Health advocacy role performance of nurses in underserved populations: A grounded theory study

AIM

Nurses' health advocacy (HA) role requires them to speak up for patients, clients, and communities in relation to healthcare. Various studies report the importance of the HA role of the nurse in healthcare. However, nurses' performance in this role is not clear yet. The present study aims to identify and explain how nurses perform their HA role in underserved populations.

DESIGN

Qualitative grounded theory by Strauss and Corbin.

METHODS

Data were gathered from three regional hospitals in Ghana with 24 registered nurses and midwives as participants through purposive and theoretical sampling techniques. Face-to-face in-depth semi-structured interviews were conducted from August 2019 to February 2020. The data were analysed using Strauss and Corbin's method and Nvivo software. The reporting follows Consolidated Criteria for Reporting Qualitative Research guidelines.

FINDINGS

The HA role performance theory emerged from data with role enquiry, role dimension, role context, role influence, role reforms and role performance as building blocks. Data analysis showed that the main concerns of the nurses during their daily practice were mediating, speaking up, and negotiating. Among others, the intervening conditions were clientele influence and interpersonal barriers, whereas the outcome was a balance between role reforms and role performance.

CONCLUSION

Although some nurses proactively initiated biopsychosocial assessment and performed the HA role, most of them relied on clients' requests to perform the role. Stakeholders should prioritise critical thinking during training and intensify mentoring programmes in the clinical areas.

RELEVANCE FOR CLINICAL PRACTICE

The present study explains the process by which nurses perform their roles as health advocates in their daily activities as nurses. The findings can be used to teach and guide clinical practice for the HA role in nursing and other health care fields. There was no patient or public contribution.

The principle of double effect and external whistleblowing in nursing

Nurses are generally expected to raise concerns when a harm or wrongdoing is committed against patients. Should their concerns not be adequately addressed, then nurses may take the decision to engage in external whistleblowing. Given that it could have a negative effect on the health care organization or service, nurses may question whether they should engage in external whistleblowing. Consequently, is there an ethical criterion to discern whether the negative effect on the health care organization or service is ethically permissible? This paper argues for the suitability of the Principle of Double Effect as an ethical criterion. The position of this paper is that external whistleblowing by a nurse when understood as an advocacy act with two effects (i.e. the effect of defending a patient and the further negative effect on the health care organization or service) can be ethically permissible through meeting the conditions of the Principle of Double Effect.

The therapeutic dimension of research about spirituality: Particularities of cancer, mental health and infertility

Healthcare is moving from a biomedical paradigm into a holistic paradigm, which includes all dimensions and needs of patients and families. Health conditions may trigger a spiritual journey for believers or non-believers bringing to light the nature of the human being and its vulnerable condition. Healthcare professionals are full participants in this life and health scenario and have an unquestionable duty related to the provision of spiritual care, on the basis of legislation, ethical codes, and on research evidence. Researchers are seizing better and broader knowledge about spirituality in healthcare, and research about this phenomenon is growing internationally. But, spirituality is considered complex, an area of intimacy and deep subjective meaning. These factors may raise some ethical concerns when submitting research projects to the ethics committees. In this paper, the authors share their experience in research about spirituality in the beginning of life issues/infertility and with adults with severe health conditions, and describe participants' perspectives on research engagement.

Preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar

Objetivos: identificar los predictores del ejercicio de la abogacía en salud por enfermeros en el contexto hospitalario. Materiales y método: estudio cuantitativo, transversal analítico, realizado con 157 enfermeros de dos instituciones hospitalarias del sur de Brasil, una pública y una filantrópica. Se realizó la recolección de datos entre los meses de septiembre y octubre del 2015. Se utilizó el instrumento Protective Nursing Advocacy Scale — versión brasileña, constituido por 20 ítems, dispuestos en cinco constructos. Para el análisis de los datos, se utilizaron elementos de la estadística descriptiva, la correlación de Pearson y el análisis de regresión lineal. Resultados: los resultados evidenciaron moderada asociación entre facilitadores al ejercicio de la abogacía y percepciones que favorecen su ejercicio. La dimensión “facilitadores al ejercicio de la abogacía” obtuvo el mayor promedio del instrumento y fue el principal predictor jurídico en salud en el contexto hospitalario, capaz de provocar en los enfermeros la sensibilidad y el deseo en abogar. Conclusiones: el sentimiento de responsabilidad por parte de los enfermeros en mantener el buen funcionamiento del equipo y manejar cuestiones conflictivas en ofrecer seguridad a los pacientes, aun ante resistencias oriundas del local de trabajo.

AÇÕES DOS ENFERMEIROS NO EXERCÍCIO DA ADVOCACIA DO PACIENTE: REVISÃO INTEGRATIVA

RESUMO: Objetivo: identificar as ações dos enfermeiros no exercício da advocacia do paciente, na literatura científica internacional publicada nos últimos dez anos. Método: revisão integrativa da literatura, cujos dados foram coletados na base de dados Cumulative Index to Nursing and Allied Health Literature e SAGE Journals Online, utilizando-se os descritores "patient advocacy" e "nursing", sendo encontrados 27 artigos. Resultados: como resultados, emergiram duas categorias: ações de advocacia exercidas por enfermeiros em diferentes nações e culturas; e ações de advocacia nos diferentes ambientes de atuação dos enfermeiros. Conclusão: acredita-se que os achados deste estudo poderão contribuir para a produção de pesquisas e conhecimentos em enfermagem, ampliando a compreensão da advocacia do paciente como um componente ético da prática dos enfermeiros.

Cancer nurses' perceptions of ethical climate in Greece and Cyprus

BACKGROUND

In recent years, the interest in ethical climate has increased in the literature. However, there is limited understanding of the phenomenon within the cancer care context as well as between countries.

AIM

To evaluate cancer nurses' perceptions of hospital ethical climate in Greece and Cyprus.

RESEARCH DESIGN

This was a quantitative descriptive-correlational comparative study with cancer nurses. Data were collected with the Greek version of the Hospital Ethical Climate Survey questionnaire in addition to demographic data.

PARTICIPANTS AND RESEARCH CONTEXT

In total, n = 235 cancer nurses working in cancer care settings in Greece and Cyprus were recruited at two national oncology nursing conferences.

ETHICAL CONSIDERATIONS

The study conforms to the principles of the World Medical Association Declaration of Helsinki and the relevant ethical approvals were obtained according to national law.

RESULTS

The results showed that in terms of the "Managers" dimension, participants working in Greek hospitals (4.30 ± 0.73) had a higher score compared to the Cyprus participants (3.66 ± 0.93) (t = -5.777, p ≤ 0.001). The perceptions of nurses working in oncology units in Greece regarding the ethical climate were more positive compared to Cyprus (M = 3.67 for Greece and M = 3.53 for Cyprus, p ≤ 0.001). Nurses with a higher level of education had a lower average ethical climate score across all dimensions. All dimensions exhibit positive and moderate to high correlations between them (r = 0.414-0.728, p < 0.01).

CONCLUSION

It is imperative to evaluate and improve the hospital ethical climate that prevails in each cancer care department. This highlights the fact that nurses working in seemingly similar cultural and organizational contexts might still have different perceptions of the ethical climate. Despite these differences, it is necessary to create the right conditions to address ethical issues. A positive ethical climate requires good relationships between healthcare professionals and the presence of good teamwork in order to ensure better healthcare provision.

Health advocacy by nurses in the Family Health Strategy: barriers and facilitators

OBJECTIVE

Identify the barriers and facilitators of health advocacy to users delivered by nurses from the Family Health Strategy.

METHOD

Qualitative study carried out with nurses from the Family Health Strategy of a city in the south of Brazil. Study participants were 15 nurses, who were interviewed. The content of the interviews was recorded, transcribed and analyzed in the light of the discursive text analysis.

RESULTS

Two categories emerged, one about the lack of organization at the workplace, bureaucracy and limitations to professional work in health environments, and another about the facilitating aspects to exercise advocacy both individually and collectively.

CONCLUSION

When nurses, provided with technical, scientific and relational knowledge, are empowered to make decisions, they are not only supported by other professionals at work but also develop actions of health advocacy to users, thus qualifying the care delivered.

"We are the best to stand in for patients": a qualitative study on nurses' advocacy characteristics in Ghana

Background

Patient advocacy has been identified as a core duty of the nurse, and certain nurse characteristics influence the performance of the role. However, these characteristics have not been adequately explored in Ghana. This study aimed to explore the perspectives of nurses about the characteristics of nurses that influence their role as patient advocates.

Methods

An exploratory descriptive qualitative study was conducted among 15 nurses from a regional hospital in Ghana. Purposive sampling was used to select participants and individual in-depth interviews were conducted in English using a semi-structured interview guide. The interviews were audio-taped and transcribed. Data analysis was done concurrently employing the principles of thematic analysis. Ethical approval was obtained for the study from the Noguchi Memorial Institute of Medical Research and the Ghana Health Service Ethical Review Committee.

Results

Themes generated revealed nurse traits which enhanced the advocacy role of nurses such as being empathetic, nurturing, ethical, assertive and persistent and nurse states which hindered the performance of the role such as fatigue and frustration. However, “compassionate” emerged as an additional nurse trait from this study. Out of empathy, participants availed themselves for patients to share their problems with them. In their nurturing roles, spending more time with patients and providing personal care fostered closeness which helped in identifying patients’ problems. Helping patients navigate the health system was also found. They perceived patient advocacy as a moral responsibility and identified good communication skills and determination to help patients get their problems solved as important in patient advocacy. Some participants also described compassion-based activities such as pleading on patients’ behalf, providing material and financial assistance, facilitating care and providing emotional support in their advocacy. However, heavy workload and lack of appreciation from patients were found to hinder the performance of the advocacy role.

Conclusions

We concluded that nurse characteristics that influence patient advocacy are comparable to those identified internationally such as being empathetic, assertiveness and fatigue. Enhancing these characteristics could help nurses overcome the negative states that undermine the patient advocacy role of nurses.

COMO ENFERMEIROS VÊM EXERCENDO A ADVOCACIA DO PACIENTE NO CONTEXTO HOSPITALAR? - UMA PERSPECTIVA FOUCAULTIANA

Objetivou-se conhecer como os enfermeiros vêm exercendo a advocacia do paciente no contexto hospitalar. Realizou-se uma pesquisa qualitativa, do tipo exploratório-descritiva, em um hospital universitário do Sul do Brasil. Foram respondentes da pesquisa 16 enfermeiros, selecionados por meio de amostragem não probabilística, do tipo bola de neve. Para a coleta de dados, foram realizadas entrevistas semiestruturadas, gravadas e transcritas, analisadas mediante análise textual discursiva e referencial teórico foucaultiano. Como resultados, emergiram duas categorias: a coragem de verdade: o exercício da advocacia mediado pelo diálogo franco; estratégias de resistência para o exercício da advocacia do paciente. Conclui-se que a estabilidade profissional e o apoio da instituição contribuem para que os enfermeiros se sintam encorajados a exercer a advocacia, mesmo diante de situações de difícil enfrentamento, utilizando-se da parrésia e de estratégias de resistência para garantir a defesa efetiva dos interesses dos pacientes.

Ethical problems experienced by oncology nurses

OBJECTIVE

To know the ethical problems experienced by oncology nurses.

METHOD

Descriptive and exploratory study with a qualitative approach, performed in inpatient units and in chemotherapy out-patients units that provide assistance to oncological patients in two capitals in the South region of Brazil. Eighteen nurses participated in this study, selected by snowball sampling type. For data collection, semi-structured interviews were carried out, which were recorded and transcribed, and then analyzed by thematic analysis.

RESULTS

Two categories were established: when informing or not becomes a dilemma - showing the main difficulties related to oncological treatment information regarding health staff, health system, and infrastructure; to invest or not - dilemmas related to finitude - showing situations of dilemmas related to pain and confrontation with finitude.

CONCLUSION

For the effective confrontation of the ethical problems experienced by oncology nurses to occur, it is important to invest in the training of these professionals, preparing them in an ethical and human way to act as lawyers of the patient with cancer, in a context of dilemmas related mainly to the possibility of finitude.

Nursing beliefs and actions in exercising patient advocacy in a hospital context

AbstractOBJECTIVEAnalyzing beliefs and actions of nurses in exercising patient advocacy in a hospital context.METHODA quantitative cross-sectional exploratory and descriptive study, conducted with 153 nurses from two hospitals in southern Brazil, one public and one philanthropic, by applying Protective Nursing Advocacy Scale - Brazilian version. Data were analyzed using descriptive statistics and analysis of variance.RESULTSNurses believe they are advocating for patients in their workplaces, and agree that they should advocate, especially when vulnerable patients need their protection. Personal values and professional skills have been identified as major sources of support for the practice of advocacy.CONCLUSIONNurses do not disagree nor agree that advocating for patients in their working environments can bring them negative consequences. It is necessary to recognize how the characteristics of public and private institutions have helped or not helped in exercising patient advocacy by nurses.

Legislating for advocacy: The case of whistleblowing

BACKGROUND

The role of nurses as patient advocates is one which is well recognised, supported and the subject of a broad body of literature. One of the key impediments to the role of the nurse as patient advocate is the lack of support and legislative frameworks. Within a broad range of activities constituting advocacy, whistleblowing is currently the subject of much discussion in the light of the Mid Staffordshire inquiry in the United Kingdom (UK) and other instances of patient mistreatment. As a result steps to amend existing whistleblowing legislation where it exists or introduce it where it does not are underway.

OBJECTIVE

This paper traces the development of legislation for advocacy.

CONCLUSION

The authors argue that while any legislation supporting advocacy is welcome, legislation on its own will not encourage or enable nurses to whistleblow.

Nursing Actions in practicing inpatient advocacy in a Burn Unit

OBJECTIVEUnderstanding nursing actions in the practice of inpatient advocacy in a burn unit.METHODA single and descriptive case study, carried out with nurses working in a referral burn center in southern Brazil. Data were collected through focus group technique, between February and March 2014, in three meetings. Data was analysed through discursive textual analysis.RESULTSThree emerging categories were identified, namely: (1) instructing the patient; (2) protecting the patient; and (3) ensuring the quality of care.CONCLUSIONSThis study identified that the nurses investigated exercised patient advocacy and that the recognition of their actions is an advance for the profession, contributing to the autonomy of nurses and the effectiveness of patients' rights and social justice.

Cross-cultural adaptation and validation of the Protective Nursing Advocacy Scale for Brazilian nurses

OBJECTIVE

to adapt culturally and validate the Protective Nursing Advocacy Scale for Brazilian nurses.

METHOD

methodological study carried out with 153 nurses from two hospitals in the South region of Brazil, one public and the other philanthropic. The cross-cultural adaptation of the Protective Nursing Advocacy Scale was performed according to international standards, and its validation was carried out for use in the Brazilian context, by means of factor analysis and Cronbach's alpha as measure of internal consistency.

RESULTS

by means of evaluation by a committee of experts and application of pre-test, face validity and content validity of the instrument were considered satisfactory. From the factor analysis, five constructs were identified: negative implications of the advocacy practice, advocacy actions, facilitators of the advocacy practice, perceptions that favor practice advocacy and barriers to advocacy practice. The instrument showed satisfactory internal consistency, with Cronbach's alpha values ranging from 0.70 to 0.87.

CONCLUSION

it was concluded that the Protective Nursing Advocacy Scale - Brazilian version, is a valid and reliable instrument for use in the evaluation of beliefs and actions of health advocacy, performed by Brazilian nurses in their professional practice environment.

Swedish nurses' perceptions of influencers on patient advocacy: a phenomenographic study

BACKGROUND

A limited number of studies have shown that patient advocacy can be influenced by both facilitators and barriers which can encourage and discourage nurses to act as patient advocates.

OBJECTIVE

This study's aim was to describe Swedish nurses' perceptions of influencers on patient advocacy.

RESEARCH DESIGN AND CONTEXT

Interviews with 18 registered nurses from different Swedish clinical contexts were analysed using the phenomenographic method.

ETHICAL CONSIDERATIONS

Ethical revisions were made in accordance with national legislation and guidelines by committees for research ethics at Karlstad University.

FINDINGS

Three levels of hierarchically related influencers on patient advocacy were found in the descriptive categories. The fundamental influencer, the nurse's character traits, was described in the perceptions that advocacy is influenced by nurse's having a moral compass, having control over the care situation, being protective and feeling secure as a nurse. The second most vital influencer, the nurse's bond with the patient, was expressed in the perceptions of knowing the patient and feeling empathy for the patient. The third level of influencers, the organisational conditions, was described in the perceptions that the organisational structures and organisational culture influence patient advocacy.

DISCUSSION

The results correspond with findings from earlier research but add an understanding that influencers on patient advocacy exist at three hierarchically related levels.

CONCLUSION

The nurse's character traits are the fundamental influencer to patient advocacy, but in order to be comfortable and secure when advocating for patients, nurses also need to be familiar with both the patient and the situation. A supposition could be that all influencers interact, which needs to be further addressed in future studies.

Moral distress: challenges for an autonomous nursing professional practice

Constantly experiencing limiting situations that hinder a professional practice coherent with its principles - of autonomy and advocacy of users' interests -, and often conditioned to experience moral distress, the nursing profession plays a prominent role in the current health model because it has the characteristic of managing the care rendered to users in a perspective of social inclusion, both in the basic health network and in hospitals. Aiming at carrying out a reflection on the nursing practice and the difficulties present in its work routine, and considering its characteristics as a profession, this article sought to make a reflection between the practice of nursing and the numerous moral challenges imposed by the routine, resulting, in many cases, in a value crisis that can reverberate directly on the quality of the service rendered, and in abandonment of the ideals of advocacy for users.

Nurses as patient advocates in oncology care: activities based on literature

This article will explore oncology nurses' patient advocacy activities and compare those activities with patient advocacy activities defined in an earlier study by the authors. Data were collected from 42 English-language peer-reviewed articles published from 2000-2010. Search terms used included cancer care and advocacy and oncology nursing and advocacy. According to the findings of the reviewed articles, oncology nurses promote the interests of their patients by analyzing patients' psychosocial and physical distress and care plans, particularly at the beginning of the illness trajectory. Oncology nurses also are instructed in the literature to educate patients about cancer management prior to the first treatment and during cancer management to promote informed consent, but not to analyze patients' information or self-determination preferences. Oncology nurses do, however, advocate for their patients by presenting and raising awareness of patients' needs and preferences in regard to the healthcare system. To some degree, this advocacy can be seen as responding to patients' care and self-determination preferences. Oncology nurses' patient advocacy activities are similar to advocacy activities defined in the context of procedural pain care but are more focused on the beginning of the illness trajectory. However, care and self-determination needs, information needs, and advocacy needs of patients with cancer vary during the illness trajectory. Those needs should be analyzed and responded to systematically.

Ethical advocacy based on caring: a model for neonatal and paediatric nurses

Advocacy has been identified as an ideal in nursing practice. National codes (Australian Nursing and Midwifery Council) and professional standards (Australian College of Neonatal Nurses) state that nurses are to respect their patients' autonomous choices and act as their advocates. This responsibility includes acting as advocates for the needs and welfare of patients, for the profession of nursing and for the interests of colleagues in nursing. However, ambiguous interpretations of the concept of patient advocacy continue to pose a number of problems for nurses in practice and in particular neonatal practice. Neonatal nurses often perceive themselves primarily as advocates for the rights of helpless and vulnerable infants in their care. Advocacy is underpinned by caring, which is a significant feature in the delivery of quality care for each baby and child. This advocacy may be expressed at the bedside, in committee meetings, in agency discussions or in the public arena.

Efficacy of the use of evidence-based algorithmic guidelines in the acute care setting for pain assessment and management in older people: a critical review of the literature

AIM

The aim of the literature review was to identify all examples of primary research using an algorithmic approach for the implementation of a clinical practice guideline relating to pain assessment and/or management within acute care, with a specific focus on older people.

DESIGN

Critical literature review.

DATA SOURCES

Inclusion criteria were; English language publications within the past 13 years; peer reviewed; research conducted within a hospital; about adult inpatients. Exclusion criteria; research located outside of a hospital context; quality improvement studies; rehabilitation studies and literature reviews.

REVIEW METHODS

Critical appraisal of the literature by using a qualitative interpretation of a translational approach. The literature was thematically mapped according to the criteria of credibility, transferability, plausibility and applicability.

RESULTS

No clinical practice guideline was found that directly related to both assessment and management of pain using an algorithm in acute care for older people. Five studies were found to have relevance and were critically evaluated.

CONCLUSION

A critique of the literature shows that an algorithmic approach is feasible for translation into a clinical practice guideline for assessment and management of pain in older people within the acute care setting.

IMPLICATIONS FOR PRACTICE

Implementation of any algorithmic approach requires consideration of the environment, culture and availability of resources.