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A holistic model of advocacy: factors that influence its use
ARTICLE IN PRESS Complementary Therapies in Nursing & Midwifery (2004) 10, 37–45
A holistic model of advocacy: factors that influence its use Sylvia M. Kubscha,*, Marsha J. Sternarda, Rebecca Hovarterb, Vicki Matzkec a
University of Wisconsin Green Bay, 2420 Nicolet Dr, Green Bay, WI 54311-7001, USA Family Practice Clinic, Chilton, WI, USA c Prevea Clinic, Green Bay, WI, USA b
KEYWORDS Advocacy; Model; Holism
Summary Although advocacy is embraced by nursing as an essential component of holistic philosophy, its scope is often limited in practice. In this article, a research study that examined the use of an expanded definition of advocacy is described. A link to the role of advocacy as a complementary therapy and in relation to facilitating the use of complementary therapies by patients is provided. Fifty-two registered nurses completed a researcher developed advocacy research instrument that assessed the use of moral–ethical, legal, political, spiritual, and substitutive advocacy along with various factors thought to influence the use of advocacy including moral development, perceived assertiveness, and perceived job security. An additional 40 RN-BSN students generated case studies of advocacy enacted in practice that were used as examples of the five categories of advocacy and to support the findings of the survey. Results indicated that moral–ethical advocacy was used more often than the other four categories. Moral stage development had a significant effect on substitutive advocacy but assertiveness and job security were not significant factors influencing any category of advocacy. r 2003 Elsevier Ltd. All rights reserved.
Introduction Nurses frequently refer to themselves as patient advocates when all they have done is call a physician, request a medication order, interpret patient needs, coordinate services, or provide information. This rather limited interpretation of the advocate reduces the importance of the role and relegates the advocate to nothing more than a ‘‘go-between’’. In contrast to this limited interpretation of the role, more comprehensive views of advocacy have been described in the literature.1–7 Presented as more than a mediator, the nurse is obligated to *Corresponding author. Tel.: þ 1-920-465-2205; fax: þ 1-920465-2854. E-mail address: [email protected] (S.M. Kubsch).
guard patient rights to competent and holistic care, preserve their values in decision-making, and protect self-determination. Curtin1 and Fowler2 propose a holistic view of advocacy expressed in five categories: moral– ethical, legal, political, spiritual, and substitutive. The purpose of this article is to describe the use of such a model of advocacy, designated the Holistic model of advocacy (HAM).
Literature review Different interpretations of advocacy were found in the literature. Millette8 differentiates bureaucratic, physician, and patient advocacy. Although nurse participants in Millette’s study ranked patient advocacy as a priority, their behavior reflected
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ARTICLE IN PRESS 38 physician or bureaucratic loyalty. Nelson4 found when the physician or bureaucracy is the prime decision-maker; the nurse advocate could be labeled a troublemaker. Pavlidis9 differentiated between workplace and patient advocacy. Workplace advocacy addresses staffing, safety, and employee competency, whereas patient advocacy involves an obligation to protect patients from harm. Foley et al.10 suggest that patient advocacy is critical for vulnerable groups such as the elderly, very young, institutionalized, imprisoned, and disabled populations. Several writers separate the concept of advocacy into components or classes of advocate activity. Rafael5 suggests advocacy includes human, existential, paternalistic, and consumer categories. Kohnke3 contends advocacy has the dimensions of self, client, and community. Curtin1 and Fowler2 propose categories of legal, moral–ethical, political, substitutive, and spiritual advocacy. Snowball7 identifies four foundations of advocacy as reactive/ proactive, therapeutic relationship, common knowledge, and cultural environment. Segesten6 depicts advocacy as a process of recognizing a trigger event, engaging in decision-making, acting out convictions, accepting additional work, and taking risks. Nelson4 proposes advocacy occurs within the roles of protector, mediator, and actor. The need for advocacy to assure consumers’ opportunity to use complementary therapies is discussed by Spencer and Jacobs11. The role of the health-care practitioner as advocate is to empower patients by providing information about and access to complementary and alternative medicine (CAM) therapies. As advocates for the patient, the health-care practitioner would review potential effects of CAM on symptoms as well as possible risks and benefits. An informed advocate would talk with patients about CAM treatment options as well as fears and anxieties associated with their use. Equipped with extensive information about CAM and access to practitioners of CAM, health-care practitioners can empower patients to take control of their health-care outcomes. Various nurse theorists define advocacy according to the nursing models they embrace. Watson12 believes effective advocacy is an essential component of nursing’s humanistic philosophy and requires a caring nurse/patient relationship. Gadow13 suggests advocacy occurs when patients are empowered to construct experiential meaning. Newman14 defines advocacy in terms of expanding consciousness and mutuality. Leininger15 promotes advocacy as a component of culturally congruent care.
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Several factors that could influence the use of advocacy were identified in the literature. Drew16 and Rushton17 reported a relationship between the nurses’ moral stage development and advocacy application. Evidence of an association between moral stage development and perceptions of advocacy was documented by Duckett et al.18 Mattiasson and Andersson19 found a positive correlation between education and advocacy. Maher and Myatt20 asserted knowledge of female health is a significant factor in advocacy for perimenopausal women. Ingram21 reported nurses who attend ethics courses engage more advocacy situations, have a greater influence, and more effectively resolve ethical conflicts. Personality attributes such as self-confidence, assertiveness, and maturity were found to influence advocacy application.17,22 Other aspects that affect the use of advocacy were age, gender, and job security. Rankin and Esteves23 found an inverse relationship between age and ethical misconduct. Duckett et al.18 reported women scored lower than men in moral reasoning tests but scored higher in application of moral reasoning to case studies. Problems related to job security and management conflicts were cited as barriers to nursing advocacy by Sellin.22 Mackereth28 contended workplace antagonism resulted in lack of advocacy for diverse cultural groups. Drew16 argued dissatisfaction with the health-care system motivated nurses to speak out and positively affected the advocacy role. The literature indicates the need for a more comprehensive understanding of the advocacy role as a holistic therapy. In the literature it is found that advocacy is embraced by nursing as an essential component of practice, is based on nursing theory, is systematically implemented, and is influenced by several factors. Gaps in the literature include the nurses’ perception of advocacy, insight into the use of advocacy as a complementary therapy, congruency between the nurses’ actions and patient expectations, advocacy needs among special populations, and documentation of success in resolving problems/dilemmas.25
Conceptual framework Because of its potential influence on the advocate role, Kohlberg’s26 theory of Moral Stage Development was selected to be the conceptual framework of this study. The theory presents three levels of moral development. A nurse functioning at the first pre-conventional level implements advocacy to avoid punishment. At the second conventional
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
level, the nurse uses advocacy because it is the ‘‘law’’ or policy and leads to approval by others. At the third post-conventional level the nurse engages the advocacy role for the good of humanity and acts autonomously as a risk-taker/role-breaker in supporting social justice. As an additional part of the conceptual framework, the authors designed the HAM that suggests five types of advocacy. The categories of advocacy contained in the model are defined as follows: Legal advocate
Moral–ethical advocate
Political advocate
Spiritual advocate
Substitutive advocate
The nurse guards the patient’s rights to competent care, to reject care, informed consent, and privacy. The nurse upholds the patient’s values in decision-making. The nurse facilitates equal access to health care. The nurse provides access to spiritual support and reassurance. The nurse protects the interests of patients who are incapable of speaking for themselves.1,2
To guide this research study the following research questions were used: (a) what is the extent of use of the total HAM and its five categories of legal, moral–ethical, political, spiritual, and substitutive advocacy in nursing practice? (b) Is there a relationship between perceived moral stage development and the use of the HAM? (c) Is there a relationship between perceived job security, perceived assertiveness, and the use of the HAM? (d) Is there a difference in the extent of use of the HAM according to the nurses’ age, level of education, and work setting? It is anticipated that analysis of this model will raise awareness of the comprehensive nature of advocacy.
Research design This study was based on descriptive, correlational, and case study designs to discover the use of the CFCAM and its five categories of advocacy. The relationships of moral stage development, assertiveness, and job security to the HAM were also explored. The effect of demographics was determined by comparing nurses grouped according to age, educational level, and work setting.
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In addition to data collected by the quantitative research instrument, 40 empirical case studies of advocacy were submitted by RN-BSN students enrolled in an on-line nursing theory course. As part of a professional roles analysis assignment, students were instructed to write about an advocacy intervention used by themselves or witnessed in clinical practice. No guidelines about which category of advocacy to write about were provided. After review of the 40 case studies, the researchers assigned the case studies to one of the five categories of advocacy.
Research instrument A research instrument, developed by the investigators, contained four Likert Scales that measured frequency of advocacy interventions, perceived job security, perceived assertiveness, and moral stage development. The Advocacy Scale consisted of five statements that considered performance within each category of advocacy over the prior month/ week/day. It ranged from rarely (one point) to several times a day (five points). The Perceived Moral Stage Development Scale contained 13 questions based on Kohlberg’s26 theory of moral stage development. The possible range of scores was 13 (low) to 75 (high) level of moral stage development. The perceived level of Job Security Scale contained one Likert-scaled item measuring the nurses’ sense of job security. Scores ranged from one (least) to five (most). The Perceived Assertiveness Scale used three Likert Scale items to measure the subject’s assertiveness in the workplace, home, and social setting. The possible range of scores were three (least) to 15 (most). The demographic section of the research instrument assessed subjects’ education level, age, gender, and work setting. To determine validity of the quantitative research instrument, an ethics professor, a physician, and a nurse manager reviewed the Advocacy and Moral Stage Development Scales for inclusiveness. Changes were made based on their expert recommendations. Reliability was determined using the test–retest method with a sample of 15 registered nurses. A Pearson r ¼ 0:89 was achieved.
Data collection and informed consent The quantitative component of the study took place in a Midwest state of the United States of America. The research instrument was hand-delivered to potential subjects in four different work settings who were provided with a consent form
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Table 1
Measures of central tendency.
Variable
Mean
SD
Possible range
n
Total HAM Political advocacy Legal advocacy Moral–ethical advocacy Substitutive advocacy Spiritual advocacy Perceived job security level Perceived assertiveness level Perceived moral stage development
12.94 2.00 2.60 2.83 2.79 2.72 4.06 11.17 62.46
4.65 1.22 1.29 1.34 1.32 0.97 0.96 1.83 14.42
5–25 1–5 1–5 1–5 1–5 1–5 1–5 7–15 31–94
52 52 52 52 52 52 52 52 52
that explained the purpose of the study, potential risks, and possible benefits. Those expressing a willingness to participate in the study received the research instrument and a stamped return envelope. Consent to participate was implied by returning the completed research instrument via surface mail. The case study component of the study took place in the virtual classroom of the Theoretical Foundations in Nursing course. Students completing the on-line course resided in 20 different states of the United States of America. All RN-BSN students who submitted advocacy case studies were provided with an electronic version of an informed consent. The 40 students agreed to participate under the condition of patient and nurse anonymity.
Results Sample The sample consisted of 52 nurses from four different health-care settings. Twenty-two worked in acute care, 20 in long-term care, eight in home health, and two in public health. Fifteen subjects held associate degrees in nursing, nine had diplomas, 25 were BSNs, and two MSNs. The nurses’ ages ranged from 20 to 30 ðn ¼ 5Þ; 31 to 40 ðn ¼ 19Þ; 41 to 50 ðn ¼ 20Þ; 51-beyond ðn ¼ 6Þ; and unknown ðn ¼ 2Þ: An additional sample of 40 case studies of advocacy was posted on-line by RN-BSN students. They did not complete the quantitative survey. Five case studies were selected as best representations of each category of advocacy contained in the HAM. Measures of central tendency generated actual range of scores, mean scores, and standard deviations for the independent and dependent variables (Table 1). The mean score for total HAM (all five categories of advocacy combined) was 12.94 out of
a potential range 5–25, indicating that the HAM was not fully employed. Of the five categories of advocacy assessed, moral–ethical advocacy was used most often (mean ¼ 2.83, possible range 1–5). Substitutive advocacy (mean ¼ 2.79) was the next most common category followed by spiritual advocacy (mean ¼ 2.73), legal advocacy (mean ¼ 2.60), and political advocacy (mean ¼ 2.00). Perceived job security had a mean score of 4.06 (possible range 1–5). Perceived assertiveness had a mean score of 11.17 (possible range 3–15). Perceived moral stage development had a mean score of 62.46 (possible range 13–75). Analysis of variance was applied to examine the effect of nurses’ age, level of education, and work setting on use of the HAM, any of the five categories of advocacy, moral stage development, job security, and assertiveness. It was found that the age of the nurse made a significant difference in moral stage development (F ¼ 3:32; P ¼ 0:028). However, age had no effect on HAM use or any of the five categories of advocacy, job security, or assertiveness. Similarly, the nurses’ level of education had no significant effect on any of the variables except perceived assertiveness (F ¼ 3:16; P ¼ 0:03). Work setting significantly affected the use of moral– ethical advocacy (F ¼ 3:15; P ¼ 0:033), but it had no effect on the four remaining categories of advocacy or on the total use of HAM, job security, or assertiveness. The Pearson r statistic tested the relationships of moral stage development, job security, and assertiveness to the HAM and the five categories of advocacy. The relationship between the nurses perceived moral stage of development and the extent of use of the total HAM was not significant (r ¼ 0:2322; P ¼ 0:098). A significant relationship was found between moral stage development and the use of the category of substitutive advocacy (r ¼ 0:3879; P ¼ 0:004), but there was no significant correlation between moral stage development and
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
Table 2
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Pearson correlation coefficients between advocacy, moral development, assertiveness, and job security. Moral stage development
Assertiveness
Job security
Total HAM
r ¼ 0:2322 P ¼ 0:098
r ¼ 0:1485 P ¼ 293
r ¼ 0:0951 P ¼ 0:503
Moral–ethical advocacy
r ¼ 0:672 P ¼ 0:636
r ¼ 0:2201 P ¼ 0:117
r ¼ 0:1754 P ¼ 0:213
Legal advocacy
r ¼ 0:0388 P ¼ 0:785
r ¼ 0:2130 P ¼ 0:130
r ¼ 0:0920 P ¼ 0:517
Political advocacy
r ¼ 0:1482 P ¼ 0:294
r ¼ 0:0263 P ¼ 0:853
r ¼ 0:2012 P ¼ 0:153
Spiritual advocacy
r ¼ 0:2538 P ¼ 0:069
r ¼ 0:0926 P ¼ 0:514
r ¼ 0:2145 P ¼ 0:127
Substitutive advocacy
r ¼ 0:3879 P ¼ 0:004n
r ¼ 0:0008 P ¼ 0:996
r ¼ 0:0564 P ¼ 0:691
n
Po0.01.
the remaining four categories or HAM use. No significant relationship was found between the nurses perceived job security (r ¼ 0:0951; P ¼ 0:503) or perceived level of assertiveness (r ¼ 0:1485; P ¼ 0:293) and the extent of use of the total HAM or any specific category of advocacy (Tables 2 and 3). Members of the research team analyzed the 40 empirical case studies of advocacy generated by the on-line RN-BSN students as part of a professional roles analysis assignment. The researchers assigned them to one of the five categories of advocacy contained in the HAM. The following are examples of each the five categories.
Five categories of advocacy
intellectually sensitive to the terminal nature of the disease, but was emotionally unready to let her father go. Allison counseled the daughter while informing the physician of the conflict. Within a few days, Marlene was more accepting of her father’s refusal of treatments and diagnostic procedures. Mr. J. continues to receive hospice care and seems more comfortable and at peace.
As a moral–ethical advocate, Allison was aware of the patient’s values, sought clarification, and acted to preserve his right to privacy. By facilitating decision-making congruent with Mr J.’s values, she functioned as a communication bridge between the daughter, patient, and physician. Allison functioned as a cultural broker between the patient and health-care system, protected the patient’s right to autonomous decision-making and preserved selfdetermination.
Moral–ethical advocacy This case study is about a long-term care nurse who acted as a moral–ethical advocate: Mr. J. had a terminal condition and was receiving hospice care in the long-term care unit. He was a kind man with a large loving family but he was tired and had voiced a desire to ‘‘stop the fight and go to sleep.’’ He long ago signed a Health Care Power of Attorney and his oldest daughter led the fight to keep him alive; ‘‘We want Dad to get better and come home.’’ Mr. J.’s family expressed their love by doing all they could to provide care for him. Allison, the nurse, was aware Mr. J. didn’t want to hurt his family by ‘‘letting go too soon.’’ The daughter, Marlene was
Political advocacy The following scenario is about a colleague of the RN-BSN students who acted as a political advocate: MB is the chairperson of our collective bargaining unit and he is active in several spheres of political action: the workplace, government, professional organizations, and community. As MB spoke at our monthly union meeting, I grasped how far he had risen when he described his role on the National VA Council that was lobbying mandatory overtime, staffing ratios, and safety in the workplace. As political action in one
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Table 3
ANOVAFEffects of demographic variables on extent and type of advocacy.
Variable
Source
d.f.
E
P
Nurse’s age
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
49 49 49 48 48 49 49 49 49
0.40 0.35 1.19 0.19 0.82 0.59 3.32 1.59 2.01
0.75 0.79 0.32 0.90 0.49 0.64 0.028n 0.20 0.13
Level nurse’s education
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
50 50 50 50 50 50 50 50 50
0.56 1.21 0.17 0.07 1.06 1.16 0.46 1.59 3.16
0.64 0.32 0.91 0.98 0.37 0.33 0.71 0.20 0.03n
Work setting
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
51 51 51 51 51 51 51 51 51
0.70 1.94 0.41 1.54 1.16 3.15 0.72 5.17 0.69
0.85 0.14 0.75 0.22 0.34 0.03n 0.55 0.0036nn 0.56
n
Po0.05. Pp0.01.
nn
sphere often affects other areas, MB’s efforts will affect the course of the nursing profession.
Nurses continually advocate for patients and families; however, the nurses’ lack of power in the health-care system makes this a formidable task. This nurse was advocating for political power of the profession and he was seeking social policy justice. MB was politically sophisticated, knowledgeable about the system, and recognized appropriate strategic interventions. He used the power of professional organizations, policy-making boards, and decision-making councils to effect meaningful change.
Spiritual advocacy The following account is about a home health-care nurse who acted as a spiritual advocate: Ann, an elderly Italian woman was referred to our VNA for treatment of an ulcer on the ball of her foot. The
ulcer did not respond despite different wound protocols including whirlpool footbaths. In Ann’s neighborhood, next to the Catholic Church, was a place called ‘‘The Grotto’’. A smaller version of Lourdes, it had religious statues, candles, benches, and a trickling waterfall that emptied into a small fountain. All this was built into a huge rock formation containing darkened, cave-like alcoves that was accessible only through a towering, black, cast-iron gate. People would go there to pray, meditate, and get special ‘‘holy water’’ from the fountain. On one of my visits, Ann brought out a clear, plastic six-inch statue of the Virgin Mary filled with water from the Grotto. She sheepishly asked if she could add the ‘‘holy water’’ to the whirlpool. I said ‘‘yes’’. Two weeks later, Ann’s ulcer was healed and she was discharged.
The home health-care nurse respected the patient’s right to seek spiritual assistance and protected those beliefs. This holistic intervention displayed sensitivity to other worldviews and communicated the nurses’ willingness to enter Ann’s life-world. The nurse implemented spiritual
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
advocacy by being fully present in the moment, participating with Ann during her search for meaning, and facilitating the power of spiritual healing.
Substitutive advocacy The following narrative is about an operating room nurse who acted as a substitutive advocate: Susan assured the History and Physical was related to the surgical procedure, she verified the surgical consent against the doctor’s orders and she evaluated the patient’s level of understanding. Susan also checked the consent form signatures and she confirmed the accuracy of the surgical site. Susan assisted the patient onto the operating room table. She maintained his dignity by only exposing necessary body parts, kept him warm with heated blankets, and protected pressure points with strategically placed gel pads. Prior to the incision, Susan, the scrub nurse, surgeon, and anesthesiologist, verified the procedure and the accuracy of the operating site.
Susan embraced the role of substitutive advocate with respect and consideration for what she knew to be the patient’s desires. Acting as a translator of these wishes for the rest of the health-care team, she recognized her duty to be an authentic voice for the patient. Susan’s awareness of the patient’s values were enhanced by a privileged relationship and provided a framework within which she could responsibly act. She met the standard of care to preserve the patients right to self-determination, protect him from physical harm, and promote a safe and dignified environment when he could not speak for himself.
Legal advocacy The following story is about a critical care nurse who acted as a legal advocate: Helen was slowly dying from an inoperable lung tumor. Because she wanted to be fully resuscitated, Helen remained intubated and on the ventilator. Some nurses began to distance themselves from the assignment because it was too emotionally draining. Others expressed anger, stating this patient was terminally ill and draining financial resources. Doreen, Helen’s nurse, found the daughter sobbing because one of the RNs told her it was time to let go. Doreen laid a calming hand on the daughter’s shoulder and quietly said, ‘‘despite what anyone else may say, there is no need to make a decision because its already been made; you and your Mom made it very clear what was to be doneFand we’re doing it. Advanced Directives are as much about keeping the machines plugged in as they are about pulling them out. We will keep caring for your Mom in hopes that we can get her to that
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comfortable place where she can let go when she’s ready.’’
As a legal advocate, Doreen was safeguarding Helen’s right to accept or refuse treatment and to be protected from incomplete or illegal practices. She was preserving the patient’s fundamental right to privacy, self-determination, and autonomous decision-making by respecting her Advanced Directive and she clearly expected others to afford similar deference. In doing so, Doreen empowered Helen by narrowing the authority differential between the health-care system and the patient. She accepted Helen’s decisions and promoted acts consistent with those wishes. These illustrative case studies provide anecdotal evidence that the five categories of advocacy are applied in clinical practice. Of the 40 case studies submitted, 14 (35%) used moral–ethical advocacy, 10 (25%) illustrated legal advocacy, six (15%) portrayed substitutive advocacy, five (12.5%) demonstrated spiritual advocacy, and five (12.5%) represented political advocacy.
Discussion There was consistency in the results of the quantitative and case study components of this study that found the category of moral–ethical advocacy was used most often (x ¼ 2:83=5; case study ¼ 35%). In the quantitative portion, total HAM was not used to its full potential as shown by actual and possible mean scores ðx ¼ 12:94=25Þ: This lack of comprehensiveness is consistent with the findings of Foley et al.27, Mallick24, Millette8, and Nelson4, who reported the use of advocacy is limited by health-care systems. Implications of this study are in agreement with those who promote more comprehensive models of advocacy.1–3,5,6 Although the literature indicated the nurses’ age, educational level, and/or work setting could influence the use of advocacy,16–18,20,21 this study found work setting made a difference in the use of only moral–ethical advocacy. The nurses’ age positively influenced moral stage development (F ¼ 3:32; P ¼ 0:028), the level of education affected perceived assertiveness (F ¼ 3:16; P ¼ 0:03), and work setting made a difference in perceived job security (F ¼ 5:17; P ¼ 0:0036). Despite the fact that other investigators17–21 found relationships between level of education and moral stage development, this study did not produce similar results. It did however find a relationship between moral stage development and substitutive advocacy (r ¼ 0:3879; P ¼ 0:004).
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These findings are consistent with the literature that suggests a relationship exists between moral stage development and the generalized use of advocacy,16,17 but notes a limited scope in the advocacy role24. Even though Sellin22 and Rushton17 found personality characteristics such as selfconfidence and assertiveness influenced the use of advocacy, this study did not concur. Further research is warranted with a focus on self-esteem, courage, and the willingness to take advocacy risks. There were a few limitations of this study. Subjects may not have interpreted the definitions of the five categories of HAM similarly. The variety of advocacy categories generated in the case studies may have been restricted by instructions that did not direct students to write about specific categories of advocacy. It is difficult to determine the subjects’ honesty in identifying their own moral stage development, since this is a sensitive topic to consider. Various personality factors other than assertiveness may have influenced the use of advocacy. Finally, although it was suggested that gender could influence the use of advocacy,23 it was not germane to this sample that included only two males. It is recommended that future research focus on the correlation between nursing experience and the use of advocacy and on personality characteristics other than assertiveness and the use of advocacy. The significant relationship found between perceived moral stage development and the category of substitutive advocacy provides a fruitful framework for the future study of advocacy. The significant difference in advocacy use according to work setting suggests the need to examine organizational culture to identify characteristics that support the advocacy role. Outcomes of advocacy need to be studied, what approaches assure the best outcomes? Advocacy should be listed among cognitive complementary therapies and describe in textbooks of complementary therapies. The results of this study have serious implications for practicing nurses and midwives and for schools of nursing who should use and teach the Holistic Model of Advocacy rather than promoting a narrow definition of the advocacy role.
Conclusion As the managed care movement gains momentum, practicing nurses and midwives will increasingly need to advocate for patients’ use of complementary therapies. In addition, they should enact the HAM and its five categories of advocacy rather than simply being a ‘‘go-between’’ the patient and health-care system. Nurses have the opportunity
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and the responsibility to intercede as risk-takers and role-breakers when advocating for patient welfare within spiritual, moral–ethical, legal, political, and substitutive contexts. Implementing advocacy as an independent complementary therapy contributes to nursing’s professionalization, enhances its caring image, and provides an epistemological foundation for growth.
References [1] Curtin LL. The nurse as advocate: a philosophical foundation for nursing. Adv Nurs Sci 1979;1:1–10. In: Snyder M, Lindquist R. editors. Complementary/alternative therapies in nursing. New York: Springer Publishing; 1998. [2] Fowler, MDM. Social advocacy. Heart and Lung 1989;18: 97–99. In: Snyder M, Lindquist R. editors. Alternative/ alternative therapies in nursing. New York: Springer Publishing; 1998. [3] Kohnke MF. Advocacy: risk and reality. St. Louis, MO: Mosby; 1982. [4] Nelson ML. Advocacy in nursing: how it has evolved and what are the implications for practice? Nurs Outlook 1998;36(3):136–41. [5] Rafael ARF. Advocacy and empowerment: dichotomous or synchronous concepts? Adv Nurs Sci 1995;18:25–32. [6] Segesten K. Patient advocacyFan important part of the daily work of the expert nurse. Scholarly Inquiry Nurs Pract 1993;7:129–35. [7] Snowball J. Asking nurses about advocacy for patients ‘‘reactive’’ and ‘‘proactive’’ accounts. J Adv Nurs 1996; 24:67–75. [8] Millette B. Client advocacy and the moral orientation of nurses. West J Nurs Res 1993;15:607–16. [9] Pavlidis A. Workplace advocacy. Nurs News 2000;24(4):13. [10] Foley BJ, Minick MP, Kee CC. How nurses learn advocacy. J Nurs Scholarship 2002;34:181–6. [11] Spencer JW, Jacobs JJ. Complementary and alternative medicine: an evidence based practice. St. Louis, MO: Mosby; 2003. [12] Watson J. Nursing: human science and human care. A theory of nursing. New York: National League for Nursing; 1988. [13] Gadow S. Existential advocacy: philosophical foundations of nursing. In: Pence T, Cantrell J, editors. Ethics in nursing: an anthology. New York: National League for Nursing; 1990. p. 41–51. [14] Newman M. Health as expanding consciousness, 2nd ed. New York: National League for Nursing; 1994. [15] Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League for Nursing Pub. No. 15-2402, 1991, p. 41. [16] Drew N. Expanding self-awareness through exploration of meaningful experience. J Holistic Nurs 1997;15:406–23. [17] Rushton CH. Creating an ethical practice environment. Crit Care Nurs Clin N Am 1995;7:387–97. [18] Duckett L, Rowan M, Ryden M, Krichbaum K, Miller M, Wainwright H, Savik K. Progress in the moral reasoning of baccalaureate nursing students between program entry and exit. Nurs Res 1997;46:222–8. [19] Mattiasson AC, Andersson L. Moral reasoning among professional caregivers in nursing homes. West J Nurs Res 1995;17:277–91.
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[20] Maher JE, Myatt KM. The perimenopausal process: a case for advocacy. Nurs Manage 1995;26(3):49–52. [21] Ingram R. The nurse as the patient advocate. Retrieved March 14, 2003 from the University of Portsmouth, Department of Humanities, School of Social and Historical Studies, 1998: http://www.richard.ingram.nhspeople.net/ student/files/advocacy.pdf [22] Sellin SC. Out on a limb: a qualitative study of patient advocacy in institutional nursing. Nurs Ethics 1995;2(1):19–29. [23] Rankin M, Esteves MD. Perceptions of scientific misconduct in nursing. Nurs Res 1997;46:270–5.
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[24] Mallick M. Advocacy in nursing: a review of the literature. J Adv Nurs 1997;25:130–7. [25] Snyder M, Lindquist R. editors. Complementary/alternative therapies in nursing. New York: Springer Publishing; 1998. [26] Kohlberg L. The philosophy of moral development: moral stages and the idea of justice. San Francisco: Harper Row; 1981. [27] Foley BJ, Minick MP, Kee CC. Nursing during a military operation. West J Nurs Res 2000;2:492–507. [28] Mackereth PA. HIV and homophobia: nurses as advocates. J Adv Nurs 1995;22:670–6.
A holistic model of advocacy: factors that influence its use Sylvia M. Kubscha,*, Marsha J. Sternarda, Rebecca Hovarterb, Vicki Matzkec a
University of Wisconsin Green Bay, 2420 Nicolet Dr, Green Bay, WI 54311-7001, USA Family Practice Clinic, Chilton, WI, USA c Prevea Clinic, Green Bay, WI, USA b
KEYWORDS Advocacy; Model; Holism
Summary Although advocacy is embraced by nursing as an essential component of holistic philosophy, its scope is often limited in practice. In this article, a research study that examined the use of an expanded definition of advocacy is described. A link to the role of advocacy as a complementary therapy and in relation to facilitating the use of complementary therapies by patients is provided. Fifty-two registered nurses completed a researcher developed advocacy research instrument that assessed the use of moral–ethical, legal, political, spiritual, and substitutive advocacy along with various factors thought to influence the use of advocacy including moral development, perceived assertiveness, and perceived job security. An additional 40 RN-BSN students generated case studies of advocacy enacted in practice that were used as examples of the five categories of advocacy and to support the findings of the survey. Results indicated that moral–ethical advocacy was used more often than the other four categories. Moral stage development had a significant effect on substitutive advocacy but assertiveness and job security were not significant factors influencing any category of advocacy. r 2003 Elsevier Ltd. All rights reserved.
Introduction Nurses frequently refer to themselves as patient advocates when all they have done is call a physician, request a medication order, interpret patient needs, coordinate services, or provide information. This rather limited interpretation of the advocate reduces the importance of the role and relegates the advocate to nothing more than a ‘‘go-between’’. In contrast to this limited interpretation of the role, more comprehensive views of advocacy have been described in the literature.1–7 Presented as more than a mediator, the nurse is obligated to *Corresponding author. Tel.: þ 1-920-465-2205; fax: þ 1-920465-2854. E-mail address: [email protected] (S.M. Kubsch).
guard patient rights to competent and holistic care, preserve their values in decision-making, and protect self-determination. Curtin1 and Fowler2 propose a holistic view of advocacy expressed in five categories: moral– ethical, legal, political, spiritual, and substitutive. The purpose of this article is to describe the use of such a model of advocacy, designated the Holistic model of advocacy (HAM).
Literature review Different interpretations of advocacy were found in the literature. Millette8 differentiates bureaucratic, physician, and patient advocacy. Although nurse participants in Millette’s study ranked patient advocacy as a priority, their behavior reflected
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ARTICLE IN PRESS 38 physician or bureaucratic loyalty. Nelson4 found when the physician or bureaucracy is the prime decision-maker; the nurse advocate could be labeled a troublemaker. Pavlidis9 differentiated between workplace and patient advocacy. Workplace advocacy addresses staffing, safety, and employee competency, whereas patient advocacy involves an obligation to protect patients from harm. Foley et al.10 suggest that patient advocacy is critical for vulnerable groups such as the elderly, very young, institutionalized, imprisoned, and disabled populations. Several writers separate the concept of advocacy into components or classes of advocate activity. Rafael5 suggests advocacy includes human, existential, paternalistic, and consumer categories. Kohnke3 contends advocacy has the dimensions of self, client, and community. Curtin1 and Fowler2 propose categories of legal, moral–ethical, political, substitutive, and spiritual advocacy. Snowball7 identifies four foundations of advocacy as reactive/ proactive, therapeutic relationship, common knowledge, and cultural environment. Segesten6 depicts advocacy as a process of recognizing a trigger event, engaging in decision-making, acting out convictions, accepting additional work, and taking risks. Nelson4 proposes advocacy occurs within the roles of protector, mediator, and actor. The need for advocacy to assure consumers’ opportunity to use complementary therapies is discussed by Spencer and Jacobs11. The role of the health-care practitioner as advocate is to empower patients by providing information about and access to complementary and alternative medicine (CAM) therapies. As advocates for the patient, the health-care practitioner would review potential effects of CAM on symptoms as well as possible risks and benefits. An informed advocate would talk with patients about CAM treatment options as well as fears and anxieties associated with their use. Equipped with extensive information about CAM and access to practitioners of CAM, health-care practitioners can empower patients to take control of their health-care outcomes. Various nurse theorists define advocacy according to the nursing models they embrace. Watson12 believes effective advocacy is an essential component of nursing’s humanistic philosophy and requires a caring nurse/patient relationship. Gadow13 suggests advocacy occurs when patients are empowered to construct experiential meaning. Newman14 defines advocacy in terms of expanding consciousness and mutuality. Leininger15 promotes advocacy as a component of culturally congruent care.
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Several factors that could influence the use of advocacy were identified in the literature. Drew16 and Rushton17 reported a relationship between the nurses’ moral stage development and advocacy application. Evidence of an association between moral stage development and perceptions of advocacy was documented by Duckett et al.18 Mattiasson and Andersson19 found a positive correlation between education and advocacy. Maher and Myatt20 asserted knowledge of female health is a significant factor in advocacy for perimenopausal women. Ingram21 reported nurses who attend ethics courses engage more advocacy situations, have a greater influence, and more effectively resolve ethical conflicts. Personality attributes such as self-confidence, assertiveness, and maturity were found to influence advocacy application.17,22 Other aspects that affect the use of advocacy were age, gender, and job security. Rankin and Esteves23 found an inverse relationship between age and ethical misconduct. Duckett et al.18 reported women scored lower than men in moral reasoning tests but scored higher in application of moral reasoning to case studies. Problems related to job security and management conflicts were cited as barriers to nursing advocacy by Sellin.22 Mackereth28 contended workplace antagonism resulted in lack of advocacy for diverse cultural groups. Drew16 argued dissatisfaction with the health-care system motivated nurses to speak out and positively affected the advocacy role. The literature indicates the need for a more comprehensive understanding of the advocacy role as a holistic therapy. In the literature it is found that advocacy is embraced by nursing as an essential component of practice, is based on nursing theory, is systematically implemented, and is influenced by several factors. Gaps in the literature include the nurses’ perception of advocacy, insight into the use of advocacy as a complementary therapy, congruency between the nurses’ actions and patient expectations, advocacy needs among special populations, and documentation of success in resolving problems/dilemmas.25
Conceptual framework Because of its potential influence on the advocate role, Kohlberg’s26 theory of Moral Stage Development was selected to be the conceptual framework of this study. The theory presents three levels of moral development. A nurse functioning at the first pre-conventional level implements advocacy to avoid punishment. At the second conventional
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
level, the nurse uses advocacy because it is the ‘‘law’’ or policy and leads to approval by others. At the third post-conventional level the nurse engages the advocacy role for the good of humanity and acts autonomously as a risk-taker/role-breaker in supporting social justice. As an additional part of the conceptual framework, the authors designed the HAM that suggests five types of advocacy. The categories of advocacy contained in the model are defined as follows: Legal advocate
Moral–ethical advocate
Political advocate
Spiritual advocate
Substitutive advocate
The nurse guards the patient’s rights to competent care, to reject care, informed consent, and privacy. The nurse upholds the patient’s values in decision-making. The nurse facilitates equal access to health care. The nurse provides access to spiritual support and reassurance. The nurse protects the interests of patients who are incapable of speaking for themselves.1,2
To guide this research study the following research questions were used: (a) what is the extent of use of the total HAM and its five categories of legal, moral–ethical, political, spiritual, and substitutive advocacy in nursing practice? (b) Is there a relationship between perceived moral stage development and the use of the HAM? (c) Is there a relationship between perceived job security, perceived assertiveness, and the use of the HAM? (d) Is there a difference in the extent of use of the HAM according to the nurses’ age, level of education, and work setting? It is anticipated that analysis of this model will raise awareness of the comprehensive nature of advocacy.
Research design This study was based on descriptive, correlational, and case study designs to discover the use of the CFCAM and its five categories of advocacy. The relationships of moral stage development, assertiveness, and job security to the HAM were also explored. The effect of demographics was determined by comparing nurses grouped according to age, educational level, and work setting.
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In addition to data collected by the quantitative research instrument, 40 empirical case studies of advocacy were submitted by RN-BSN students enrolled in an on-line nursing theory course. As part of a professional roles analysis assignment, students were instructed to write about an advocacy intervention used by themselves or witnessed in clinical practice. No guidelines about which category of advocacy to write about were provided. After review of the 40 case studies, the researchers assigned the case studies to one of the five categories of advocacy.
Research instrument A research instrument, developed by the investigators, contained four Likert Scales that measured frequency of advocacy interventions, perceived job security, perceived assertiveness, and moral stage development. The Advocacy Scale consisted of five statements that considered performance within each category of advocacy over the prior month/ week/day. It ranged from rarely (one point) to several times a day (five points). The Perceived Moral Stage Development Scale contained 13 questions based on Kohlberg’s26 theory of moral stage development. The possible range of scores was 13 (low) to 75 (high) level of moral stage development. The perceived level of Job Security Scale contained one Likert-scaled item measuring the nurses’ sense of job security. Scores ranged from one (least) to five (most). The Perceived Assertiveness Scale used three Likert Scale items to measure the subject’s assertiveness in the workplace, home, and social setting. The possible range of scores were three (least) to 15 (most). The demographic section of the research instrument assessed subjects’ education level, age, gender, and work setting. To determine validity of the quantitative research instrument, an ethics professor, a physician, and a nurse manager reviewed the Advocacy and Moral Stage Development Scales for inclusiveness. Changes were made based on their expert recommendations. Reliability was determined using the test–retest method with a sample of 15 registered nurses. A Pearson r ¼ 0:89 was achieved.
Data collection and informed consent The quantitative component of the study took place in a Midwest state of the United States of America. The research instrument was hand-delivered to potential subjects in four different work settings who were provided with a consent form
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Table 1
Measures of central tendency.
Variable
Mean
SD
Possible range
n
Total HAM Political advocacy Legal advocacy Moral–ethical advocacy Substitutive advocacy Spiritual advocacy Perceived job security level Perceived assertiveness level Perceived moral stage development
12.94 2.00 2.60 2.83 2.79 2.72 4.06 11.17 62.46
4.65 1.22 1.29 1.34 1.32 0.97 0.96 1.83 14.42
5–25 1–5 1–5 1–5 1–5 1–5 1–5 7–15 31–94
52 52 52 52 52 52 52 52 52
that explained the purpose of the study, potential risks, and possible benefits. Those expressing a willingness to participate in the study received the research instrument and a stamped return envelope. Consent to participate was implied by returning the completed research instrument via surface mail. The case study component of the study took place in the virtual classroom of the Theoretical Foundations in Nursing course. Students completing the on-line course resided in 20 different states of the United States of America. All RN-BSN students who submitted advocacy case studies were provided with an electronic version of an informed consent. The 40 students agreed to participate under the condition of patient and nurse anonymity.
Results Sample The sample consisted of 52 nurses from four different health-care settings. Twenty-two worked in acute care, 20 in long-term care, eight in home health, and two in public health. Fifteen subjects held associate degrees in nursing, nine had diplomas, 25 were BSNs, and two MSNs. The nurses’ ages ranged from 20 to 30 ðn ¼ 5Þ; 31 to 40 ðn ¼ 19Þ; 41 to 50 ðn ¼ 20Þ; 51-beyond ðn ¼ 6Þ; and unknown ðn ¼ 2Þ: An additional sample of 40 case studies of advocacy was posted on-line by RN-BSN students. They did not complete the quantitative survey. Five case studies were selected as best representations of each category of advocacy contained in the HAM. Measures of central tendency generated actual range of scores, mean scores, and standard deviations for the independent and dependent variables (Table 1). The mean score for total HAM (all five categories of advocacy combined) was 12.94 out of
a potential range 5–25, indicating that the HAM was not fully employed. Of the five categories of advocacy assessed, moral–ethical advocacy was used most often (mean ¼ 2.83, possible range 1–5). Substitutive advocacy (mean ¼ 2.79) was the next most common category followed by spiritual advocacy (mean ¼ 2.73), legal advocacy (mean ¼ 2.60), and political advocacy (mean ¼ 2.00). Perceived job security had a mean score of 4.06 (possible range 1–5). Perceived assertiveness had a mean score of 11.17 (possible range 3–15). Perceived moral stage development had a mean score of 62.46 (possible range 13–75). Analysis of variance was applied to examine the effect of nurses’ age, level of education, and work setting on use of the HAM, any of the five categories of advocacy, moral stage development, job security, and assertiveness. It was found that the age of the nurse made a significant difference in moral stage development (F ¼ 3:32; P ¼ 0:028). However, age had no effect on HAM use or any of the five categories of advocacy, job security, or assertiveness. Similarly, the nurses’ level of education had no significant effect on any of the variables except perceived assertiveness (F ¼ 3:16; P ¼ 0:03). Work setting significantly affected the use of moral– ethical advocacy (F ¼ 3:15; P ¼ 0:033), but it had no effect on the four remaining categories of advocacy or on the total use of HAM, job security, or assertiveness. The Pearson r statistic tested the relationships of moral stage development, job security, and assertiveness to the HAM and the five categories of advocacy. The relationship between the nurses perceived moral stage of development and the extent of use of the total HAM was not significant (r ¼ 0:2322; P ¼ 0:098). A significant relationship was found between moral stage development and the use of the category of substitutive advocacy (r ¼ 0:3879; P ¼ 0:004), but there was no significant correlation between moral stage development and
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
Table 2
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Pearson correlation coefficients between advocacy, moral development, assertiveness, and job security. Moral stage development
Assertiveness
Job security
Total HAM
r ¼ 0:2322 P ¼ 0:098
r ¼ 0:1485 P ¼ 293
r ¼ 0:0951 P ¼ 0:503
Moral–ethical advocacy
r ¼ 0:672 P ¼ 0:636
r ¼ 0:2201 P ¼ 0:117
r ¼ 0:1754 P ¼ 0:213
Legal advocacy
r ¼ 0:0388 P ¼ 0:785
r ¼ 0:2130 P ¼ 0:130
r ¼ 0:0920 P ¼ 0:517
Political advocacy
r ¼ 0:1482 P ¼ 0:294
r ¼ 0:0263 P ¼ 0:853
r ¼ 0:2012 P ¼ 0:153
Spiritual advocacy
r ¼ 0:2538 P ¼ 0:069
r ¼ 0:0926 P ¼ 0:514
r ¼ 0:2145 P ¼ 0:127
Substitutive advocacy
r ¼ 0:3879 P ¼ 0:004n
r ¼ 0:0008 P ¼ 0:996
r ¼ 0:0564 P ¼ 0:691
n
Po0.01.
the remaining four categories or HAM use. No significant relationship was found between the nurses perceived job security (r ¼ 0:0951; P ¼ 0:503) or perceived level of assertiveness (r ¼ 0:1485; P ¼ 0:293) and the extent of use of the total HAM or any specific category of advocacy (Tables 2 and 3). Members of the research team analyzed the 40 empirical case studies of advocacy generated by the on-line RN-BSN students as part of a professional roles analysis assignment. The researchers assigned them to one of the five categories of advocacy contained in the HAM. The following are examples of each the five categories.
Five categories of advocacy
intellectually sensitive to the terminal nature of the disease, but was emotionally unready to let her father go. Allison counseled the daughter while informing the physician of the conflict. Within a few days, Marlene was more accepting of her father’s refusal of treatments and diagnostic procedures. Mr. J. continues to receive hospice care and seems more comfortable and at peace.
As a moral–ethical advocate, Allison was aware of the patient’s values, sought clarification, and acted to preserve his right to privacy. By facilitating decision-making congruent with Mr J.’s values, she functioned as a communication bridge between the daughter, patient, and physician. Allison functioned as a cultural broker between the patient and health-care system, protected the patient’s right to autonomous decision-making and preserved selfdetermination.
Moral–ethical advocacy This case study is about a long-term care nurse who acted as a moral–ethical advocate: Mr. J. had a terminal condition and was receiving hospice care in the long-term care unit. He was a kind man with a large loving family but he was tired and had voiced a desire to ‘‘stop the fight and go to sleep.’’ He long ago signed a Health Care Power of Attorney and his oldest daughter led the fight to keep him alive; ‘‘We want Dad to get better and come home.’’ Mr. J.’s family expressed their love by doing all they could to provide care for him. Allison, the nurse, was aware Mr. J. didn’t want to hurt his family by ‘‘letting go too soon.’’ The daughter, Marlene was
Political advocacy The following scenario is about a colleague of the RN-BSN students who acted as a political advocate: MB is the chairperson of our collective bargaining unit and he is active in several spheres of political action: the workplace, government, professional organizations, and community. As MB spoke at our monthly union meeting, I grasped how far he had risen when he described his role on the National VA Council that was lobbying mandatory overtime, staffing ratios, and safety in the workplace. As political action in one
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Table 3
ANOVAFEffects of demographic variables on extent and type of advocacy.
Variable
Source
d.f.
E
P
Nurse’s age
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
49 49 49 48 48 49 49 49 49
0.40 0.35 1.19 0.19 0.82 0.59 3.32 1.59 2.01
0.75 0.79 0.32 0.90 0.49 0.64 0.028n 0.20 0.13
Level nurse’s education
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
50 50 50 50 50 50 50 50 50
0.56 1.21 0.17 0.07 1.06 1.16 0.46 1.59 3.16
0.64 0.32 0.91 0.98 0.37 0.33 0.71 0.20 0.03n
Work setting
Total HAM Legal advocacy Political advocacy Spiritual advocacy Substitutive advocacy Moral–ethical advocacy Moral stage development Perceived job security Perceived assertiveness
51 51 51 51 51 51 51 51 51
0.70 1.94 0.41 1.54 1.16 3.15 0.72 5.17 0.69
0.85 0.14 0.75 0.22 0.34 0.03n 0.55 0.0036nn 0.56
n
Po0.05. Pp0.01.
nn
sphere often affects other areas, MB’s efforts will affect the course of the nursing profession.
Nurses continually advocate for patients and families; however, the nurses’ lack of power in the health-care system makes this a formidable task. This nurse was advocating for political power of the profession and he was seeking social policy justice. MB was politically sophisticated, knowledgeable about the system, and recognized appropriate strategic interventions. He used the power of professional organizations, policy-making boards, and decision-making councils to effect meaningful change.
Spiritual advocacy The following account is about a home health-care nurse who acted as a spiritual advocate: Ann, an elderly Italian woman was referred to our VNA for treatment of an ulcer on the ball of her foot. The
ulcer did not respond despite different wound protocols including whirlpool footbaths. In Ann’s neighborhood, next to the Catholic Church, was a place called ‘‘The Grotto’’. A smaller version of Lourdes, it had religious statues, candles, benches, and a trickling waterfall that emptied into a small fountain. All this was built into a huge rock formation containing darkened, cave-like alcoves that was accessible only through a towering, black, cast-iron gate. People would go there to pray, meditate, and get special ‘‘holy water’’ from the fountain. On one of my visits, Ann brought out a clear, plastic six-inch statue of the Virgin Mary filled with water from the Grotto. She sheepishly asked if she could add the ‘‘holy water’’ to the whirlpool. I said ‘‘yes’’. Two weeks later, Ann’s ulcer was healed and she was discharged.
The home health-care nurse respected the patient’s right to seek spiritual assistance and protected those beliefs. This holistic intervention displayed sensitivity to other worldviews and communicated the nurses’ willingness to enter Ann’s life-world. The nurse implemented spiritual
ARTICLE IN PRESS A holistic model of advocacy: factors that influence its use
advocacy by being fully present in the moment, participating with Ann during her search for meaning, and facilitating the power of spiritual healing.
Substitutive advocacy The following narrative is about an operating room nurse who acted as a substitutive advocate: Susan assured the History and Physical was related to the surgical procedure, she verified the surgical consent against the doctor’s orders and she evaluated the patient’s level of understanding. Susan also checked the consent form signatures and she confirmed the accuracy of the surgical site. Susan assisted the patient onto the operating room table. She maintained his dignity by only exposing necessary body parts, kept him warm with heated blankets, and protected pressure points with strategically placed gel pads. Prior to the incision, Susan, the scrub nurse, surgeon, and anesthesiologist, verified the procedure and the accuracy of the operating site.
Susan embraced the role of substitutive advocate with respect and consideration for what she knew to be the patient’s desires. Acting as a translator of these wishes for the rest of the health-care team, she recognized her duty to be an authentic voice for the patient. Susan’s awareness of the patient’s values were enhanced by a privileged relationship and provided a framework within which she could responsibly act. She met the standard of care to preserve the patients right to self-determination, protect him from physical harm, and promote a safe and dignified environment when he could not speak for himself.
Legal advocacy The following story is about a critical care nurse who acted as a legal advocate: Helen was slowly dying from an inoperable lung tumor. Because she wanted to be fully resuscitated, Helen remained intubated and on the ventilator. Some nurses began to distance themselves from the assignment because it was too emotionally draining. Others expressed anger, stating this patient was terminally ill and draining financial resources. Doreen, Helen’s nurse, found the daughter sobbing because one of the RNs told her it was time to let go. Doreen laid a calming hand on the daughter’s shoulder and quietly said, ‘‘despite what anyone else may say, there is no need to make a decision because its already been made; you and your Mom made it very clear what was to be doneFand we’re doing it. Advanced Directives are as much about keeping the machines plugged in as they are about pulling them out. We will keep caring for your Mom in hopes that we can get her to that
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comfortable place where she can let go when she’s ready.’’
As a legal advocate, Doreen was safeguarding Helen’s right to accept or refuse treatment and to be protected from incomplete or illegal practices. She was preserving the patient’s fundamental right to privacy, self-determination, and autonomous decision-making by respecting her Advanced Directive and she clearly expected others to afford similar deference. In doing so, Doreen empowered Helen by narrowing the authority differential between the health-care system and the patient. She accepted Helen’s decisions and promoted acts consistent with those wishes. These illustrative case studies provide anecdotal evidence that the five categories of advocacy are applied in clinical practice. Of the 40 case studies submitted, 14 (35%) used moral–ethical advocacy, 10 (25%) illustrated legal advocacy, six (15%) portrayed substitutive advocacy, five (12.5%) demonstrated spiritual advocacy, and five (12.5%) represented political advocacy.
Discussion There was consistency in the results of the quantitative and case study components of this study that found the category of moral–ethical advocacy was used most often (x ¼ 2:83=5; case study ¼ 35%). In the quantitative portion, total HAM was not used to its full potential as shown by actual and possible mean scores ðx ¼ 12:94=25Þ: This lack of comprehensiveness is consistent with the findings of Foley et al.27, Mallick24, Millette8, and Nelson4, who reported the use of advocacy is limited by health-care systems. Implications of this study are in agreement with those who promote more comprehensive models of advocacy.1–3,5,6 Although the literature indicated the nurses’ age, educational level, and/or work setting could influence the use of advocacy,16–18,20,21 this study found work setting made a difference in the use of only moral–ethical advocacy. The nurses’ age positively influenced moral stage development (F ¼ 3:32; P ¼ 0:028), the level of education affected perceived assertiveness (F ¼ 3:16; P ¼ 0:03), and work setting made a difference in perceived job security (F ¼ 5:17; P ¼ 0:0036). Despite the fact that other investigators17–21 found relationships between level of education and moral stage development, this study did not produce similar results. It did however find a relationship between moral stage development and substitutive advocacy (r ¼ 0:3879; P ¼ 0:004).
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These findings are consistent with the literature that suggests a relationship exists between moral stage development and the generalized use of advocacy,16,17 but notes a limited scope in the advocacy role24. Even though Sellin22 and Rushton17 found personality characteristics such as selfconfidence and assertiveness influenced the use of advocacy, this study did not concur. Further research is warranted with a focus on self-esteem, courage, and the willingness to take advocacy risks. There were a few limitations of this study. Subjects may not have interpreted the definitions of the five categories of HAM similarly. The variety of advocacy categories generated in the case studies may have been restricted by instructions that did not direct students to write about specific categories of advocacy. It is difficult to determine the subjects’ honesty in identifying their own moral stage development, since this is a sensitive topic to consider. Various personality factors other than assertiveness may have influenced the use of advocacy. Finally, although it was suggested that gender could influence the use of advocacy,23 it was not germane to this sample that included only two males. It is recommended that future research focus on the correlation between nursing experience and the use of advocacy and on personality characteristics other than assertiveness and the use of advocacy. The significant relationship found between perceived moral stage development and the category of substitutive advocacy provides a fruitful framework for the future study of advocacy. The significant difference in advocacy use according to work setting suggests the need to examine organizational culture to identify characteristics that support the advocacy role. Outcomes of advocacy need to be studied, what approaches assure the best outcomes? Advocacy should be listed among cognitive complementary therapies and describe in textbooks of complementary therapies. The results of this study have serious implications for practicing nurses and midwives and for schools of nursing who should use and teach the Holistic Model of Advocacy rather than promoting a narrow definition of the advocacy role.
Conclusion As the managed care movement gains momentum, practicing nurses and midwives will increasingly need to advocate for patients’ use of complementary therapies. In addition, they should enact the HAM and its five categories of advocacy rather than simply being a ‘‘go-between’’ the patient and health-care system. Nurses have the opportunity
S.M. Kubsch et al.
and the responsibility to intercede as risk-takers and role-breakers when advocating for patient welfare within spiritual, moral–ethical, legal, political, and substitutive contexts. Implementing advocacy as an independent complementary therapy contributes to nursing’s professionalization, enhances its caring image, and provides an epistemological foundation for growth.
References [1] Curtin LL. The nurse as advocate: a philosophical foundation for nursing. Adv Nurs Sci 1979;1:1–10. In: Snyder M, Lindquist R. editors. Complementary/alternative therapies in nursing. New York: Springer Publishing; 1998. [2] Fowler, MDM. Social advocacy. Heart and Lung 1989;18: 97–99. In: Snyder M, Lindquist R. editors. Alternative/ alternative therapies in nursing. New York: Springer Publishing; 1998. [3] Kohnke MF. Advocacy: risk and reality. St. Louis, MO: Mosby; 1982. [4] Nelson ML. Advocacy in nursing: how it has evolved and what are the implications for practice? Nurs Outlook 1998;36(3):136–41. [5] Rafael ARF. Advocacy and empowerment: dichotomous or synchronous concepts? Adv Nurs Sci 1995;18:25–32. [6] Segesten K. Patient advocacyFan important part of the daily work of the expert nurse. Scholarly Inquiry Nurs Pract 1993;7:129–35. [7] Snowball J. Asking nurses about advocacy for patients ‘‘reactive’’ and ‘‘proactive’’ accounts. J Adv Nurs 1996; 24:67–75. [8] Millette B. Client advocacy and the moral orientation of nurses. West J Nurs Res 1993;15:607–16. [9] Pavlidis A. Workplace advocacy. Nurs News 2000;24(4):13. [10] Foley BJ, Minick MP, Kee CC. How nurses learn advocacy. J Nurs Scholarship 2002;34:181–6. [11] Spencer JW, Jacobs JJ. Complementary and alternative medicine: an evidence based practice. St. Louis, MO: Mosby; 2003. [12] Watson J. Nursing: human science and human care. A theory of nursing. New York: National League for Nursing; 1988. [13] Gadow S. Existential advocacy: philosophical foundations of nursing. In: Pence T, Cantrell J, editors. Ethics in nursing: an anthology. New York: National League for Nursing; 1990. p. 41–51. [14] Newman M. Health as expanding consciousness, 2nd ed. New York: National League for Nursing; 1994. [15] Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League for Nursing Pub. No. 15-2402, 1991, p. 41. [16] Drew N. Expanding self-awareness through exploration of meaningful experience. J Holistic Nurs 1997;15:406–23. [17] Rushton CH. Creating an ethical practice environment. Crit Care Nurs Clin N Am 1995;7:387–97. [18] Duckett L, Rowan M, Ryden M, Krichbaum K, Miller M, Wainwright H, Savik K. Progress in the moral reasoning of baccalaureate nursing students between program entry and exit. Nurs Res 1997;46:222–8. [19] Mattiasson AC, Andersson L. Moral reasoning among professional caregivers in nursing homes. West J Nurs Res 1995;17:277–91.
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[20] Maher JE, Myatt KM. The perimenopausal process: a case for advocacy. Nurs Manage 1995;26(3):49–52. [21] Ingram R. The nurse as the patient advocate. Retrieved March 14, 2003 from the University of Portsmouth, Department of Humanities, School of Social and Historical Studies, 1998: http://www.richard.ingram.nhspeople.net/ student/files/advocacy.pdf [22] Sellin SC. Out on a limb: a qualitative study of patient advocacy in institutional nursing. Nurs Ethics 1995;2(1):19–29. [23] Rankin M, Esteves MD. Perceptions of scientific misconduct in nursing. Nurs Res 1997;46:270–5.
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[24] Mallick M. Advocacy in nursing: a review of the literature. J Adv Nurs 1997;25:130–7. [25] Snyder M, Lindquist R. editors. Complementary/alternative therapies in nursing. New York: Springer Publishing; 1998. [26] Kohlberg L. The philosophy of moral development: moral stages and the idea of justice. San Francisco: Harper Row; 1981. [27] Foley BJ, Minick MP, Kee CC. Nursing during a military operation. West J Nurs Res 2000;2:492–507. [28] Mackereth PA. HIV and homophobia: nurses as advocates. J Adv Nurs 1995;22:670–6.