undertaken in support of individuals, families, systems, communities, and issues. Nurses are widely viewed as advocates for patients and their families. Some have suggested that patient advocacy is an integral part of nursing practice (Vaartio, Leino-Kilpi, Salantera, & Suominen, 2006). In modern nursing practice, nurses serve as advocates when they ensure that patients understand the treatments they are receiving while in the hospital, or serve as a translator between the patient and members of the health care team. Many nurses work to coordinate care and help patients navigate the complexities of the health system.

In the community setting, nurses frequently work with residents and community leaders to advocate for healthier neighborhoods. Working alongside members of the community, community health nurses seek to mitigate the social determinants of illness through advocacy at the individual, system, and policy levels. As experts in the delivery of health care and the promotion of health, nurses are also frequently engaged in issue advocacy, addressing such issues as access to care and disease prevention.

Through professional organizations such as the American Nurses Association (ANA) and the American Association of Nurse Anesthetists (AANA) (see Chapter 35), nurses serve as advocates for the nursing profession itself by educating and appealing to state and federal legislators and policymakers to promote safe workspaces for nurses and to safeguard the nursing scope of practice.

Patient advocacy is a frequently described, but poorly understood, concept in nursing. It is viewed as a central tenet of nursing practice, both in the U.S. and around the world (Allcock, 1989; Altun & Ersoy, 2003; Bu & Jezewski, 2007; Foley, Minick, & Kee, 2000; Gale, 1989; Hanks, 2005; Kohnke 1978; Mathes, 2005; McSteen & Peden-McAlpine, 2006; Morra, 2000; Vaartio, et al., 2006). Despite widespread acceptance of the role of patient advocate by nurses in the published literature, there is little understanding of what nursing advocacy is, how (and whether or not) it is performed by nurses, and what results from nursing advocacy (Baldwin, 2003; Grace, 2001; Mallik, 1998).

Winslow (1984) identified two major metaphors—loyalty and advocacy—espoused by nursing leaders and educators from the profession’s birth through the mid 1980s. Loyalty as a metaphor for practice was rooted in the “battle against disease” and featured rigid hierarchies that were prevalent in military practice settings through the 1940s (Winslow, 1984). Instructional books from the early period of the profession characterized the nurse as a warrior in the battle against disease and illness, glamorizing a life of “toil and discipline” in which nurses pledged loyalty to their physician leaders (Winslow, 1984). The primary goal of loyalty by nurses was to project and reinforce confidence in the health care enterprise. Nurses were explicitly taught that loyalty to the physician equated with faithfulness to the patient (Winslow, 1984). This was particularly important prior to the advent of penicillin and other modern therapies, when many infectious diseases could not be effectively treated and seeking medical care often made little difference in whether the patient’s condition improved or deteriorated.

The primacy of loyalty as a nursing ethic came under attack in 1929 in a most unusual place. In a hospital in Manila, The Philippines, a physician ordered a new graduate nurse, Lorenza Somera, to administer cocaine injections, instead of procaine injections, to a tonsillectomy patient (Winslow, 1984). Somera loyally carried out the physician’s order, resulting in the death of the patient. Although it was clear that the physician had erred in ordering the wrong medication, he was acquitted of all charges while Somera was found guilty of manslaughter for failing to question the orders of the physician (Winslow, 1984). The Somera case sparked worldwide protests from nurses and served to push nursing toward independent practice and accountability. It was also one of many events that led to a reconceptualization of the dominant nursing metaphor from loyalty to physicians to advocacy for patients (Winslow, 1984).

During the 1960s and 1970s, influenced by feminist and consumer-rights ideologies, nursing advocacy became the dominant metaphor for nursing (Hewitt, 2002; Mallik, 1998; Winslow, 1984). The concept of “nurse as advocate for the patient” recognized the inherently oppressive nature of patienthood, wherein the patient is vulnerable as a result of his or her illness and unable to care for himself or herself (Bu & Jezewski, 2007). Advocacy for the patient was thus framed as rejection of loyalty to the physician, freeing nurses to develop their own professional identity. Indeed, adoption of the patient advocate role occurred simultaneously with the professionalization of nursing (Porter, 1992; Shirley, 2007). As a construct for nursing practice, advocacy had the advantage of being seen as morally good for patients, as well as providing an opportunity for nursing to promote professional autonomy (Kosik, 1972; Winslow, 1984). Typical of the literature produced during this period, Kosik (1972) asserted that “nurses must serve as advocates,” arguing that:

Early forms of nursing advocacy borrowed heavily from legal models of advocacy and centered on consumerism and patients’ rights. Through this lens, the nurse acted as a guardian and intervened when these rights were threatened by the medical establishment (Bramlett, Gueldner, & Sowell, 1990; Mallik, 1997a; Mallik & Rafferty, 2000; Winslow, 1984). This form of advocacy was eventually codified in the ANA Code of Ethics in 1978, which proclaimed that:

The Canadian Nurses Code of Ethics also identifies areas where nurses must advocate on behalf of their patients. The Code provides in part that “nurses must intervene if others fail to respect the dignity of persons in care” and that “nurses must advocate for appropriate use of interventions in order to minimize unnecessary and unwanted procedures that may increase suffering” (Code of Ethics for Registered Nurses, 2002). The Canadian code also commands that nurses should “advocate for health and social conditions that allow persons to live and die with dignity” as well as “intervene if other participants in the health care delivery system fail to maintain their duty of confidentiality” (Code of Ethics for Registered Nurses, 2002).

Some U.S. state boards of nursing have codified, and thus mandated, nursing advocacy by including language in nurse practice acts that either explicitly or implicitly define an advocacy role. For example, the Indiana Nursing Practice Act defines Registered Nursing to include “advocating the provision of health care services through collaboration with or referral to other health professionals” (Indiana Nursing Practice Act, 2008).