(I992)8,47-53

Inknsivc and Cnlicnf Core Nursing

0 Longman Gmup UK Ltd 1992

Advocacy in critical care - an evaluation of the

implications for nurses and the future

J. W. Albarran

Patient advocacy is now considered an integral part of a nurse’s role, however there
is continued debate concerning whether a nurse can ever truly represent patients’
views and interests.
The purpose of this paper is to examine why it is necessary for nurses in critical
care areas to consider patient advocacy from professional, ethical and moral
perspectives. First definitions of advocacy are reviewed, and this is followed by a
critical evaluation of the legitimacy of the idea that nurses are the ideal health care
professionals to be patient advocates. In conclusion key issues are identified and
recommendations made for preparing future nurse advocates.

rights and interests, but according to Brown

INTRODUCTION ( 1985) and Fowler ( 1989) advocacy is also about
securing that each patient has equal access to
Nursing as an emerging profession is seen to be
quality and quantity of care, which must be
adopting new values, characteristics and prac-
tailored to meet the patient’s expressed needs. A
tices, one of which is advocacy. Since the mid-
more recent and broader interpretation of advo-
seventies there has been much debate on
cacy sees the nurse striving towards:
whether a nurse can fulfil the role of an advocate
(Annas, 1974; Donahue, 1978), this presumably ‘ensuring that patients have enough informa-
being viewed as desirable for nurses and per- tion to enable them to exercise control over
ceived as a patient need. Advocacy thus became a their own health care, that their legal and
statement of nursing commitment to a social and moral rights are respected and health care
ethical ideology (Jenny, 1979). resources are adequate to provide an appro-
The most widely accepted definition of advo- priate quality and quantity of care,’ (Webb,
cacy emphasises a concern with informing 1987; p 34)
patients and supporting their decisions
Implied within these definitions are the elements
(Kohnke, 1982). Castledine (1981) adds that this
of patient autonomy, the promotion and safe-
must also include safeguarding the patients’
guarding of human rights, social justice and
informed consent. In Brown’s (1985) view, a
nurse advocate must ensure that patients have
J. W. Akrran SRN EN6 125 DipN, Intensive Care
the benefits and possible side-effects of treat-
Unit, Southmead General Hospital, Westbury-On-
Trym, Bristol, BSlO 5NB ment disclosed and are made aware of available
(Requests for offprints to JWA) alternate therapies, so that decisions about their
Manuscript accepted 8 November 1991 health are informed and autonomous. Thus,

47
48 INTENSIVE AND CRITICAL CARE NURSING

there are a number of practical issues which pants in advocacy, reflecting an increased level
form a basis on which nurses in critical care areas of assertiveness and a sense of developing pro-
can begin to consider whether to choose to be fessionalism (Borley, 1988; Penticuff, 1989).
patient advocates. However, Brown (1985) sug- Over the last decade other factors contribut-
gests that advocacy by nurses requires a long ing to this shift towards professionalism have
term commitment, which must stretch beyond been concern with standards of care (Royal
the clinical area and not be confined solely to College of Nursing (KCN), 1980) and demands
those in hospital settings (Fowier, 1989). The on nurses to be more responsible and accounta-
effectiveness of nurses as advocates will depend ble for their decisions and use of resources,
on their open-mindedness, knowledge of self, particularly within the current political climate.
clients, society, and health care institutions The public’s expectations of the National Health
(Kohnke, 1982). Service have also risen and patients as consumers
Debates in favour of an advocacy role are of health care services are more aware of their
primarily based on the existence of a nurse- rights. Partly in response to these issues the
patient relationship (Annas, 1974; Borley, 1988; nursing profession’s regulating body, the United
Salvage, 1987), which enables the nurse to Kingdom Central Council for Nursing, Mid-
understand the patient’s values, priorities and wifery and Health Visiting (UKCC) issued a code
expectations. This is apparent in Intensive Care of conduct which declares that all nursing prac-
Units (ICUs) where nurses are continually in titioners must be accountable for their actions,
close contact with their clients, which places safeguarding the interests of patients at all times,
nurses in a unique position to articulate the and have regard for the adequacy of resources
patients’ interests. For example, Penticuff’s and workloads that may threaten standards of
(1989) research indicates that the clinical exper- practice, (UKCC, 1984). The code directs nurses
tise of neonatal nurses and the closeness they to take a more responsible and pro-active role in
had with their patients enabled the carers to advocacy, presumably attempting to assure the
recognise and assess infant suffering and this in public of the profession’s commitment and
turn sparked various acts of advocacy. Nurses in intentions. Indeed advocacy is viewed as integral
this study reported that they were able to influ- to the exercise of accountability by nurses
ence clinical practice by formal discussion with (UKCC, 1989).
medical staff, which led to a more frequent According to Thompson et al, (1988) nurses
review of the analgesia for neonates. Other have varied ethical, moral and professional
changes in the management of patient care responsibilities as well as a duty to the public.
included planned periods of rest, and on oc- They are responsible for those patients who are
casions requesting a multi-disciplinary meeting incapable of making rational choices, for
on behalf the family, to discuss whether further instance those who are brought in as emergency
invasive care was beneficial or harmful to the admissions, who may be confused, traumatised
infant. or unconscious. It is suggested that in return for
Closeness with patients has also been the trust given by an unconscious, critically ill
enhanced by the introduction of the nursing patient, the nurse has a moral duty to respect
process, which has enabled nurses to focus on and value the patient’s humanity, and to act as an
patients’ individuality, special needs for care and advocate for the patient while he/she is unable to
interests. This new emphasis in the delivery of contribute to decisions affecting his/her health,
care tends to return autonomy to the client, in this way the nurse fulfils a human responsi-
while nurses have gained increased professional bility (Ball, 1990; Leino-kilpi, 1990). Further-
responsibility and accountability for all aspects more Penticuff (1989) argues that in caring for
of care within their area of practice (Kumbold, patients who are unable to exercise their auto-
1986; Sawyer, 1988). Such changes have caused nomy, the duty of nurses should be grounded in
nurses to shift from being merely loyal team ethical principles that reinforce an ethic of the
members to being more active and vocal partici- good, promote human values and individuality,
 INTENSlVEAND<;RITICALCARENURSIN<; 49

as these are some of the concepts that form the the interests, values and rights of patients and
philosophy of advocacy. their families with confidence and insight.
Discussion about the advocacy of nurses often
Copp ( 1986) identified critically ill patients as a
centres on whether nurses can ever fulfil such a
temporarily vulnerable group in need of a nurse
role. The key constraints have been identified
advocate. Many of these patients may be unable
within a historical context. Maggs (1981) views
to communicate due to intubation and mechani-
the development of nursing in the context of
cal ventilation, pharmacological or other inva-
‘control mechanisms,’ which have been instru-
sive measures and therefore are unable to
mental in determining the subservience and
convey their wishes, and have no strength or
unquestioning obedience of nurses to an institu-
emotional reserve to articulate their needs or
tional hierarchy. Trandel-Korenchuck and
interests. They are dependent on thoughtfully
Trandel-Korenchuck (1983a) have similarly
planned nursing interventions with the purpose
described how medical dominance, restrictive
of achieving everything that the patient would
hospital procedures, contractual responsibilities,
do if he were able. In contrast some patients
and the socialisation of women have led to lack of
appear unwilling to participate in their own
autonomy, authority, equality or self-respect
health care, favouring a compliant role and
amongst nurses. In turn these values have
entrusting all responsibility of care to the nurs-
become internalised as norms of behaviour,
ing staff (Waterworth & Luker, 1990). In these
hence the submissive roles of nurses have been
instances there appears to be justification for
maintained (Davis 8c Aroskar, 1983; Lovell,
nurses acting in the role of patient advocate. It
1981) and this makes it impossible for nurses to
would seem that apart from planning the
act as patient advocates (Trandel-Korenchuck &
delivery of patient care systematically, and
Trandel-Korenchuck 1983b). Roberts (1983)
developing close relationships with patient and
has added that the establishment of a male
families, critical care nurses also have a moral
health care monopoly has also been crucial in
duty to protect the patients’ rights and auto-
explaining the uneven degree of authority, the
nomy, ensuring that their humanity is valued
lack of unity and divisiveness amongst nurses. It
and respected. In view of nurses’ many pro-
is arguable, therefore, whether nurses can rep-
fessional and ethical duties to patients one would
resent anyone, even themselves. Alternatively,
therefore expect a nurse to be the ideal health
one may contend that these writers are describ-
care professional to act as a patient advocate.
ing an American feminist mood of the late
This will include ensuring that there are suitably
Seventies, and their reasoning must be taken in
qualified nurses caring for patients, and avail-
that context.
able technological resources are used appro-
Since the nurse is closest to the patient, there is
priately to guarantee an optimum level of care
an underlying assumption in much of the
for the critically ill and ventilated patient.
discussion that the patient will choose a nurse as
Furthermore the proximity to patients allows
his advocate. However, this may be unlikely as
nurses the privileged position to understand,
the nurse may be viewed with suspicion, and
support and represent a patient’s requests, even
seen to be unreceptive, or untrustworthy due to
when this includes choosing not to be resus-
her working partnership with medical staff
citated (Decoste, 1990).
(Annas, 1974). Equally the nurse may not be
Critical care nurses are in many respects the willing to accept an added duty when she has
ideal health care workers to act as patient advo- other demands, a stressful workload or commit-
cates, as their combination of clinical expertise, ments. There may be a lack of agreement
technical and theoretical abilities and special between the values of the nurse and the patients’
knowledge of the patients have secured their family (Penticuff, 1989), and this may compli-
position within the multidisciplinary intensive cate the nurses’ position as an advocate. Further-
care team, (Atkinson, 1987; Penticuff, 1989). more, the nurse can never be certain what the
These qualities have thus enabled nurses to voice patient wants, and this uncertainty may become
50 INTENSIVEANDCRlTlCALCARENURSlNG

more apparent when dealing with those who do hcence towards the patient. However in a mater-
not speak English or are culturally different nalistic (or paternalisitc) role, the nurse acts in
from the carets. what she believes to be the patient’s best inter-
Kesearch by McKinley (1980) revealed that ests. Clearly this is at odds with the notion of the
only 49% of a sample of 33 ITU nurses, stated nurse as an advocate, and one is reminded that:
that they would advocate on behalf of patients ‘Paternalism and advocacy cannot co-exist’
who were unable to participate in their own care. (Marchewka, 1983; p 1073). Yet, even if
4 1% of nurses recognised that patient advocacy Kohnke’s (1982) model of advocacy is adopted,
was an important role, but were not sure if they there are inherent problems related to inform-
could act in this manner, instead they felt that ing and supporting the patient. For example, if a
complex judgements should be handed over to client makes a decision to smoke soon after a
doctors. (The remaining 10% felt it was inappro- myocardial infarction in spite of being informed
priate for nurses to act as patient advocates.) In a about the consequences for his health, one
similar study, nurses working in a variety of wonders how nurses can support the patient’s
settings including ITU, were asked what deci- choice and at the same time reconcile this with
sions they or the Charge Nurse/Sister should their role as health educators.
consider if faced with an adult patient’s request For nurse practitioners there also appear to be
not to be resuscitated (Lawrence & Fart-, 1982). many unresolved difficulties in relation to advo-
Their responses suggest that legal consequences, cacy and some aspects of the Code of Conduct
patients’ wishes and contacting medical staff (UKCC, 1984). Young (1989) has suggested that
should be taken into account in that order. interpretation of the first clause of the code has
Furthermore Lawrence and Farr (1982), also been a source of anxiety for practitioners. It
reported a strong lack of concensus about the might be suggested that safeguarding the
nurses’ role as independent decision-makers in welfare of patients may be viewed as an attempt
dealing with ethical dilemmas. Both these to avoid being charged with negligence. Young
studies serve to illustrate that nurses are poorly (1989) adds that further conflicts will arise when
prepared for advocate situations and believe that the nurse acts as a patient advocate, because this
intricate ethical decisions are more the realm of may entail contravention of other clauses of the
doctors. This latter notion is certainly the cur- code such as failing to work in collaboration with
rent opinion of hospital consultants, many of other members of other disciplines or respect
whom believe that nurses should be evasive or their contribution. Thus, as an advocate the
even lie to their patients when asked about nurse’s loyalties are challenged, whether to
treatment, diagnosis, or prognosis (Lyall, 1990). respect the patient’s interests and rights or
This adds weight to the view that, in spite of adhere strictly to the Code.
being closest to clients, nurses still lack self Those who have chosen the advocacy crusade,
esteem or confidence in their right to make have done so at great personal and professional
ethical decisions, and that medicine still controls costs (Nursing, 89; Kegan, 1984; Smith, 1980).
the level of nursing autonomy. If nurses are ever Beardshaw (1981) highlighted many of the
to succeed as patient representatives, these reasons why nurses fail to speak up on behalf of
factors will be crucial in the future. patients. These include, fear of harrassment,
Critical care nurses are faced with other con- lack of support from managers, conflict in
flicts. In many instances little is known about a loyalties, losing one’s job, suspension and pro-
patient except for his condition, and he may well fessional discreditation. A very recent example
be intubated and ventilated. In these circum- of this is the case of Pink (Wright, 1990), a charge
stances it is impossible to ensure that the patient’s nurse who began writing to his health authority
personal interests are represented; and it would and later the national press about the inadequate
seem that the nurse can act only in a maternalis- standards of care in a number of wards for which
tic manner (Marchewka, 1983), demonstrating he was responsible, and has been the subject of
the principles of beneficence and non-male- an inquiry of alleged misconduct.
 INTENSIVE AND CRITICAL CARE NURSING 51

In the light of these issues it remains ques- Currently, the persistence of institutional and
tionable whether nurses would act as advocates medical dominance has to a large extent main-
and challenge the institution or other colleagues, tained the subservience of nursing. Nurses’ self
when their own interests may be placed in esteem has additionally been undermined by
jeopardy (Porter, 1988). Equally as employees, their own belief that they are unable to deal with
nurses have contractual obligations and as such complex moral issues and therefore unable to
are accountable to the organisation in which they respond effectively as advocates or in decision-
work, which also expects loyalty and unquestion- making. This appears to be in part due to
ing obedience (Nelson, 1988). Indeed, for some inadequate preparation of nurses for this role
time now general managers have been demand- and the lack of cohesiveness within the pro-
ing that nurses should not comment publicly fession.
about the state of the health service or on the In practice, there seem to be many constraints
effects of new reforms on standards of care which impinge on nurses’ ability to represent
(Cole, 1987; Hancock, 1991). This is becoming individual patients’ needs and interests, yet there
more evident as hospital managers develop their are many instances when a duty of care
own corporate image, and redefine nurse prac- empowers them to act in this capacity. In the end
titioners’ working rights and terms of there are no hard and fast rules; each nurse must
employment (Nursing Times, 1991). Where decide and account for herself. Yet her decisions
there is an obvious clash for a nurse between must be informed and include the patients’ own
loyalty to a patient and loyalty to the institution, expressed wishes and her motives for pursuing
it would appear that the patient will come first, so an advocate role. However, Brown (1985) and
long as the nurse’s prospects are not threatened. Melia (1988) urge nurses to consider their
Even where such a threat exists the recent motives in their role as advocates and warn
introduction of a confidential telephone line, against abusing patient-advocacy as a means of
(announced at the Koyal College of Nursing solving personal disputes, or pursuing private
annual conference,) offers to nurses who have principles, or to raise the professions’ status and
witnessed a deterioration of standards of care or credibility.
in the quality of service the hope of becoming For the future there are urgent issues to be
whistle blowers and yet remaining anonymous addressed by the profession. Firstly, a clearer
(Hancock, 1991; Turner, 1991). definition of the concept of advocacy within
nursing is needed to avoid ambiguities. Secondly
a charter or Patients Bill of Kights such as those
CONCLUSION proposed by Annas (1974), might be introduced
in Britain and although it may not be legally
In conclusion, at present there are many sound binding, it may be a useful reminder for those
arguments that strongly favour the view that involved with the delivery of care. Alternatively
critical care nurses need to take a more pro- developing a philosophy of care will direct
active role as patient advocates. This need stems nurses to the purpose of nursing interventions,
from professional, moral and ethical perspec- remind staff of their commitment to each indi-
tives. Indeed, UKCC (1989) directives convey vidual, and delineate boundaries with other
the expectation that those who are responsible disciplines, but more importantly it will unite
for the delivery or management of care at nurses in their common stated beliefs and values,
whatever level will seek to ensure that patients’ (Johns, 1989a, 1989b; Komhanyi, 1990). Stated
rights and interests are protected. The literature philosophies may thus encourage staff to be
reviewed suggests that nurses are strategically aware of their pledged intentions to safeguard
placed to represent the welfare of patients as and the unique interests of clients and be responsive
when necessary. Such aspirations seem to derive to these.
from a commitment to reassure society about Some authors consider emphasis should be on
nursing’s caring intentions. the development of assertiveness skills for
52 INTENSIVE AND CRITICAL CARE NURSING

nurses, in order that they may function as Davis AJ, Aroskar M A 1983 Ethical dilemmas and
Nursmg practice. 2nd Ed. Appleton-Century Crofts,
effective patient advocates, (Bond, 1986; Baugh,
East Norwalk, Connecticut, USA
1989). Others agree, but suggest that nurses’ Decoste B 1990 The many faces of advocacy: victory
educational development at basic and post-basic and peace. American Journal of Nursing 9 (1): SO-X2
Donnahue M P 1978 The nurse: patient advocate?
levels must include preparation in ethical deci-
Nursing Forum 17 (2): 143-35’1
sion making (Nelson, 1988), understanding Fowler M D 1989 Social advocacv. Heart and Lunar 18 0

their role in relation to advocacy (Morrison, (I): 97-99

Hancock C 199 I Blowing the trumpet, Nursing Times
1991), and the legal dimensions associated with
87 (34): 26-28
undertaking this function (Tingle, 1988). Over- .Jenny J 1979 Patient advocacy-another role for nursing?
all it seems logical that advocacy is integral with International Nursing Keview 26 (6): 176-1X1
Johns C ISXYa; l9X9b Developing a philosophy.
nursing, indeed as the aim of nurses working in
Nursing Practice 3 (1): 2-4; 3 (2): 2-6
critical care areas is to meet the needs of uncon- Kohnke M F 1982 Advocacy what is it? Nursing and
scious patients until such time that they are able Health Care 3 (6): 3 14-3 IX
Lawrence.J A, Farr E H 1982 The nurse should
to participate actively in their own health care, it
consider. Critical care issues. .Journal of Advanced
would seem that advocacy in ITU and nursing Nursing 7: 223-229
are synonymous. If critical care nurses are to Leino-kilpi H 1996 Responsibility and accountability in
Intensive Care Nursing. Intensive Care Nursing 6 (2):
maintain their present commitment to safe-
92-95
guard the interests of patients and uphold the Love11 M C 19S 1 Silent but perfect ‘partners’:
UKCC Code of Conduct (1984), they need to Medicine’s use and abuse of women. Advances in
Nursing Sciences 83 (2): 25-40.
continue developing their education, asser-
Lyall J 1990 Cycles of Evasion. Nursing Times 86 (34):
tiveness skills, and research knowledge base, as 16-F-17
well as demanding greater collaboration with Maggs C 19X2 ‘Control Mechnisms’ and ‘the new nurses’
1881-1914. Nursing Times, Occasional Papers 77
other disciplines in all decisions affecting the
(25): 97-100.
wellbeing of patients and their nursing care, Marchewka A E 19X3 When is pdternahsm,justihable?
whether at the bed-side or the arena of policy- AmericanJournal of Nursing 83 (7): 1072-1673
Mckinley S 19X6 An advocacy role for the critical care
making.
nurse. Australian .Journal of Advanced Nursing 11
(3): 255-263
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