“I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane men and women; of beings sunk to a condition from which the unconcerned world would start with real horror.”
Nurses have a long history of advocating on behalf of and alongside patients, families, and communities to promote health, equality, and justice. Nursing is widely respected for effective professional advocacy that has expanded the professional role of the registered nurse and created safer working conditions for nurses. Florence Nightingale’s revolutionary advocacy around the environment of care and Margaret Sanger’s pursuit of reproductive freedom for women exemplify nursing advocacy.
Despite a history rooted in speaking for and working on behalf of the most vulnerable among us, nursing’s relationship with advocacy is complicated. Perhaps this is because the profession was for many years defined by loyalty to others—namely to physicians and hospitals—and not to patients. Echoes of this tension reverberate today, as nurses are routinely challenged as they navigate between loyalty to physicians and hospitals, and advocacy on behalf of patients, families, and communities. Complicating matters, nursing schools and institutions do not necessarily prepare students to serve as advocates. Many nurses find the idea of advocacy on behalf of patients (and even themselves) to be daunting. The nursing profession has also sent mixed signals about the value of advocacy, and there has been scant research into what exactly nursing advocacy looks like.
This is a chapter about advocacy at the individual, community, and system levels—and advocacy’s relationship to policy. Because this is a chapter about advocacy, this is also a chapter about nursing. Although nursing’s relationship with advocacy deserves refinement, nursing practice is rooted in advocacy on behalf of and alongside those who are sick, vulnerable, and in need of care.
The Definition of Advocacy
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.
The Nurse as Patient Advocate
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).
Consumerism, Feminism, and Professionalization of Nursing: The Emergence of Patients’ Rights Advocacy
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:
[N]ursing cannot afford not to allow nurses to become patient advocates. Advocacy is where the action is. Through patient advocacy we can all begin to address ourselves to the real issues of the day. Patient advocacy is our hope for the future. (Kosik, 1972, p. 698)
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:
[I]n the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, or illegal practice(s) by any member of the health care team or the health care system itself, or any action on the part of others that is prejudicial to the client’s best interests. (Bernal, 1992, p. 18)
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).
Philosophical Models of Nursing Advocacy
While patients’ rights advocacy formed the basis of nursing advocacy and remains the dominant conception of nursing advocacy, nursing theorists have advanced competing conceptualizations of advocacy that seek to define a unique nursing advocacy. Sally Gadow advanced an “existential advocacy” whereby the nurse’s role is to help patients clarify their values and the illness experience, and exercise their right to self-determination (Gadow, 1983). The premise underlying existential advocacy was that nurses are uniquely situated to advocate for patients, because they frequently spend the most time with patients and have an intimate connection with patients and their families. She also viewed advocacy as a moral imperative, with the ultimate goal being to increase patient autonomy (Hanks, 2005).
Writing during the same period as Gadow, Curtin (1979) sought to situate nursing advocacy as “human advocacy.” Curtin invited nurses to help patients identify meaning and purpose in their illness with the ultimate goal of enhancing patient autonomy (Curtin, 1979; Mallik, 1997a).
Occupying something of a middle ground between patients’ rights advocacy and the philosophical advocacies of Gadow and Curtin (1979), Kohnke developed a model of functional advocacy that called nurses to serve as brokers of information and supporters of patient decision making (Kohnke, 1978, 1980). Like the other models, Kohnke assumed that patients were in need of advocacy so they could be freed of oppression by the medical structure. More than any other theorist of the time, Kohnke expressly suggested that physicians persecuted patients (whom she calls victims) through their “we know best” attitude (Kohnke, 1980). An illustration appearing with her work in the American Journal of Nursing (AJN) depicts the physician as a puppet-master manipulating a helpless patient, with the nurse as a “rescuer,” attacking the physician with the banner of health (Kohnke, 1980).
While nursing advocacy has been widely internalized as a core professional value by many nurses, critics have questioned the utility of nursing advocacy as a framework for practice and have argued that few nurses are actually engaged in advocacy activities. Several critics have questioned whether or not nurses have the capacity to serve as advocates, noting that many nurses lack the institutional and personal power required to advocate for patients’ rights (Bernal, 1992; Grace, 2001; Hanks, 2007; Hewitt, 2002; Mackereth, 1995; G. W. Martin, 1998). Hewitt (2002) points out that “for the nurse to be in a position to empower patients, it is necessary for the nurse to be first empowered” (p. 444).
While it is well understood that the oppressive nature of the medical establishment impairs patient autonomy, it is less clear why nurses view themselves as well suited to act as patient advocates (Mallik, 1997b; G. W. Martin, 1998; Negarandeh, Oskouie, Ahmadi, & Nikravesh, 2008; O’Connor & Kelly, 2005). One central theme in the nursing advocacy literature is that nurses are uniquely situated to serve as patient advocates because they spend the most time with patients and have the most influence over the patient’s experience while the patient is hospitalized or ill (Bu & Jezewski, 2007; Curtin, 1979; Hanks, 2007; G. W. Martin, 1998; Schroeter, 2002, 2007). The intimacy of nursing care has been suggested as the mechanism by which nurses are able to engage in existential advocacy behaviors (i.e., empowerment advocacy) (Curtin, 1979). In a study of nursing elite in the United Kingdom, Mallik (1998) found that nursing leaders viewed the intimate nursing relationship with suspicion. One subject in her study stated:
[T]his complete “under the skin oneness” is a piece of impertinence really. I mean somebody who has 55 years of history behind them walks through the door and suddenly you are their best friend and you know everything there is to know about them, it’s a bit beyond the pale. (Mallik, 1998, p. 1005)