Nursing Forum Volume 42, No. 4, October-December, 2007 171
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ORIGINAL ARTICLES
Barriers to Nursing Advocacy: A Concept Analysis
AUTHORS RUNNING HEAD:
Barriers to Nursing Advocacy: A Concept Analysis
Barriers to Nursing Advocacy: A Concept Analysis
Robert G. Hanks, RN, C, MSN, FNP-C
Advocacy for clients is viewed as an essential
function of nursing; however, to be effective
advocates for patients, the nurse must often
overcome barriers to being an effective advocate.
This concept analysis of barriers to nursing
advocacy uses the Walker and Avant method of
concept analysis. By analyzing the barriers to
effective nursing advocacy for clients, nursing can
then find strategies to manage those barriers and
maximize the nurse’s advocacy efforts. Concept Analysis: Mental Stigma
Search terms
Barriers, concept analysis,
nursing, patient advocacy
Robert G. Hanks, RN, C, MSN, FNP-C, is a Clinical Instructor at the School of Nursing, University of Texas at Arlington, Arlington, TX.
Introduction and Concept Selection
Advocacy for clients is an important aspect in current professional nursing care and is considered to be a fundamental value of professional nursing by several nursing scholars. Since the origin of the client advocate in the 1970s (Annas & Healey, 1974), nursing has been viewed as the ideal profession to take on this advocate role (Annas, 1974) due to the intimate relationship of the client and nurse. The main act of advocating is viewed as part of nursing ethics by supporting patient autonomy (Gadow, 1989). Advocacy is found in all ethical codes for nursing (Hamric, 2000), including the American Nurses Association (ANA) Code of Ethics for Nurses (2001).
Nursing has not always practiced advocacy; rather, it is a relatively new role for nursing, emerging in the United States in the 1980s (Hamric, 2000). Barriers exist that prevent nurses from advo- cating for their clients, which will be examined in this article. For nurses to be effective advocates, an examination of the barriers that prevent nurses from fully realizing their role as nursing advocates must be performed in order to overcome these barriers.
Aim of Analysis
The aim of this analysis is to analyze critically the concept of barriers to nursing advocacy in order to provide clarity and direction for future inquiries into this subject. In addition, examining the barriers to nursing advocacy may result in more effective nursing education and interventions regarding nursing advocacy and the possibility of overcoming the barriers to provide effective nursing advocacy. Concept Analysis: Mental Stigma
172 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
Methodology
The methodology used in this concept analysis is the Walker and Avant (2005) concept analysis method (Table 1), which is derived from Wilson’s (1963) classic concept analysis procedure (Table 2). The Walker and Avant method was selected because it was determined to be more suitable for this novice author to use. Concept Analysis: Mental Stigma
Sample Selection
Articles for this concept analysis were selected using searches of Cumulative Index of Nursing and
Allied Health (CINAHL), MEDLINE, PsychInfo, and Sociological Abstracts. The databases chosen encompass the literature associated with the keyword combinations used. The combination of keywords used for the searches included the following: (a) patient advocacy, (b) nursing, (c) subservience, and (d) barriers. By including PsychInfo and Sociological Abstracts, a larger sample of literature was uncovered. The time period for the literature searches were as follows: (a) CINAHL 1982–2005, (b) MEDLINE 1966–2005, (c) PsychInfo 1967–2005, and (d) Sociological Abstracts 1963–2005, which are the limits of the databases at the library used. The resulting 55 abstracts were reviewed for content about nursing advocacy and barriers to advocacy with a total of 36 articles used for this analysis. Each of the selected articles from the literature was read for themes and contribution to the body of literature about nursing advocacy and barriers to nursing advocacy. Concept Analysis: Mental Stigma
Relevance of Literature Reviewed to the Selected Concept
The literature used for this concept analysis reflects the historical progress of nursing advocacy and, imbedded in this progress, the barriers to nursing advocacy. An examination of the barriers to nursing advocacy will help to focus nursing on overcoming the barriers and provide more effective nursing advocacy for clients.
Relevance to Nursing
Most nursing scholars and many nonnursing scholars agree that nursing advocacy for clients is a fundamental part of nursing practice (Annas, 1974; Curtin, 1979). This concept is reflected in ethical codes for nurses that include advocacy for clients (ANA, 2001; Hamric, 2000). If nurses are to be effective at nursing advocacy for their clients, then an understanding of barriers, both actual and potential, will help the nurse realize effective nursing advocacy.
Table 1. Walker and Avant Concept Analysis Method (2005, p. 65)
1. Select a concept 2. Determine the aims or purposes of analysis 3. Identify all uses of the concept that you can discover 4. Determine the defining attributes 5. Identify a model case 6. Identify borderline, related contrary, invented, and
illegitimate cases 7. Identify antecedents and consequences 8. Define empirical referents
Table 2. Wilson Concept Analysis Procedure (1963, pp. 23–36)
1. Isolate questions of concept 2. Right answers 3. Model cases 4. Contrary cases 5. Related cases 6. Borderline cases 7. Invented cases 8. Social context 9. Underlying anxiety 10. Practical results 11. Results in language. Concept Analysis: Mental Stigma
Nursing Forum Volume 42, No. 4, October-December, 2007 173
Most nursing scholars and many nonnursing
scholars agree that nursing advocacy for
clients is a fundamental part of nursing
practice (Annas, 1974; Curtin, 1979).
Uses of Concept
For the purposes of this article, the definitions have been narrowed to the nursing context accord- ing to the most recent version of the Walker and Avant method of concept analysis (2005). In order to understand the complex nature of the concept of barriers to nursing advocacy, nursing advocacy and barriers to nursing advocacy were analyzed separately.
Advocacy is derived from advocate, which is a “person that pleads a case on someone else’s behalf” (Oxford Online, 2006). Another source defines advocacy as “the act or process of advocating or supporting a cause or proposal” (Merriam-Webster Online, 2006a). Advocacy has been defined as correcting a deficit of a client by another (Grace, 2001), informing a person of their rights and providing information (Segesten, 1993), supporting the client (Kohnke, 1982), and giving voice to silent patients (Gadow, 1989).
Nurse is defined as “a person who is skilled or trained in caring for the sick or infirm especially under the supervision of a physician” (Merriam- Webster Online, 2006c). The ANA (2003) defines nursing, in part, as “provision of a caring relationship that facilitates health and healing” and “attention to the range of human experiences and responses to health and illness within the physical and social environments.” However, in nursing literature, nursing advocacy is a combined term that has been used to
define nurses advocating for their clients (Curtin, 1979). Most definitions of nursing advocacy in the nursing literature sample are describing attributes rather than actual definitions. Concept Analysis: Mental Stigma
Barriers are defined as “something immaterial that impedes or separates” (Merriam-Webster Online, 2006b). Barriers are not defined per se in the sample of nursing literature, but rather are qualified by the attributes of barriers.
Defining Attributes
Nursing Advocacy
The attributes of nursing advocacy vary in the sample. The nurse advocate is most commonly associated with protector of patient rights (Bandman, 1987; Becker, 1986; Foley, Minick, & Kee, 2000; Gadow, 1980; Gadow, 1989; Kubsch, Sternard, Hovarter, & Matzke, 2003). In this role, the nurse is protecting the fundamental rights of the patient’s self-determination over the patient’s care. Congruent with this concept is the informer role of the nurse advocate in which the nurse provides information to the patient about the patient’s care (Chafey, Rhea, Shannon, & Spencer, 1998; Curtin, 1979; Kohnke, 1980; Watt, 1997). Empowerment is also cited as an attribute of nursing advocacy (Chafey et al.; Lindahl & Sandman, 1998; Smith & Godfrey, 2002). The role of patient supporter is also contained in the nurse advocate role (Kohnke, 1982; Watt, 1997), with a related term, partnership, also being used in the literature (Gadow, 1983; Lindahl & Sandman; Snoball, 1996). A similar attribute, repre- sentative, is suggested by Copp (1986). Finally, the attribute therapeutic relationship has been recom- mended by Snoball. Concept Analysis: Mental Stigma
Barriers to Nursing Advocacy
The attributes of barriers to nursing advocacy are infrequently found in the literature. The most common attribute is conflict of interest between the nurse’s
174 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
responsibility to the patient and the nurse’s duty to the institution where the nurse is employed (Jenny, 1979; Miller, Mansen, & Lee, 1983; Pullen, 1995; Robinson, 1985; Walsh, 1985). Similar attributes of institutional constraint (Kohnke, 1980), including lack of support (Millette, 1993) and lack of power (Hewitt, 2002; Miller et al.), have been identified as barriers. An additional barrier to nursing advocacy is the nurse’s lack of education (Pankratz & Pankratz, 1974; Penticuff, 1989) and time (Miller et al.; Segesten, 1993). Threats of punishment are also considered an attribute of barriers to nursing advocacy (Mallik, 1997). Finally, a historical barrier of nursing being a feminine pro- fession with a tradition of subservience to the medical profession is also considered a barrier to nursing advocacy (Hamric, 2000; Winslow, 1984).Concept Analysis: Mental Stigma
Cases
Model Case
F.N. is a new graduate from an associate degree program and she has obtained her first nursing position at a small, private, community hospital. F.N. is very grateful to her new employer for a position, as it is the only hospital within 80 miles, and openings for registered nurses have been curtailed in the past year. The supervisor of F.N. is domineering, and is constantly reminding F.N. of her obligation to the hospital and physicians. The client load is heavy, often leaving F.N. with little time to discuss issues with her clients.
Mr. J. is a new client that has been admitted for renal disease and cellulitis of the left foot. The physician orders meperidine for pain management, which Mr. J. requests and receives each hour. After a day of this therapy, Mr. J. starts to have twitching movement in his arms. Concerned, F.N. discusses this issue with the supervisor. The supervisor tells F.N. to continue to administer the meperidine and “not ask questions.” The supervisor further informs F.N. that meperidine is the hospital standard and that
the hospital has “been using it for years.” Mr. J. is having muscle cramps due to the continuous twitching and requests that F.N. call the physician. However, F.N. has 10 other clients to care for, and fearing a reprisal from her supervisor, F.N. administers another dose of meperidine without consulting the physician. Concept Analysis: Mental Stigma
Borderline Case
P.M. is an experienced nurse with 20 years’ experience in the surgical area. She is caring for 10 clients that are postoperative. One of the patients, W.M., complains of incisional pain, but is concerned about the side effects of the medication that is ordered. P.M. administers the pain medication anyway, telling W.M. that she will come back later and discuss his concerns.
Related Case
Q.D. is a nurse working in a large long-term care facility. The length of employment for the nursing staff is less than 1 year, leaving the facility chronically short staffed. The facility is also undergoing budget constraints due to lower Medicare payments. Q.D. has been working two shifts per week of overtime during the past month, and is fatigued. Her supervisor asks her to work another shift of overtime on her only day off. Q.D. politely states that she needs to rest on her day off and spend time with her family. The supervisor reminds Q.D. how short the facility is of nursing staff. Q.D. replies that although she understands the facility’s position, Q.D. must first assure that she remains healthy and able to provide the best care to her clients by allocating sufficient rest periods from work.
Contrary Case
P.D. is a clinical nurse specialist working on a surgical ward. The floor nurses have asked her to come and evaluate the pain management of Mr. J., a new client
Nursing Forum Volume 42, No. 4, October-December, 2007 175
that has been admitted for renal disease and cellulitis of the left foot because, according to the floor staff, the charge nurse “won’t do anything.” Mr. J. is receiving large amounts of meperidine and has now developed muscle twitching. P.D. is aware of the neurotoxic metabolites of meperidine. After performing a detailed examination and having Mr. J. express his concerns, P.D. calls the prescribing physician and asks the physician to discontinue the meperidine, even though this is the preferred pain medication at the hospital and this particular physician’s preference. The meperidine is discontinued and morphine is ordered as the pain medication for Mr. J. After 24 hr, Mr. J. is rating minimal pain, and the muscle twitching has subsided. Concept Analysis: Mental Stigma
Invented and Illegitimate Cases
The invented and illegitimate cases are not required using this method of concept analysis (Walker & Avant, 2005). The concept of barriers to nursing advocacy has been sufficiently demonstrated using the model, borderline, related, and contrary cases. Concept Analysis: Mental Stigma
Antecedents
The antecedents to barriers of nursing advocacy are related to the need for nursing advocacy for the client. Advocacy for patients stems from a vulnerable population that loses power to represent or defend itself (Copp, 1986) or an individual that is neglected or intimidated (Chafey et al., 1998). The antecedents of barriers include employment conditions, fear of loss of employment, fatigue, frustration, and burnout (Chafey et al.). Inadequate education has been cited as a barrier to nursing advocacy (Copp; Jenny, 1979; Pankratz & Pankratz, 1974).
Consequences
The consequences of the barriers to nursing advocacy are of great importance but also seem simplistic. The
major consequence of the barriers to nursing advocacy is ineffective advocacy for the client by the nurse (Mallik, 1997). A secondary but related consequence of the barriers to nursing advocacy is continuing unresolved issues about patient care (Andersen, 1990). Concept Analysis: Mental Stigma
Empirical Referents
The barriers to nursing advocacy are found in the literature; however, the literature identifies few research studies or instruments on nursing advocacy or the barriers to nursing advocacy. In 1991, Hatfield explored the relationship between a nurse’s level of ethical reasoning and the factors that influence the nurse as an advocate, namely, autonomy and agency support. Hatfield authored the “Nursing Advocacy/ Beliefs & Practices” (NABP) scale for her dissertation study. The NABP scale measures the constructs of patient autonomy, nursing autonomy, and agency support (Hatfield, 1991). The correlation coefficient for the relationship between nurses’ beliefs about patient autonomy and ethical judgment was statistically significant (
r
= .5040;
p
= .01), leading to a conclusion that a nurse’s perception of autonomy in practice is influenced by ethical judgment. Concept Analysis: Mental Stigma
Ingram (1998) modified the NABP scale into the “Patient Advocacy Scale” for use with nurses in the UK. Although this scale was developed in 1998, it has yet to be utilized in studies (Ingram, personal communication, October 6, 2005). With a convenience sample of acute care nurses in the UK (
n
= 86), Ingram concluded that two factors, educational level and attendance in ethics courses, were predictive of PAS scores. However, the relationships between the two variables and PAS were weak: educational level (
r
= .3333;
p
= .002), and ethics course attendance (
r
= .2561;
p
= .017) (Ingram). Further exploration into nursing advocacy was performed in a study by Millette (1993) by asking nurses to choose from three models of advocacy (institutional, physician, and client) in a survey format with the client advocate model being chosen most frequently. Concept Analysis: Mental Stigma
176 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
Although the direct measurement of barriers to nursing advocacy has not been found in the literature, it may be possible to measure the barriers that have been identified by various authors cited in this article. Three attributes—education, time, and threats of punishment—could be measured without further delineation. Other attributes, including conflict of interest, institutional constraint, lack of support, and lack of power, may require additional inquiry to be measurable. Concept Analysis: Mental Stigma
. . . it may be possible to measure barriers
that have been identified by various authors
cited in this article. Three attributes—
education, time, and threats of
punishment—could be measured without
further delineation.
Implications for Nursing Practice and Education
The implications for nursing practice are that nurses need to overcome barriers to become effective nursing advocates for their clients. Although this is an ideal situation, the threat of job loss, retribution, intimidation, or ostracism can be real barriers ( Jenny, 1979; Miller et al., 1983; Pullen, 1995; Robinson, 1985; Walsh, 1985). Nurses need strategies to overcome barriers so that they can seek what is best for the client, including advocating in light of institutional and interdisciplinary constraints (Hewitt, 2002; Kohnke, 1980; Miller et al.; Millette, 1993).
Nursing education has an important role in educat- ing student nurses on the role of client advocacy in
nursing and how to effectively manage the barriers to be successful nursing advocates for the client ( Jenny, 1979; Pankratz & Pankratz, 1974). This educational approach could include not only the student nurse in the prelicensure program but continuing education for the practicing nurse.
Conclusion
Nursing has claimed client advocacy as an important core component of nursing practice. Nursing literature has several articles on philosophical stances on nursing advocacy. What has been found to be lacking is a clear understanding of the barriers to nursing advocacy that have been clearly and separately delineated in the literature. This article represents a concept analysis on the barriers to nursing advocacy in order to clarify the concept and provide a basis for further research into the barriers of nursing advocacy. Concept Analysis: Mental Stigma
This article represents a concept analysis on
the barriers to nursing advocacy in order to
clarify the concept and provide a basis for
further research into the barriers of nursing
advocacy.
Author contact: rghanks@utmb.edu, with a copy to the Editor: nursingforum@gmail.com
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