What Exactly Is Patient Advocacy?

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February 13th, 2012

By , 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).

Advocate

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:

  1. Make sure the client agrees to receiving the information.
  2. Either have the necessary information or know how to get it.
  3. Want the client to have the information.
  4. Present the information in a way that is meaningful to the client.
  5. Accept the fact that there may be those who do not wish the client to be informed.

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:

  • The right to select values they deem necessary to sustain their lives.
  • The right to decide which course of action will best achieve the chosen values.
  • The right to dispose of values in any way they choose without coercion by others.

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.

5 Responses to “What Exactly Is Patient Advocacy?”

  1. Carol Gino Says:

    I think this was a terrific article. It contains many of the nuances of nursing practice as well as the traps to that same practice. Still, in order for us to be able to function as professionals, we need to have a standardized scope of practice provided by an organization that has grown and redefined themselves in the same way nurses are being asked to raise their educational standards to get an BS to be an RN. Without direct pay, we will always be at the mercy of the corporations we work for, and no matter what our ability or education, we will always be at risk of intimidation and the real threat of punishment. Before our organizations can ask more of us, we must ask more of them for professional nursing to survive.

  2. Nancy Wilson Says:

    We need total reform of the nursing profession so that we truly are professionals and not lackeys that simply work for others that abuse us. Time to stand up and fight to be real professionals.

  3. Andrew Lopez, RN Says:

    Thank you Jennifer Olin for covering Amanda’s case, here is the latest:

    The War Against Amanda Trujillo, April 25, 2012, Mother Jones, RN, Nurse Ratched’s Place:”I still support Amanda Trujillo and some people who have read the allegations against Amanda have questioned my judgment. Frankly, I don’t believe these allegations because I personally know two other nurses who have been reported to their nursing boards by their former employers. One of my friends was reported to the BON after she spoke up about unsafe nursing practices at a shady nursing home, and the other was reported after he chastised hospital administration for placing psychiatric patients and staff in an unsafe environment. Their former employers cooked up all kinds of false allegations against my friends who are both stellar nurses. Their former employers crucified their character, but in the end they were both cleared of any wrongdoing by their respective state nursing boards. There is an escalating pattern of abuse as more unscrupulous employers are using nursing boards as the ultimate scare tactic to keep nurses “in their place. ” Amanda is just another victim of this ploy.”
    http://www.nurseratchedsplace.com/2012/04/the-war-against-amanda-trujillo/

  4. Andrew Lopez, RN Says:

    Thank you Jennifer for following Amanda’s case, this is from TruthAboutNursing.org

    Fired for educating a patient? TruthAboutNursing.org, May 2012:”On February 1, the Phoenix CBS affiliate KPHO-TV ran a short but good item by Peter Busch about veteran local nurse Amanda Trujillo, who said she had been fired by Banner Del Webb Hospital and had a complaint filed against her with the state board of nursing because she had educated a patient about the risks of an upcoming surgery and scheduled a consult about hospice. A hospital spokesman reportedly said that “the doctor, ultimately, is the focal point that directs care for patients” and that “company policy” forbids nurses to order a case management consult. The report does not mention other accounts suggesting that these events were set in motion because the patient’s surgeon was displeased that the patient had decided against the surgery.”
    http://www.truthaboutnursing.org/news/2012/may/trujillo.html

  5. suki Says:

    Where is Amanda’s case at this time? I cannot seem to find anything out about it. The problem continues widespread throughout the valley. Nurses continue to be bullied, threatened for merely speaking up for their patients. As employees we all must sign that we fully understand what Corporate Compliance is at our respective facilities. However, it is a smokescreen. Nothing is done with the information we report to the Compliance officer. Or rather until they figure out who did the anonymous reporting. Then you will be dealt with. Generally harassed and then fired.

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