Dissertation on Advocacy

The Oxford English Dictionary defines the term advocate as "one who pleads the case of another" (1989). The legal view of advocacy encompasses the definition of advocacy as a consultation between client and lawyer before a court proceeding (Woodrow 1997). The International Council of Nursing (ICN) has included nurse advocacy in their code since the 1970s. In recent nursing literature "nurse advocacy" has become somewhat of a buzzword connected with the concepts of nurse autonomy, ethics, moral issues and the view of patients as health consumers.

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Although the nurse that advocates for their client has no real legal standing among the health professions, the importance of such advocacy arises often as a binding, if legally un-recognized, unsaid contract between the nurse and the client.

Henderson's theory of nursing says that advocacy is "a separate identity, not included in the medical models of treatment" (Henderson, 1960). The question arises, Is Nurse based advocacy on the client's behalf more of a philosophical endeavor taken on by the nurse as an overpowering internal drive to protect the client? Or does the advocacy of the client's rights and wishes by nurses serve an ideal avenue for the lobbying of said rights in a legal and political venue? The arguments for both sides are persuasive, leaving that fine line uncrossed by either side.

Advocacy for the client has evolved throughout the years in the medical community an endeavor taken on by the professional nurse. History shows us that the archaic reverence given to physicians is slowly becoming a thing of the past. Florence Nightingale first introduced the theory of patient advocacy in an indirect manner. Her belief that "the world was unsafe, requiring that the patient be protected from its environmental and social effects on health" (Nightingale 1969) was in fact a first time recognition of patients' personal well being addressed outside the physical well being of a patient. Nightingale inadvertently planted the seed of trust between the nurse and the patient to grow a strong bond between the two. This basic belief of patient-nurse bonding has been taken as one of the fundamental standards of nursing responsibility in the modern day profession. Beginning in the 1960s, Virginia Henderson theorized that nursing should be patient led instead of institution led, meaning that the nurses responsibilities and loyalties should fall more to the actual patients wishes and concerns than that of an economically driven institution. Henderson believed that "the nature of nursing is a separate identity formed to encompass skills not included in the medical model of treatment, based upon ethical constructs, as opposed to task oriented behaviors" (Henderson, 1960). In other words, nurses have something better to offer other that bedpans and bandages.

The autonomy of the nursing profession allows the nurse to inform, instruct and speak for the individual patient. The nurse is often times put in the middle of patient’s wishes and the physician's demands. The ability to mediate such conflicts is the foundation of advocacy. Carol Willard, a nursing professor from Manchester College of Midwifery and Nursing in Manchester, England says, "autonomy of the nurse as well as the patient must be paramount in making ethical decisions regarding the capacity to determine ones own destiny" (Willard, 1995). When an otherwise healthy person is suddenly hospitalized and independence is taken away, it is taken for granted that the patient will be compliant and conform to "rules" set by his or her physician. If the patient does not agree with the action the doctors find necessary for treatment, what recourse does that patient have? Here is when the nurse advocate is to step in and speak on behalf of the patient. The true nature of nursing is to provide care and comfort to ones patient. Student nurses are taught that the welfare of the patient is always first and foremost in every aspect of care. If said patient is fearful of a possibly life-saving procedure and questions the doctor's orders, how far should the nurse go on behalf of the patient? At what level of authority does the nurse give in when advocating for a patient? Nurse Theorist Sally Gadow believes that "existential advocacy is the essence of the nurse's participation with the patient" (Gadow 1980). Gadow also believes that nursing advocacy is "based upon the principle that freedom of self-determination is the most valuable human right"(1980). While a patients right to self-determination is essential to the patient himself, criticism of that belief should be noted on the nurses behalf. Nurses must be concerned with questioning the authority of the doctor because of the ramifications and backlash that could potentially put the nurse out of a job, or at the very least, mark her as a troublemaker. Taken at the personal level of patient concern, the nurse can speak without fear of retribution, but as the nurse travels up the chain of command, the more powerful the obstacles become. The inner determination of each individual nurse comes into question here. Should the nurturing, internal drive of the nurse to protect the patient at any cost be the vehicle for advocacy? In many nursing theory frameworks this point remains undefined. Advocacy in the sense of patient-nurse bonding is an obligation of nurse professionals, but in the legal sense, advocacy takes on a whole other connotation.

To be a legal representative for the patient is far beyond the reach of an ordinary nurse. The Citizen Advocacy Information and Training (CAIT) guidelines state, "Advocates owe those they represent a duty of loyalty, confidentiality, and a commitment to be zealous in the promotion of their cause" (Willard, 1995). The CAIT also states that advocates should be unpaid and independent from any health business. The transformation of health care from compassion based service, to one of strong financial goals has brought the need for patient advocacy to the forefront of the health care systems. 

The ordinary nurse is hardly in the position to lobby for legislative laws and regulations of patients rights on a full time basis. The independent advocate is unrestrained by conflict of the subservience of nurses to doctors, therefore alleviating the fear of reprisal in a profession setting. The independent advocate is free of emotional attachment to patients that a nurse would have while caring for the sick and dying. The independent advocate would be outside the realm of office politics and doctors egos.

Most importantly the independent advocate would be better positioned to drive patient rights home to congress, as having the time to commit to such an undertaking is not a privilege most nurses have. The benefit of independent advocacy would also address that very problem of time constraint and quality of care often imposed on over-worked and underpaid nurses. The duty of beneficence to the patient is one a nurse uses on a personal level, creating that unbreakable bond so needed by those who cannot care for themselves.

The concept of nurse advocacy is not recognized by the law (Mallik & McHale 1995). The nurse must cross the fine line of advocacy carefully. Without specific guidelines and knowledge, the potential for accountability weighs heavily upon the nurses shoulders. One wrong move and a nurse's career may be over, another wrong move and a patient's life may be over. Advocacy has a definite place in the nursing profession, the voice of the patient must be heard above all other clamor. If the nurse is not empowered enough to lay it on the line, neither will the patient be empowered enough to tow the line.

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