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Patient advocacy:

Continuing professional development The management of prostate cancer 45-53

Author guidelines

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a concept analysis

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Multiple-choice self-assessment

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Practice profile assessment

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Patient advocacy:

a concept analysis

Baldwin MA (2003) Patient advocacy: a concept analysis. Nursing Standard. 17, 21, 33-39. Date of acceptance: October 8 2002.

Abstract

Aim To clarify the ill-defined concept of patient advocacy and develop a model. Method An eclectic concept analysis was used in the study. Results Results of the analysis reveal that advocacy has three essential attributes:

valuing, apprising and interceding. Antecedents to advocacy include a vulnerable population and a nurse willing to take on the responsibility for advocacy. The consequences of acting as a patient advocate can be potentially negative or positive for patient and nurse. On their own, the attributes are one of a number of helping strategies. Conclusion Advocacy is a contemporary nursing issue comprising three essential attributes. Individually, each of the attributes is a helping strategy used in nursing. Only when all three attributes are present can advocacy be said to be realised.

T HE TERM advocacy has appeared in nursing literature for almost two decades (Hewitt 2002, Mallik 1997). Much of the literature

has attempted to legitimise and encompass patient advocacy in the role of the nurse. However, reser- vations about the suitability of the nurse to act as patient advocate have also been expressed (Allmark and Klarzynski 1992, Copp 1986, Walsh 1985). Advocacy first appeared in the Project 2000 nurs- ing curriculum (UKCC 1988). Codes of conduct and guidelines for professional practice provide evi- dence that advocacy is a condition of contempo- rary professional nursing practice (NMC 2002, UKCC 1992, 1996).

Literature review

Concepts are labels to describe phenomena that provide a ‘concise summary of thoughts’ (Meleis 1991). A problem with advocacy, however, is the myriad of definitions and explanations. Descriptions range from counsellor, watchdog and representa- tive (Abrams 1978) to potential whistleblower (Ahern and McDonald 2002, Andersen 1990). There does appear to be a consensus that advocacy involves one person representing another (Allmark and Klarzynski 1992, Konke 1982a, 1982b, Morrison 1991). However, for Copp (1986), it means more than speaking for another as it involves interven- tion for ‘vulnerable’ people who require it. There are a number of models of advocacy. Fowler (1989) has suggested four:

Guardian of patients’ rights.

Preservation of patient values.

Champion of social justice in the provision of health care.

Conservator of patients’ best interests.

The first and second models are concerned with patients’ legal rights to health care and treatment, with the second also encompassing individual val- ues. The third model is based on inequalities and inconsistencies in healthcare provision. The final model demands that the nurse has autonomy to empower patients. It is with this model that the codes of professional conduct (NMC 2002, UKCC 1992) are concerned. Conservator of patients’ best interests is particularly evident in clause 2.4 of the NMC (2002) code, which states that the nurse ‘must promote the interests of patients and clients’. Mallik (1997), however, states that advocacy mod- els are inconclusive and that there is a need for clar- ification. Indeed, the increasing literature advancing

Moyra A Baldwin RGN, RCNT, RNT, Cert Ed, Diploma in Advanced Nursing Studies, DipN, BSc(Hons), MMedSci, Member of Institute for Learning and Teaching in Higher Education, is Senior Lecturer, Chester College of Higher Education, School of Nursing and Midwifery, Arrowe Park Hospital, Wirral. Email: m.baldwin@chester.ac.uk

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For related articles visit our online archive at:

www.nursing-standard.co.uk and search using the key words below.

Key words

Patients: empowerment

Research methods

These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.

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art & science research Box 1. Concept analysis methods ■ Concept development ■ Concept delineation

Box 1. Concept analysis methods

Concept development

Concept delineation

Concept comparison

Concept clarification

Concept correction

Concept identification

(Morse 1995)

advocacy as a nursing activity led Snowball (1996) to suggest that advocacy is just a buzzword: a ‘con- venient label for diverse activities’ (Snowball 1996). Conceptual clarity is required to provide the evi-

dence base for advocacy in nursing.

Aim

The aim of this research was to clarify the concept

of advocacy and to develop a model of advocacy.

Method

Concept analysis is a method of enquiry that elicits clarification, identification and meaning of words (Norris 1982, Walker and Avant 1988, 1995). Several methods of concept analysis exist to aid clarifica- tion and there is considerable reference to Wilson’s logical positivist approach (1971). Logical positivism, in philosophy, is concerned with analysis of propo- sitions in an attempt to show that it is possible to ‘know’ something for certain (Russell 1984). Walker and Avant (1983) adapted this method for the study of nursing concepts and much of the litera- ture in which the purpose of the study is to exam- ine a specific concept has used this approach. Burnside and Haight (1992) elucidated the differ- ence between the concepts of reminiscence and life review. Gilje (1992) clarified the concept of ‘presence’ as a phenomenon in nursing, and Jacobs (1993) and Mairis (1994) clarified grief and dignity, respectively. Holcomb et al ’s (2002) report on the concept of nursing productivity used this method. Wilson’s (1971) and Walker and Avant’s (1983) approaches to conceptual analysis have been crit-

icised, however, for simplifying complex concepts (Morse 1995). Rodgers (1989) considered that Wilson’s (1971) method represented a static view of concepts and was a reductionist approach. Her philosophical examination of the foundations of con- cept analysis revealed two distinct views of concepts, namely entity and dispositional (Rodgers 1989). The first focuses on the concept as an entity in itself, and therefore removes the meaning of the concept from context. Both Wilson’s (1971) and Walker and Avant’s (1983) approaches provide an entity view. In con- trast the dispositional view emphasises an individ- ual’s ability to perform specific behaviours as a result of being clear about the concept in question. Here the concern is with the use of concepts in reality and it can be seen to be relevant to exploration of con- cepts relating to the practice of nursing. In an attempt to address her criticism of Wilson’s (1971) approach, Rodgers (1994) advanced an evo- lutionary cycle of concept development, which acknowledged that concepts are influenced by ‘sig- nificance’, ‘use’ and ‘application’. Her method brought about analysis that is practice related, as it focused on application of a concept in practice. This hybrid model, along with that of Wilson (1971) and that of Walker and Avant (1983), however, was rejected by Morse (1995) in favour of an alterna- tive: an interpretative approach that used qualita- tive research methods to establish a concept’s maturity. Using qualitative methodology and drawing on Bolton’s (1977) ‘rules of relation’, Morse (1995) proposed analysis of primary and secondary data to determine whether the object of enquiry could be considered a concept. The rules of relation are fivefold, concepts are:

Table 1. The stages for concept analysis

 

Stages for concept analysis

Authors supporting

Identify the concept of interest

Walker and Avant (1983) Rodgers (1994) (implied by Wilson 1971)

Determine the aims or purpose of the analysis

Walker and Avant (1983) Rodgers (1993)

Identify and select an appropriate realm or sample for data collection

Rodgers (1993, 1994)

Identify attributes, antecedents and consequences of the concept

Walker and Avant (1983) Rodgers (1989, 1993) Morse (1995) – concept development

Identify a model case of the concept, if appropriate

Wilson (1971)

Rodgers (1994)

Identify implications for further development of the concept

Rodgers (1993)

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art & science research Table 2. Attributes of advocacy     Attributes Valuing Apprising

Table 2. Attributes of advocacy

   

Attributes

Valuing

Apprising

Interceding

Definition

A

therapeutic relationship

Promoting and protecting

Acting as an intermediary between patients and:

in

which to secure patients’

patients’ rights to be involved in decision-making and informed consent

freedom and self-determination

– family

– significant others

 

– healthcare providers

Evidence

Curtin 1979, 1983 Gadow 1980 Konke 1982a, 1982b, 1982c Robinson 1985 Salladay and McDonnell 1989 Smith 1979

Barton 1991 Chamorro and Applebaum 1988 Konke 1982b

Conway-Rutkowski 1982 Copp 1986 Curtin 1979 Marshall 1991 Sines 1993 Winslow 1984

The expressions of the ways in which an indi- vidual’s experience are organised.

The result of particular experiences becoming general.

The result of co-ordination of elements.

Used to organise events and must be capable of being applied to new ones.

Formed by examining the correlation between

application of a rule to a particular situation and its results. Having identified that a concept exists, application of the ‘rules of relation’ clarifies which of Morse’s (1995) six concept analysis approaches is the best framework for a particular concept analysis (Box 1). While Morse’s (1995) approach is comprehensive, it is also more complex to a novice concept ana- lyst. The method for the analysis and clarification of the concept advocacy used in the author’s study was an eclectic one based on Wilson’s (1971), Walker and Avant’s (1983) and Rodgers’s (1989) methods. Morse’s (1995) work on concept devel- opment and qualitative thematic analysis has also influenced the approach to this study. The stages and evidence to support their inclusion are shown in Table 1. Data sources include nursing, research and scholarly literature.

Results

Attributes of patient advocacy The defining attributes, that is, those consistently occurring char- acteristics throughout the literature included the following:

A therapeutic nurse-patient relationship in which to secure patients’ freedom and self-determination.

Promoting and protecting patients’ rights to be involved in decision-making and informed consent.

Acting as an intermediary between patients and

their families or significant others, and between them and healthcare providers. The attributes identified are summarised as valuing,

apprising and interceding, and inherent in each is the nurse who is proactive as well as reactive. Evidence to support the defining attributes and their definition is shown in Table 2. Valuing Analysis of the literature demonstrates that valuing is one attribute of advocacy. It is an essen- tial attribute of a therapeutic nurse-patient rela- tionship that secures patients’ freedom and self-determination. Valuing is that which the advo- cate holds dear, prizes or cherishes. Valuing has two components: valuing patients’ individuality and valuing self. The patient advocate is one who, while providing expert care, maintains ‘individualization and humanity’ (Smith 1979). Gadow (1980) expressed valuing as: ‘the nurse is in the ideal posi- tion among healthcare providers to experience the patient as a unique human being with individual strengths and complexities’. Similarly, Curtin’s (1979) concept of advocacy is based on the common humanity between nurse and patient for she maintained that: ‘we are human beings, our patients or clients are human beings, and it is this shared humanity that should form the basis of the relationship between us’. Gadow (1980) placed valuing the patient’s indi- viduality at the core of her philosophical founda- tion for nursing. She contended that the right to determine meaning for oneself was the most supreme human freedom, a freedom subsumed within the right to self-determination. Gadow (1980) wrote of the nurse advocate helping patients to ‘authentically’ exercise their freedom of self-deter- mination. By this she meant a way in which one reaches decisions that are absolutely one’s own. Valuing self - Konke (1982a) claimed that the advo- cacy role was action filled and suggested that it had risks. While supporting patients’ decisions the nurse risks being labelled an informer and precip- itating anger in others. The best antidote to these risks and ‘hidden hazards’ was open-mindedness, which included knowledge of oneself and an

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art & science research understanding of one’s own attitudes, values and beliefs. She believed that knowledge

understanding of one’s own attitudes, values and beliefs. She believed that knowledge dispelled the myths of advocacy and, like advocacy, began with the self. Knowledge affords the advocate the infor- mation necessary to inform patients, and self-know- ledge enables the advocate to support patients in their decisions. Robinson (1985) argued that advocacy involved enabling patients to make decisions freely without pressure and encouraging patients to make informed decisions. The advocate takes responsibility for ensuring goals and priorities are client-centred. A successful patient advocate is a nurse ‘who is first able and willing to set aside personal agendas and unit politics’ (Salladay and McDonnell 1989). To do this the nurse needs to know his or her own val- ues, beliefs and opinions. Apprising The second attribute is apprising, which is a combination of informing, advising and edu- cating. Konke (1982b) claimed that informing and supporting were at the heart of patient advocacy. Advocacy involves enabling patients to make their own decisions regarding health care, which will encourage the likelihood of them obtaining the health care of their choice. However, advocacy goes beyond merely assisting patients with their decisions. It involves helping them to reason and deliberate (Barton 1991). This requires that the patient is knowl- edgeable, before making the decision, about the impli- cations, consequences and alternative options on offer. Thus the advocate acts as a ‘sounding board’ so that patients can arrive at the right decision aware of the ramifications of their decisions. Chamorro and Applebaum (1988) enriched the apprising component by arguing that advocacy involved not only disclosing the consequences of proposed treatment plans but also the conse- quences of foregoing the treatment. This second attribute demands the skills of informing and advis- ing so that the advocate can promote and protect patients’ rights to be involved in decision-making and informed consent. Interceding The final attribute is interceding. It means coming between parties and intervening or mediating where necessary. Patient advocacy demands that the nurse helps patients to overcome barriers to meeting their needs (Curtin 1979, Winslow 1984). Reference to transcending barriers is sup- ported in the literature, which recognises nursing’s role in re-humanising and re-personalising patients’ experiences of healthcare services. Bureaucratic hospital systems and the power ascribed to healthcare professionals render the patient population vulnerable and impotent, as does the disease process (Curtin 1979). Kahn et al (1972) asserted that: ‘advocacy has existed for as long as there have been powerless groups in need of a champion’. In their position of powerlessness, patients require someone to speak for them, and in some cases mediate on their behalf. Interceding

was identified by Marshall (1991) and Sines (1993) as an advocate’s role. Both authors included medi- ating between parties as one of the advocate’s functions. Copp (1986) identified interceding in respect of vulnerable people. As hospitalisation ren- ders patients vulnerable, there is a need for an advocate who is able and willing to intercede on their behalf. Most literature pertains to interceding between patients and healthcare providers. Some identifies that the patient’s advocate intercedes between patients and family or significant others (Conway- Rutkowski 1982).

Antecedents and consequences

Antecedents and consequences are stages of con- cept analysis that are often ignored (Walker and

Avant 1995), yet they enrich an analysis by plac- ing the concept in context. The analysis reveals that there are two parties involved in patient advocacy

– the nurse and the patient. Therefore, there are

antecedents and consequences for both parties (Figure 1). Antecedents Antecedents are events that must occur before the concept (Walker and Avant 1995). The analysis has shown that the nature of the sit- uation preceding patient advocacy is twofold. First there is the context of vulnerability whereby the patient, simply by being a patient, is vulnerable.

The patient in his or her vulnerable state might be facing conflict or in a situation that requires a deci- sion. Second, there is a need for the nurse, who is to act as the patient’s advocate, to take responsi- bility for assisting the patient. Patient – Much of the literature analysed referred to patient vulnerability. Abrams (1978) clearly described how on becoming a patient there was

a need for an advocate. On entering hospital the

patient experiences loss of control over his or her life, and loss of identity and initiative. Being hos- pitalised removes one from the family and the natural supportive network families provide. The patient faces a strange environment with potential

worries about health problems as well as concerns about separation from family (Abrams 1978, Jenny 1979). Recent government publications provide

evidence that patient vulnerability remains an issue

in the 21st century, for example, publications guid-

ing patients through the network of health services (DoH 2001). In addition to being vulnerable, patients face con- flicts and situations demanding decision-making. Barton (1991) identified this antecedent when she claimed that advocacy was a vehicle for enabling patients to refuse treatment. Citing a case study of a patient who refused chemotherapy twice, on the grounds of wishing to secure herself a ‘quality of life’, Barton (1991) demonstrated how a vul- nerable patient faced conflict. The case study

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art & science research Figure 1. Attributes, antecedents and consequences of patient advocacy Antecedents Patient
Figure 1. Attributes, antecedents and consequences of patient advocacy Antecedents Patient – vulnerability Nurse
Figure 1. Attributes, antecedents and consequences of patient advocacy
Antecedents
Patient
– vulnerability
Nurse
– willingness
– conflict
– responsibility
Attributes
Valuing
Advocacy
Interceding
Apprising
Consequences
Patient
Nurse
Positive
– self-determination
– satisfaction
Negative
Patient
– discomfort
Nurse
– risk

demonstrated the first antecedent of vulnerability in that the patient (who had a cancer diagnosis) was experiencing a certain degree of persuasion from medical personnel as well as her family. There is evidence also that in this vulnerable state the patient was in a situation causing her conflict as she was refusing treatment. Brett (1998) likewise noted how conflict and vulnerability were inherent in the experience of the hospitalised older person. The strange environment and protocols may make older patients adopt a subordinate role where they find themselves agreeing with powerful healthcare professionals and feel a need to comply with rather than refuse treatment (Brett 1998). Nurse – Willingness and responsibility are the two antecedents pertaining to the nurse. Fay (1978), recognising that education would promote the advocacy role, assigned students course work that explicitly encouraged them to take responsibility for, and to become, patient advocates during clin- ical experience. In Barton’s (1991) case study, the patient did not benefit from the services of an

advocate. There was no nurse willing to take responsibility to continue to assist her with her deci- sion and she was persuaded on the third occasion to consent to chemotherapy. Ahern and McDonald’s (2002) survey of nurses’ beliefs relating to whistle- blowing and advocacy supported the existence of the two antecedents: nurses who reported mis- conduct believed in patient advocacy and felt they had a responsibility to patients. Consequences Consequences are those events that occur as a result of the concept (Walker and Avant 1995). As with antecedents there are positive and negative consequences for both patient and nurse. Patient – A positive consequence for the patient is that his or her autonomy is secured (Barton 1991, Graham 1992, Konke 1982a). Literature addressing nursing ethics also notes that patient advocacy is supported by the principle of autonomy because the nurse is obliged to enable patients to be self-determining. Teasdale’s (1998) advocacy flow chart, based on an analysis of 150 critical incidents, ended with patient empowerment which supports self-determination.

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art & science research Box 2. Advocacy: a model case A 55-year-old woman with a diagnosis

Box 2. Advocacy: a model case

A

55-year-old woman with a diagnosis of inoperable pancreatic cancer was offered

the opportunity of participating in a randomised controlled trial (RCT) involving cytotoxic chemotherapy. The patient confided to the nurse involved in her care that

she was having difficulty deciding whether or not to participate in the trial. The GP and the patient’s family were supportive of the trial. Participating in an RCT meant that she had no control over whether she would have to remain in hospital: one of the treatments involved being an inpatient. The patient asked the nurse to help her find out more information about the specific drug. The nurse, with the support of the patient’s family, contacted a national organisation’s helpline and obtained written information about the nature of the cancer and the drug to be trialled. She also contacted the oncologist who provided additional information about the drug. Stating that the patient had a poor prognosis, the oncologist hoped that the trial might be able to offer some ‘quality of life’, although what this involved could not be specified. The patient, in possession of the information the nurse had provided, decided not

to

enter the trial.

Table 3. Advocacy

Implications for practice

 

Assessment

Antecedents Consequences Own advocacy skills

Planning

Patient participation Decision-making strategies

Advocating

Using relationship building skills Promoting and protecting patients’ rights to be involved in decision-making and informed consent Mediating, informing and supporting

Evaluating

Criteria of effectiveness – consequences

A negative consequence that was implied in the

literature, however, is patient discomfort. Discomfort appears more apparent when there is competition for the role of advocacy between professionals

(Copp 1986). Konke (1982b) provided the most tangible evidence for the less desirable aspect of advocacy from the patient’s perspective. She claimed that it was a human trait to want to blame others in situations where the decision made turns out not to be the best one. Nurse – A positive consequence for the nurse is job satisfaction; however, the negative aspect relates to perceived and actual risk in terms of career. Literature pertaining to the nurse’s role clearly identifies advocacy as an ideal which, in turn, is a means to self-actualisation and a positive conse- quence of advocacy (Henderson 1961, NMC 2002). From Henderson’s early writing to current codes of professional conduct, being an advocate can help

the nurse to fulfil his or her role and is thus a pos- itive influence. It is grounded in the caring ethic (Curtin 1979).

A negative consequence, however, is advanced

explicitly by Andersen (1990), namely whistle- blowing. Other authors less forthright than Andersen (1990) also support the notion that advocacy is a risky business (Abrams 1978, Copp 1986, Fay 1978). Graham Pink was a charge nurse

working in care of the older person’s wards on night duty at Stockport. After unsuccessfully rais- ing concerns with his managers over a period of two years, he decided to publicly report how understaffing was causing inadequate care. Pink was dismissed. However, his employers said that

it was not because of whistleblowing. They took

action when a patient’s relatives complained that the information supplied to the press had been sufficient for them to identify who was being written about and this had caused them distress. Further examples of these risks are evident in Hunt’s (1995) whistleblowing survey results.

Model case

A model case taken from practice rather than cre-

ated, as Wilson (1971) suggested, follows Walker and Avant’s (1995) next stage of concept analysis. This is shown in Box 2.

The attributes of advocacy have been identified

as valuing, apprising and interceding. For this prac-

tice incident to qualify as a model case then all three needed to be present. The nurse demonstrated valu- ing in that her actions were aimed at gaining more information for the patient so that she could make an informed decision. Apprising and interceding

were also present through the nurse’s use of vari- ous sources to inform the patient. She was engaged

in interceding when she took responsibility for ‘com-

ing between’ two parties: the patient and oncolo- gist, and the patient and national helpline.

Discussion

The attributes of advocacy elicited from analysis of

nursing, research and scholarly literature are valu- ing, apprising and interceding. While each has been addressed individually, in reality they overlap. Concept analysis reveals that patient advocacy is a combina- tion of three essential helping strategies. Only when

all three attributes are combined is advocacy realised.

The deliberate, logical and systematic approach of assessment (Table 3) is required to determine those situations in which advocacy is appropriate and possible. Identifying patients who are vul- nerable and who require an advocate is essential. Additionally the potential advocate needs to observe for other situations in which to advocate for patients. The advocate needs to be aware of the antecedents so as not to miss opportunities that may be less apparent than merely being a mem- ber of, or stereotyped into, a vulnerable group. While assessing for situations of advocacy the advocate needs also to consider the consequences.

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art & science research This will include weighing the benefits against the costs to the nurse

This will include weighing the benefits against the costs to the nurse and patient. It is possible fol- lowing one negative experience that an advocate may assess the consequences in novel situations to be too great to implement advocacy. Patient participation is required. The fact that the antecedents for advocacy include vulnerable patients who may also be experiencing conflict in making decisions serves to illustrate the importance of their involvement in the process. As the purpose of advo- cating has been demonstrated as enabling patients to exercise their right to freedom and self-deter- mination, their active involvement is fundamental. Instruments of evaluation are not readily available for advocacy, however, the author suggests that the consequences of advocacy may be useful cri- teria to determine effectiveness. Nurses should be aware that valuing, apprising and interceding are required if they are to engage in patient advocacy. There will be situations in which nurses practise all of the skills noted as attributes, but not necessarily simultaneously. On their own the attributes are one of a number of helping strate- gies. Advocacy is possible only when all three attrib- utes are present.

Conclusion

The results from the analysis of the concept of advocacy reveal that it is a combination of three essential helping strategies. Only when valuing, apprising and interceding are combined can advo- cacy be realised. From the discussion, exploring implications for practice, along with the identifi- cation of antecedents and consequences, it can be concluded that advocacy is an essential and necessary requisite of nursing

advocacy is an essential and necessary requisite of nursing Implications of practice ■ Patient advocacy is

Implications of practice

Patient advocacy is a combination of valuing, apprising and interceding

Antecedents to advocacy include a vulnerable population and a nurse willing to take on the responsibility for advocacy

The consequences of acting as a patient advocate can be potentially negative or positive for both patient and nurse

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