February 13th, 2012
By Jennifer Olin, BSN, RN
One of the many topics raised by the case of Arizona nurse Amanda Trujillo, her firing by Banner Health, and their subsequent complaint to the state’s Board of Nursing, is did she step out of bounds while advocating for her patient?
As I remember it, from day one of nursing school, it was ingrained in us that advocacy, particularly patient advocacy, is one of our most important nursing duties. I know that’s what I remember from all those years ago. Or is it?
So, I went to the sources; nursing textbooks. I still had my copy of Fundamentals of Nursing (Kozier & Erb, fifth edition) and I borrowed a friend’s textbook of the same title (Potter & Perry, sixth edition); and I asked an acquaintance who is currently in nursing school to look at her version of Fundamentals (Taylor et.al., seventh edition). In this very unscientific survey I found my memory was on point. In all three texts, from different years and different authors, nurse as patient advocate is found repeatedly in the first 100-200 pages (and these textbooks have over 1500 pages apiece).
An advocate is one who pleads the cause of another; and a patient advocate is an advocate for clients’ rights. In that role, the nurse protects the client’s human and legal rights and provides assistance in asserting those rights if the need arises. Advocacy may include, for example, providing additional information for a patient who is trying to decide whether or not to accept a treatment (Potter & Perry). This is a central theme in Trujillo’s case. Or, the nurse may defend a patient’s rights in a general way by speaking out against policies or action that might endanger their well-being or conflict with their rights.
According to nurse and attorney Mary Kohnke Wagner, in the American Journal of Nursing article, The Nurse as Advocate, the actions of an advocate are to inform and support. An advocate informs clients of their rights in a particular situation, and provides them with the information needed to make an informed decision.
There are several steps involved in being an effective patient advocate:
An advocate must know how to provide support in an objective manner. They must be careful not to convey approval or disapproval of the client’s choices. Underlying patient advocacy are the beliefs that individual have the following rights:
Barriers to Nursing Advocacy
When we talk about coercion by others or those who do not wish the client to be informed we are talking to about just some of the barriers nurses can face when advocating for their patients. By analyzing the barriers to effective advocacy nurses can then develop strategies to manage those obstacles and maximize their advocacy efforts.
The most common attribute is conflict of interest between the nurse's responsibility to the patient and the nurse's duty to the institution where the nurse is employed. Other barriers include lack of support and lack of power. Threats of punishment are also considered an attribute of barriers to nursing advocacy, like being reprimanded, poor evaluations, and ultimately being fired. Finally, a historical barrier of nursing being a feminine profession with a tradition of subservience to the medical profession is also considered a barrier to nursing advocacy.
The implications for nursing practice are that nurses need to overcome barriers to become effective nursing advocates for their clients. That would be in an ideal situation however, the threat of job loss, retribution, intimidation, or ostracism are very real. Nurses need strategies to overcome barriers so that they can provide the best possible education and services for their patients.
Strategies for Overcoming Barriers
The biggest barrier most nurses face when acting as a patient advocate are institutional barriers. Every nurse must know the definition of their scope of practice in both their practice state, and their healthcare facility. How the nurse’s role is defined is different behind every door. Nurses may find little to no support in the advocacy role from administrators, physicians, and even nursing peers. Knowing the written rules will help be a more effective advocate.
Clear, effective communication will help overcome institutional barriers when in advocate mode. The nurse’s ideas and suggestions will be better received if spoken clearly and emotional reactions like anger and frustration are kept to a minimum. Body language counts. Every OR nurse knows even with the face almost completely covered the eyes can give away every secret. Leaning forward, pointing fingers, or crossing arms across the chest can all be viewed as hostile or confrontational.
Language, both spoken and written, makes a difference in the effectiveness of client advocacy, as well. Keep the focus on the patient. Document everything. If you have an interaction with the patient and they express a strong opinion, for or against a treatment option or plan of care, make sure you put it in your nurse’s notes and put a copy on the front of the chart for all to see or make a point of discussing with a nurse manager or the physician so everyone is aware of the patient’s concerns.
Knowing where your professional organizations stand on the subject of advocacy can also be helpful but don’t count on that holding any real weight if a conflict arises. Learn your employer’s administrative structure, what committees might support your advocacy track and talk to your peers; they may have dealt with similar situations and be able to provide practical advice.
Nursing education has an important role in teaching student nurses about the role of client advocacy in nursing and how to effectively manage the barriers to be successful advocate. At the institutional level, find a mentor or preceptor who has a strong record as a patient advocate to help understand and navigate the process.
Nurse as advocate falls under the heading of “professional responsibilities and roles” in all those nursing textbooks I surveyed. Nursing has claimed client advocacy as an important core component of nursing practice. Nurses who function responsibly as advocates for themselves, their clients, and the community must have an objective understanding of the ethical issues in health care as well as knowledge of the laws and regulations that affect nursing practice and public health.
As nurses we should be able to support a patient’s healthcare experience through advocacy for the patient without worrying about how our institutions, organizations, administrators, physicians, managers and peers will see our efforts. We should not have to worry about reprimands or retribution when doing the job we are, in fact, trained and taught to do. Keeping open lines of communication, forming relationships with other members of the healthcare team, and being very aware of the rules of practice should make the advocacy role easier. However, as Amanda Trujillo, RN, has experienced there still are no guarantees.