SINCE THE DAYS of Florence Nightingale, patient advocacy has been an important nursing responsibility. Nightingale laid the foundation for patient advocacy by consistently insisting on quality of care, including a safe and clean environment, and basic human rights for all.1-4 Personal attributes of effective nurse advocates include professional competence, objectivity, flexibility, empathy, self-motivation, accountability, commitment, a sense of responsibility, and strong coping skills.5
The American Nurses Association (ANA) Code of Ethics for Nurses clearly identifies a professional nursing responsibility to protect the rights of patients.6 State nurse practice acts may also mandate that nurses act as patient advocates. Nurses must understand and comply with these professional guidelines.6,7 Blurred professional boundaries can be problematic in long-term nurse-patient relationships. Patient advocates must work to keep the relationship therapeutic and patient-centered.8
Despite a long history, the role of nurses as patient advocates is poorly understood.2,5 While patient advocacy extends to the broader social system, this article is limited to the advocacy responsibilities of nurses providing direct care through hospital and home-care organizations or of those self-employed as private patient advocates. See https://healthadvocatecode.org for more information on the role.9
The advocacy role, defined
Advocates defend patients' rights and interests and assure the safety of those who can't advocate for themselves. This includes patients who are children, unconscious, mentally ill, illiterate, uninformed, or intimidated and fearful of healthcare professionals.1,5
Advocates ensure that patients' autonomy and self-determination are respected. Serving as the link between patients and the healthcare system, they also contribute to the patient/family decision-making process and speak up when problems go unnoticed or when the patient or family can't or won't address them.2,5,7,10
While technology provides many benefits, it also poses technical, ethical, and communication issues.11 Many patients receive care at various places and from different providers with only brief contact with the professionals working with them. Care has shifted from hospitals to ambulatory care facilities, so patients and families bear more responsibility for their well-being. Many of them have trouble comprehending information, navigating the healthcare system, and making appropriate decisions.5,12,13
Patient advocacy extends to the patient's family and support system, who should be included in the patient's care if done in a positive way with the patient's consent. Nurse advocates support the patient's best interests while respecting the family's important role. They attend healthcare team meetings with the patient and family to clarify any communication problems and ensure information from the healthcare team is complete and correct.14
Advocates become facilitators when patients and family members need to discuss uncomfortable information or explore its implications. Nurses may sometimes need to advocate for patients against their families. With conflict, efforts should be made to find a common goal. Communication should be assertive but not aggressive.6,14
The advocacy process can be complicated and require in-depth assessment and negotiation to develop a care plan in the patient's best interests.5,10,12
The advocacy process has four stages.
- First is the assessment of needs, which focuses on the patient, situation, setting, risks, and available healthcare resources.5 Establishing therapeutic relationships with patients is essential to understanding their interests and personal values, which includes what makes them unique and what they want and need from their healthcare providers. This requires nurses to assess the patient's level of awareness, cognitive function, and understanding of his or her patient rights.5,9
Many questions can be included in the needs assessment. Are the patients aware of their diagnoses, prognoses, and treatment options? Do they want a second opinion, or do they wish to refuse treatment? Do they want certain significant others involved in the decision-making process? What are their cultural and spiritual needs? Have their rights and choices regarding care been respected?5
- The second step is identifying the patients' specific goals. Most goals of patient advocacy are aimed at fostering partnerships between patients, families, and healthcare professionals while empowering patients in the decision-making process.5 Nurses may need to translate hospital policies and clinical information into layman's language as well.11 Nurses can provide information on the various options recommended by the healthcare team and help patients practice assertiveness in expressing their wishes.5
Advocates follow the patient's directives, not their own or the family's. Each patient is an individual with distinct needs; no single approach fits all.9,11 When patients are ambivalent or reluctant to explore options, motivational interviewing may help. Nurses using this technique don't impose their own opinions on the patient; rather, they elicit and explore the person's beliefs.15 When the nurse accepts a patient's informed choices, the patient gains a sense of control and improved self-image.5
- The third step is implementing the advocacy plan. Nurse advocates facilitate communication with all members of the healthcare team regarding the patient's preferences. They incorporate patient-identified goals into the plan of care and provide objective guidance. They support patients by negotiating and compromising when conflicts of interest arise, maintaining safety and care coordination throughout the entire course of the illness.5,11
- In the fourth step, nurse advocates evaluate the outcome of their advocacy behaviors. The ANA Scope and Standards of Practice suggest evaluations be criterion-based, systematic, ongoing, and focused on the attainment of expected outcomes. These evaluations should include the patient, the family, his or her caregivers, and other members of the healthcare team.6,16
Advocacy in organizational settings
The healthcare organization's commitment to promoting nurse-patient advocacy is of utmost importance. Healthcare administrators must maintain an effective and efficient chain of command. Clinical nurses need to know where to report concerns and how to access the chain of command. They must be assured that they have the support of their supervisors and others in leadership roles.5,7
Without this support in place, as in organizations lacking a shared decision-making process, nurses may have limited opportunities to advocate proactively. Nurses who defend patients' interests may be labeled troublemakers, and their advocacy may be seen as disrespect or disloyalty to coworkers. Feelings of anger and helplessness may emerge, causing a lack of motivation and fear of retaliation.5,7
Another barrier is inadequate staffing, leaving insufficient time for advocacy activities. Nurse advocates may be unsure how to address an issue, lack knowledge about established advocacy processes, or display weak assertive communication skills.7,17
Organizations can promote patient advocacy from within. Experienced nurses can mentor those less comfortable with the role.
Working with physicians as colleagues instead of an authoritarian presence is another important strategy. All nurses are responsible to keep patients safe and participate in organizational advocacy improvement efforts. Continuing-education programs will broaden the nurse's perspective here.1,7
Private independent patient advocacy
Private independent patient advocacy is a fast-growing profession, one very suitable to nurses. These independent professionals are usually paid directly by the patient or family. Private patient advocacy is an upcoming business model. Nurses are prime candidates for this role because of their professional training and focus on quality patient care.18
Information is available for those who want to enter the practice. Educational resources can be found at www.patientadvocatetraining.com and http://cmsa.org.
Written service contracts with patients and families are important considerations. Areas to cover include the expectations of both parties with clear delineation of duties, written releases allowing access to medical records, physician and patient consents, and payment structure.19
Patients can experience adverse outcomes and other problems can occur. Therefore, purchasing quality malpractice insurance is a must to protect nurses from possible legal action. It's relatively inexpensive and available through many professional organizations. Documenting all interventions in writing, including communications with physicians and other healthcare providers, is a must.20,21
Be cautious about transporting clients in one's personal car, which can be a legal risk. Case managers need proof that their vehicles are legally licensed, liability insured, and well maintained. Private patient advocates should contact their insurance companies to ascertain if commercial auto insurance is needed. A written waiver from the client and family is another possibility.22
Private patient advocates provide in-depth personalized care to the patient and family throughout the treatment process. For example, they help patients select treatment options that best meet their needs—medically, financially, and practically—so they can comfortably navigate the healthcare system. Private patient advocates may also do research to ensure that patients are prepared, informed, and engaged in the treatment process and have a voice in their care. These advocates may provide hospital bed monitoring or accompany patients to healthcare appointments. In addition, they review and negotiate medical bills.23 Their purpose is threefold: providing quality care, preventing medical errors, and protecting patient rights.24
Independent case managers come from various professional disciplines.25 Certification isn't currently required for private patient advocates. However, the Patient Advocate Certification Board has developed a certification process to board-certify healthcare professionals working as case managers. Registration is now available for the 2018 exams; access information at https://pacboard.org. This certification adds to the nurse case manager's professional credibility.20
Membership in the Aging Life Care Organization, formerly the National Association of Geriatric Care Managers, is a resource for nurse case managers working with older adults. Membership in this group validates the geriatric care manager's education and expertise and is highly recommended.26
Private patient advocates work with case managers, who also coordinate care between the patient and the healthcare team. Although their roles overlap, case managers focus more on the clinical aspects of treatment and care plan implementation and may have less interest in tasks such as driving clients to medical appointments or being with them during a hospital stay. Both work with patients and families to coordinate services and refer patients to other disciplines and outside community resources, which is especially important for insurance and financial concerns and complex social problems, such as domestic violence.5,11,24
Supporting patient autonomy
At its best, advocacy is proactive behavior that improves or corrects a situation, rather than a report of something that's gone wrong.7 Assuring that patients maintain their autonomy in directing their healthcare is a challenging nursing role that takes moral courage as well as clinical skill and knowledge.11
Head to www.nursing2018.com for more information on motivational interviewing.
Motivational interviewing for patients with mood disorders
Motivational interviewing: A journey to improve health
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23. Alliance of Professional Health Advocates. An overview of the profession of patient advocacy. 2017. https://aphadvocates.org/profession-overview
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