© Springer International Publishing AG 2017P. Anne Scott (ed.)Key Concepts and Issues in Nursing Ethics10.1007/978-3-319-49250-6_8
8. The Nurse as Patient Advocate?
National University of Ireland Galway, Galway, Ireland
P. Anne Scott
The need to act as an advocate for the patient, as an important part of the nurse’s role in the 21st Century, appears to be taken for granted; this is especially the case in the nursing literature, and in the British, Irish and international nurseing practice contexts. However while some nurse scholars, nursing registration bodies, professional organisations, and many practising nurses seem quite happy with the rhetoric of ‘nurse as patient advocate’ this is not an uncontroversial stance. A number of authors have challenged both the basis for the claim that nurses should be patient advocates, and the possibility of such a role for nurses.
Given that claims to the advocacy role for nurses are continuing to appear both in our literature and in our codes of practice it seems relevant to ask what the notion of nurse advocacy means, and what are the relative strengths and weaknesses of claims for and against an advocacy role for nurses.
KeywordsAdvocacyNurse advocacyNursing roleCodes of practicePatient advocate
Two Case Studies
Alice, a 12 year old girl, is admitted to her local paediatric hospital with a history of “pins and needles” and loss of power in her right hand and right leg. Staff observation reveals apparent loss of power and sensation in the girl’s right hand and arm. She also has reduced sensation and power in her right leg which she tends to “drag” when she is encouraged to walk.
Following a number of examinations by various specialists, a battery of blood tests, X-rays and ultrasound, that required the removal of the brace from Alice’s teeth, the initial diagnosis of multiple sclerosis, followed by a variety of other neurological conditions, are ruled out and “functional disorder of unknown origin” is the working diagnosis.
Alice’s immediate family – 14 year old brother and parents – are very concerned, attentive, and visit regularly. Alice is frightened. She has no idea what is wrong with her or what is happening. The nurses pop into her room a few times a day – to make her bed, take her temperature and so on. The doctors come and go. The physio has also been to have look at her. The only person who really talks to her from the hospital is the really nice lady who brings the food. She recognised pretty quickly what Alice does and does not like to eat and saves Alice little treats and the peach yogurt that Alice loves. Alice feels home sick and no-one seemed to know when she will get home.
A middle aged man is admitted to the medical unit via the Emergency Department (ED) with severe dyspnoea, coughing and distress. The patient is 6 days post transurethral prostatectomy (TURP). His surgery and immediate post-operative period was uneventful and Mr. S was discharged home on the third post-operative day. Over the following days he becomes increasingly breathless and is referred by his GP to A&E as an emergency, The GP suspects that Mr. S has developed a pulmonary embolism (PE).
Following initial assessment in ED, Mr. S is given iv antibiotics, placed on oxygen via nasal catheters and eventually transferred to the medical ward to await a scan to confirm the initial diagnosis of PE. Mr. S is accompanied by his wife. Shortly after arrival on the ward Mr. S is admitted by a pleasant nurse and told that the doctor would be along to see him. As it is now 9.30 pm he will not be sent for the scan until tomorrow (Saturday).
Approximately 30 minutes later the Registrar arrives and following a cursory conversation and “look” at Mr. S the Registrar says that probably Mr. S has a “clot on your lung” and he will “put” Mr. S on warfarin. Mr. S’s elderly uncle, who lives in Scotland and who had been on warfarin for many years, has just been taken off Warfarin and put on a newer drug that his doctors said was more effective and had fewer side effects. Therefore in response to the Registrar’s comment that he will put Mr. S on Warfarin Mr. S and his wife ask what exactly the Warfarin is for and if there is not alternative, newer drugs with fewer side effects? The Registrar indicates again that Mr. S likely has a clot and that this needs to be treated. Mr. S and his wife explain that they just want more information about Warfarin and what the alternatives are. The Registrar says that this is fine, he will speak with the Consultant, and come back to Mr. S.
Sometime later the night nurse comes around and speaks to Mr. S as she is doing the nightly medicine round. She says “I hear you have refused medication”. Mr. S tries to explain that he has not refused medication he has simply asked for information on Warfarin and what the alternatives are. The following morning the Consultant comes to visit Mr. S. She has also been told that Mr. S has refused his medication…
25 years ago Allmark and Klarzynski (1992, p. 33) suggested that “The notion that nurses either are, or should be, patient advocates now seems to be part of the nursing cannon.” However, while some nurse scholars, for example Tomaschewski-Barlem et al. (2015), nursing registration bodies (Nursing and Midwifery Board of Ireland (NMBI) 2014), professional organisations (American Nurses Association (ANA) (2015), and many practising nurses seem quite happy with the rhetoric of ‘nurse as patient advocate’ this is not an uncontroversial stance. Many authors have challenged both the basis for the claim that nurses should be patient advocates and indeed the possibility of such a role for nurses (Allmark and Klarzynski 1992; Seedhouse 2000; Negarandeh et al. 2006).
Advocacy: Some Definitions
In order to begin to explore this notion of the nurse as patient advocate, and to assess the relative strengths and weaknesses of the arguments, it is useful to look at how the term ‘advocacy’ is used in the nursing literature.
In a seminal article on advocacy in nursing Curtain (1979, p. 2) distinguished her notion of advocacy in nursing from the legal concept.
The concept of advocacy implied here is not the concept implied by the patient rights movement, not the legal concept of advocacy, but a far more fundamental advocacy founded upon the simplest and most basic of premises … our common humanity.
Bandman and Bandman (2002, p. 23) states of nurse advocacy:
The nurse who understands the advocacy role promotes, protects and thereby advocates patient interests and rights in an effort to make them whole and well again.
This statement does not really enlighten us as to the meaning of advocacy in the nurse-patient context. It also raises the question, “Is there anything here particular to the nursing role?”
Seedhouse (2000) distinguishes between what he terms “the normal sense of advocacy” and “the nurse theorist sense of advocacy”. Seedhouse claims that
In everyday use advocacy is a simple notion. An advocate speaks on behalf of some other person (or persons)… On this sense an advocate supports people by taking their side directly.
An advocate in the normal sense cannot be impartial. She must take the part of the person for whom she is advocating. If she tries to take a balanced view, or advocates what she thinks, rather than what her client wants, then she is not advocating in the normal sense. … The nurse theorist sense of advocacy is considerably broader than the normal one…
In contrast to the normal sense, the nurse theorist understanding is that an advocate supports people by providing, or helping them obtain some of their basic human needs. Both the normal and the nurse theorist… agree that advocates support other people, but the nature of this support is different. On the normal sense the advocate says:
‘You’re not getting what you want, would you like me to back you up as you try to get it? … But on the nurse theorist sense the advocate says: ‘You have some fundamental problems. Let me sustain you as much as I possibly can’ (Seedhouse 2000, p. 16–17).
Seedhouse’s description of the ‘nurse theorist sense’ of advocacy seems in keeping with the notion of advocacy as expressed by theorists’ such as Curtain (1979), and bodies such as the NMC (2015), NMBI (2014) and ANA ( 2015). Conversely Seedhouse’s ‘normal sense’ of advocacy is in keeping with the definition of advocacy expressed by a number of authors such as Allmark and Klarzynski (1992) and by the Citizens Information Board, Ireland (CIB) (2015).
Advocacy is a means of empowering people by supporting them to assert their views and claim their entitlements and where necessary representing and negotiating on their behalf (CIB 2015, p. 1).
We appear to have two different conceptualisations of advocacy being expressed here. In order to decide which one is most reasonable one may be driven to ask “What is the core meaning of the concept ‘advocacy’?” According to Paley (1996) we can only come to a reasonable level of clarity regarding what ‘advocacy’ means if we locate the term within a particular theory. For example this might be a theory of nursing- or nursing interventions – or caring or patient need. If we accept that one of the foundations of nursing is the requirement to provide safe, humane, holistic, good quality care to our patients (Scott et al. 2014) then it seems important to ask what our patients may require, in terms of advocacy, from the nurse caring for them?
The Patient Experience
For the purposes of this chapter ‘patient’ is taken to refer to an individual hospitalised or in institutional care due to mental or physical illness or disabilities; people like Alice and Mr. S described in the case studies at the beginning of this chapter, for example. One might usefully ask ‘Why would such an individual need an advocate’? Why would a patient need support, information, or someone to speak up for him or her?
It seems that there are at least two possible reasons that a hospitalised patient might need someone to fulfil an advocacy role:
Illness is likely to cause an individual distress, increased vulnerability, and dependency. Knowledge deficits and / or institutional structures and processes may also mean that the capacity of the individual to make informed decisions regarding appropriate treatment is curtailed or undermined. These kinds of issues are clearly at play when one considers the types of situations Alice and Mr. S find themselves in.
A second reason that a patient may be perceived as requiring a patient advocate to work on his / her behalf, is the power imbalance within the practitioner – patient relationship; and the fear that this imbalance will result in an undermining of patient autonomy. The more powerful clinician, guided by the principle of beneficence (doing good / working in the patient’s best interests), may fail to recognise that the nature and content of ‘good’ may be understood differently from the practitioner and patient perspectives. There is increasing evidence that patients and practitioners may differ both in perceptions and priorities regarding patient care (Papastavrou et al. 2011). What a clinician perceives to be in the patient’s best interests, from a health perspective, may not be accepted by the patient as being in his / her overall best interests; something which a smoker or a mountain climber might readily accept for example. However, because of the power imbalance the patient’s voice may not be either sought or listened to. Thus the patient may have little ability to influence his / her care or treatment, unless he / she has recourse to a patient advocate. Again this power imbalance does seem to be a factor in both the scenarios describing Alice and Mr. S’s experience of hospitalisation. Alice is isolated, lonely, and home sick. There is no sense from the case study that any nurse has developed a relationship with her or is helping Alice understand what is planned for her care, discharge, and so on. Mr. S and his wife simply want information and a clear explanation regarding why Warfarin is the drug of choice in this case. Yet their entirely reasonable concerns are not being addressed – or are being misunderstood. Mr. S is being labelled as “refusing treatment”. Unintended intimidation can be the result of health care worker / patient encounters. Even the most outspoken and educated can be impacted by the “expert”. This is a particular concern when one considers that many patients in acute hospitals tend to be older, with lower levels of education. There is a clear risk that they lose their voice.
The need and right which both Alice and Mr. S have for information regarding their treatment and care is being ignored – as is their need and right to participate in decision-making about their care. Both information and being enabled to participate in choosing options and decisions regarding his / her care are key elements of respecting patient autonomy.1
It seems that the concerns regarding the lack of recognising and supporting patient autonomy expressed in the cases above, in combination with recent investigations and reports from both the Department of Health in England and Wales (Francis 2010) and the Irish Health Information and Quality Authority (HIQA 2015), give sufficient reasons to accept that the need for a patient advocate may be a reality, for at least some patients within the healthcare setting.