THE LIVED EXPERIENCE OF NURSING ADVOCACY Robert G Hanks Key words: nursing; nursing advocacy; patients; qualitative research Nursing advocacy for patients is considered to be an essential component of nursing practice. This phenomenological qualitative pilot study explored registered nurses’ lived experience of nursing advocacy with patients using a sample of three medical-surgical registered nurses. The guiding research questions were: (1) how do registered nurses practicing in the medical-surgical specialty area describe their experiences with nursing advocacy for their patients; and (2) what reflections on educational preparation for their professional roles do registered nurses identify as related to their practices of nursing advocacy with their patients? Data analysis procedures were based on Moustakas’ data analysis method, and Lincoln and Guba’s criteria were applied for rigor. The emergent themes were: speaking out and speaking for patients; being compelled to act on unmet needs of patients; fulfillment and frustration; the patient is changed; primarily learned on the job; and confidence gained through practice. The findings increase the body of knowledge surrounding nursing advocacy as practiced by nurses.

Introduction Nurses in practice, education and research agree that nursing advocacy for patients, referred to as nursing advocacy in this article, is an important nursing function.1,2 The American Nurses Association Code of Ethics reflects its commitment to advocacy for patients in all settings and under all conditions.3 Nursing advocacy is a relatively new, overtly practiced role for nurses, emerging in the USA in the 1980s.4 Over the last quarter century, researchers and practitioners alike have tried to discover and employ a better understanding of this phenomenon; however, there is ambiguity about what nursing advocacy means and how it is practiced and taught. An exhaustive review of the literature conducted during the preparation of this study revealed that basic descriptive research that aims to build knowledge about nursing advocacy and describe how practicing nurses experience it still needs to be carried out. Qualitative research methods are best suited to capturing and describing the essence and meaning of nursing advocacy from the perspective of

Address for correspondence: Robert G Hanks, The University of Texas at Arlington, School of Nursing, Box 19407, Arlington, TX 76019, USA. Tel: ⫹1 817 2722776 ext. 24867; Fax: ⫹1 817 2725006; Email: [email protected]

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nurses who know the phenomenon of nursing advocacy. The findings from this study contribute to building shared meanings of nursing advocacy among the nursing profession.

Study aim The purpose of this qualitative pilot study was to describe the lived experiences of nursing advocacy as practiced by registered nurses. A phenomenological perspective was employed to answer the following research questions:

• How do registered nurses practicing in the medical-surgical specialty area describe their experiences with nursing advocacy for their patients?

• What reflections upon educational preparation for their professional roles do registered nurses identify as related to their practice of nursing advocacy with patients?

Background and significance Since the beginning of the patient advocate movement in the 1970s,5 nursing has been viewed as the ideal profession to practice advocacy on behalf of its clients,1 primarily because of the intimate nature of the relationships nurses have with their patients. The main act of advocating is often viewed as an integral component of nursing ethics whereby the actions of the nurse support the autonomy of the patient.6 Given that nursing advocacy emerged as an overtly recognized component of nursing practice in the 1980s4 and is still a relatively new role for nursing, it stands to reason that ongoing research can effectively add to and refine knowledge about its meaning, practice and patient-focused outcomes. The studies about nursing advocacy reported in the literature employ both qualitative and quantitative methods. A synthesis of the nursing advocacy literature suggests that four areas of knowledge about the phenomenon have been identified and continue to be researched. They are: (1) teaching, education, and learning; (2) influencing factors; (3) components of nursing advocacy; and (4) consequences of nursing advocacy.

Teaching, education and learning Descriptions of teaching, education and learning about nursing advocacy were found in several studies. Altun and Ersoy7 showed that the teaching of nursing ethics is one effective means of promoting the development of nursing advocacy behaviors and role competencies in nursing students. Another research team found that the level of education attained by practicing nurses influenced their perceived assertiveness, an attribute believed to be linked to nursing advocacy competencies.8 Pankratz and Pankratz9 reported similar findings in that nurses with higher levels of education also scored higher on an autonomy scale, leading the researchers to suggest that higher educational attainment can be a liberating force that facilitates the practice of

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nursing advocacy. Additionally, the study indicated that specialization in nursing was positively associated with higher autonomy scores.9 Perry’s10 study also supported this concept with a finding of positive correlation between autonomy and highest degree held. Findings from a qualitative study by Mallik11 suggest that acting as an advocate may be dependent on a nurse’s educational level. There is controversy within the nursing profession about whether or not nursing advocacy can be taught. Foley et al.12 found that nurses learned advocacy by observing other nurses acting as advocates. Other researchers reported that teaching nursing advocacy is an important means by which students learn the role13 and that education about clinical knowledge, managed care and resource management necessarily includes the salient aspects of nursing advocacy for use in practice.14

Components and influencing factors Several influencing forces affect the nursing advocacy process. Characteristics of the nurse are cited in studies as one of the more important factors in nursing advocacy.15,16 Self-concept, values, confidence and beliefs comprise the emotional components of the nurse advocate.10,12,13 Emotional and moral distress caused nurses to advocate for clients in certain studies,15,17–19 as well as moral obligation.20 Additionally, vulnerable clients have been found to be a causative factor in nurse advocacy by several authors.21–23 The work setting is also cited as a factor in nursing advocacy. Two studies cited physician support or behavior as a component of nursing advocacy actions.13,14 The work environment also contributes to how nursing advocacy is practiced.8,11,13,15 The behaviors most frequently cited as evidence that nursing advocacy is being practiced on behalf of patients include acting as the patient’s voice,24 protecting the patient24 and bridging the gap between the patient and others.22 Empowerment of patients is cited by two groups of researchers as being analogous to the essentials of nursing advocacy.13,25 Additional components of nursing advocacy include relationship building14,25,26 and improving communication.21 Other aspects that are cited in research studies as components of nurse advocacy include the concepts of caring,16,27 respect28 and conviction;23 that is, to be an effective advocate, the nurse must have a sense of caring, respect and conviction for the patient’s welfare.

Consequences of nursing advocacy The consequences of nursing advocacy can be a career dilemma for nurses. Some authors discuss the practice of nursing advocacy as a form of risk taking11 that can result in frustration14,21 and anger.21 In the working environment, nurses can experience punishment and lowering of status, such as a demotion in the institutional hierarchy,21,23 and being labeled by peers as an instigator, troublemaker or whistleblower.16 The act of advocating for patients can result in disruption of relationships in the working environment: with peers, other health care workers and institutional administration.16 Although nursing advocacy is practiced in all nursing specialties, relevant research involving medical-surgical nurses is scarce. Among the studies reviewed, only three

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have samples that are exclusive to medical-surgical nursing, indicating a paucity of qualitative research studies of nursing advocacy using this population.23,26,28 The results of this study may therefore make a contribution to narrowing the gap in knowledge among this group and about the phenomenon of advocacy.

Method Design This pilot study used a phenomenological inquiry method that is particularly suited to describing the lived experiences of several individuals regarding a particular phenomenon.29 Phenomenology traces its foundation to the philosophical perspectives of Husserl and the methodology has been used extensively by researchers in sociology, psychology and nursing.30 This study used transcendental phenomenology as outlined by Moustakas, in which preconceptions are bracketed out and the analysis results in a structural description of experiences.30 Phenomenology is especially suited to understanding the essence of experiences involving advocacy in this particular study, which aimed to reveal the participants’ lived experiences with nursing advocacy and their views on the roles nursing education plays in the preparation of nurse advocates.31

Setting and sample The study participants, renamed Jane, Pam and Kay to protect their anonymity, were purposively recruited from the population of practicing professional medical-surgical nurses at a large university medical center in southwest USA. The three eligible and consenting participants were enrolled in this institutional review board approved study. Inclusion criteria were: (1) one year of full-time experience in the medicalsurgical specialty area working as a registered professional staff nurse; (2) experience of practicing nursing advocacy for a patient in the workplace setting; and (3) legally recognized as a registered professional nurse.

Data collection The data collection methods for each participant included a 90-minute semistructured interview and completion of a one-page biodemographic profile. After each participant had signed an informed consent form, the interviews were conducted by the researcher in settings of the participants’ choice. Jane’s interview was conducted at her home, Pam’s at her work office, and Kay’s in the researcher’s work office. The interviews were conducted at times when the researcher and the participant were alone in the building or house, with the doors securely closed to prevent the interview being overheard. Each audio-taped interview was transcribed by a trained transciptionist and the content was verified by the researcher for accuracy. The following statements were used as an interview guide:

• Tell me about an experience you have had where you felt you advocated for a patient in the workplace setting. Nursing Ethics 2008 15 (4)

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• Tell me about your nursing education experiences that prepared you to be a nursing advocate.

• Talk about what it is like for you to act as a patient advocate in your practice of nursing.

Data analysis In the first step in this analysis, the researcher wrote a full description of his own experiences with nursing advocacy. According to Moustakas, the personal history of the researcher illuminates the core of the problem (in this particular case, nursing advocacy experiences) and allows for bracketing of preconceptions by the researcher.30 Analysis of the interview transcripts began as the transcripts were received from the transcriptionist, using the method described by Moustakas.30 The transcripts from the interviews were then analyzed for statements about the participants’ experiences with nursing advocacy. These statements were listed to develop non-repetitive, non-overlapping lists.29 They were then grouped into units (labeled meaning units) with a textual description of the experience for each of the meaning units.29 The researcher’s own descriptions of nursing advocacy, together with the transcripts, were examined for all possible meanings of how nursing advocacy is experienced.30 Finally, a written description of the meaning and essence of the experience was developed.31

Rigor Rigor was measured against the following four criteria: (1) credibility; (2) dependability; (3) confirmability; and (4) transferability.29 The criterion of credibility was met by using faithful descriptions and interpretations of the participants’ experiences. In addition, the participants were allowed to verify their own experiences and interpretations.32 Dependability was maintained by an external reviewer being able to reach the same conclusions using the raw study data and analytical documents.31 Confirmability was supported by maintaining a verifiable audit trail of movement through the data, including field, interview and methodological notes. Confirmability was further supported by the external reviewer being able to arrive at the same conclusion with the same data set.31 The final criterion, transferability, will be measured by applying the findings to similar samples.32

Findings The findings from the demographic profiles and interviews revealed that all three participants had strong backgrounds in medical-surgical nursing. Jane, age 51, had the most extensive experience in nursing with 27 years, including 16 in the medicalsurgical specialty. Jane’s highest degree was a PhD in nursing and she had decided to return to a staff nurse position after teaching medical-surgical nursing in the academic setting. Pam, age 31, had 8 years of experience, including 3.5 years in the medical-surgical specialty, and had earned a master’s degree in nursing. Kay had extensive full time experience in medical-surgical nursing. At age 47, Kay had 11 years of experience in the medical-surgical specialty, and a baccalaureate degree in nursing. Nursing Ethics 2008 15 (4)

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The following themes emerged from the three interview transcripts after analysis using the method outlined by Moustakas.30 The findings are presented in the order of the associated research questions, which related to the nurses’ experiences with nursing advocacy and their educational preparation for the advocacy role.

Nurses’ experiences with advocacy The first research question related to the lived experience of the medical-surgical nurse with the experience of advocacy. The following two themes emerged from the data and are supported by quotes from the transcripts. Speaking out and speaking for patients From the interviews, the theme of speaking out and speaking for patients was strongly emphasized by the study participants. Kay stated that ‘most nurses I work with, along with myself, feel that we should do what we need to do for the patients’ and that she was not inhibited from speaking out about a patient’s concern: ‘I do not have a problem speaking to the physicians, to the therapists, even to case managers … with concerns of the patient.’ Jane recalled that advocacy included speaking out for patients using a chain of command: ‘I had diligently worked through those, you know, positions and the chain of command that you’re supposed to work.’ Kay succinctly noted that nursing advocacy occurs when ‘I’m speakin’ for the patient’. Compelled to act on unmet needs of patients The participants felt compelled to act as nurse advocates based on unmet patients’ needs. Kay recalled an incident where ‘I got to meet her [patient’s family member] and she thanked me because they were going to send him [patient] to a nursing home and he ended up going to a rehab and doing better.’ Jane reflected on what compelled her to advocate: ‘All day it was like calling and calling and not really getting any responses.’ Pam was obliged to advocate when her patient was dying: ‘You could tell he was not comfortable with the fact that he was dying and he didn’t know what to do about it.’

Experiences with outcomes of advocacy The first research question concerning nurses’ experience with advocacy elicited the outcomes of the advocacy actions. Nurses experienced both fulfillment and frustration as outcomes of their advocacy, but additionally believed that patients had been changed by their nursing advocacy. Fulfillment and frustration The participants in this pilot study experienced both fulfillment and frustration with the nurse advocate role. Pam described the fulfillment she felt after being an advocate for a marginalized patient: ‘You know that you’ve done something, um, good for the patient, that you’ve helped them, and that you hope that it will make a positive difference in their life. It’s just very satisfying.’ She also stated that being a nurse advocate was ‘joyful’ to her. Kay stated that, after an act of advocacy: ‘I felt good because I knew he [the patient] had more potential to do more than he wanted to do.’ Nursing Ethics 2008 15 (4)

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The nurse advocacy role is not, however, without drawbacks. Jane called to mind an incident where advocacy was a frustration: ‘After I had diligently worked through those, you know, positions and the chain of command that you’re supposed to work without jumping anybody … um, you know, left me feeling very frustrated.’ Although this was a single finding of frustration in the three interviews, it may demonstrate a negative case of nursing advocacy outcome. Patient is changed Together with the theme of fulfillment and frustration with nursing advocacy actions goes the theme that the patient has been changed in a positive manner by the advocacy actions. Pam remembered seeing a change in a patient after her advocacy actions: ‘I was able to see him [patient] a couple of days later and, I mean it didn’t change his life, but he seemed like a different person and he felt … more at peace about it.’ Kay talked about an incident when she advocated and the patient had changed: ‘They were gonna send him to a nursing home and he ended up going to a rehab and doing better … and going back home.’

Educational preparation for advocacy role The second research question focused on the participants’ educational preparation for the nurse advocate role. This resulted in two main themes: (1) nursing advocacy learned on the job; and (2) additional experience with advocacy increased the participant’s confidence with the nurse advocate role. Primarily learned on the job From the data obtained, nursing advocacy appears to be learned after graduation from the initial entry level program. Pam described how she learned to be a nurse advocate: ‘I started out in orientation, as a new graduate, the preceptor that I was working with was, um, amazing. She was the ultimate patient advocate, and I think that, through her role modeling, I saw how she was with patients.’ Jane reflected: ‘In my program … there was not a defined role of the nurse being an advocate.’ Kay stated that her advocacy skills were ‘self-taught … because of my background coming in as nurse assistant and also growing up in a poor family.’ Confidence gained through practice Confidence through practice in being a nurse advocate was an additional theme regarding the education of nurse advocates. Pam described that her confidence increased and that: ‘Advocacy was learned … from my work and practice experiences. I think that I didn’t get a lot of it … when I was in school as an undergraduate, because I didn’t get any of that from school.’

Discussion This is the first pilot study of a sample of exclusively medical-surgical nurses located in the USA. Although similar findings have been found in the literature, it is premature to state strong similarities between results from previously published Nursing Ethics 2008 15 (4)

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studies owing to the small sample size and differing nursing culture. However, common themes can be found in the literature that coincide with the findings of this pilot study. The identified theme of speaking out and speaking for patients as an experience of nursing advocacy is reflected in other research studies. Foley et al.24 found nurses defining advocacy as acting as patients’ voice. O’Connor and Kelly22 reported that nurses felt that by providing communication they were bridging the gap between patients and others in the environment: a similar concept to speaking for patients. The nurses in this study felt compelled to act on the unmet needs of patients as part of the nursing advocacy experience. This echoes a similar theme of nursing advocacy, that of intervening on behalf of patients.13 Other studies have shown that emotional and moral distress caused nurses to advocate for patients,15,16,18,19 as did moral obligation,17 although these stressors did not emerge in this pilot study. Vulnerable patients have been noted to be a causative factor in nurse advocacy.21–23 This mirrors the marginalized patient with unmet needs that the nurses in this study stated compelled them to advocacy. The body of research literature cites consequences of nursing advocacy, such as frustration11,14,21 and anger.21 Additionally, in the work environment, advocacy can be viewed as risk taking,11 and can result in punishment and lowering of rank in the institution.21,23 Nurses who advocate may be viewed as disrupting relationships within an institution,16 and can be labeled as instigators.16 Only Jane mentioned frustration with nursing advocacy actions; however, the other consequences of advocating found in the literature were not reflected in the interviews. This study revealed a full spectrum of consequences according to the participants’ experiences: Kay felt free to advocate without consequences, while Jane feared retribution for advocating. With regard to changing patients, there is a paucity of information in the literature about patients’ responses to nurse advocacy actions, but this study revealed that nursing advocacy can change patients’ attitudes and outcomes in a positive manner. This finding of nursing advocacy being learned on the job has been suggested by previous studies in which nurses learned advocacy by observing other nurse advocates.12 Supporting the need for education regarding advocacy in nursing programs, Altun and Ersoy7 found that teaching nursing ethics is effective in developing the role of patient advocate in nursing students. Many studies reflect that higher education leads to increased perceived assertiveness and to speculation that advocacy8 and acting as an advocate may be dependent on educational level.11 In the current study, Pam and Jane cited increased education as enhancing their ability to advocate for patients, although each admitted their basic nursing programs provided little relevant education.

Implications One of the main implications from this pilot study is that more descriptive studies are needed with larger samples from more nursing specialties. In this particular study the participants had extensive experience in the medical-surgical specialty and two participants had graduate degrees, which contrasts with nurses with less education and experience. The preliminary findings suggest that nursing advocacy education can be improved in basic nursing programs, which reflects the published Nursing Ethics 2008 15 (4)

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nursing advocacy literature. The study revealed that nursing advocacy is learned on the job after graduation from an initial professional nursing program. Using this finding can help to direct nursing education programs to provide a realistic view of nursing advocacy in the workplace and allow for both didactic and clinical experiences with nursing advocacy before graduation. In addition, the study showed that there is real patient benefit to nursing advocacy outcomes that could be included in the educational process for nursing students. Lastly, as captured in this study, nursing advocacy experiences can be both negative and positive events, which, for the beginning student, can be stressed as the realistic perspective of nursing advocacy in the workplace.

Acknowledgement The author wishes to thank Professor Judith Drew, University of Texas, Galveston, for helpful assistance in establishing dependability and confirmability of the data. Robert G Hanks, The University of Texas Medical Branch, Galveston, TX, USA.

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