The nurse as the patients’ advocate- is it time to put down the banner?

At a time when governments around the world are increasingly turning their attention to addressing healthcare related harm, Dr Bernadette Eather, the Director Patient Safety at the NSW Clinical Excellence Commission , challenges us to think about a broader definition of harm and the nurses role in patient advocacy to improve safety.

In patient safety, harm is most often defined as an unintended physical injury resulting from, or contributed to, by medical care. Harm is rarely considered to be seen as an impact on a patient’s confidence. However, movements to support and empower decision making by patients like #wearenotwaiting, demonstrate that redefining harm to patients should include disempowerment and harm to their confidence.

One particular role for individuals to play in patient safety, which has emerged in the later part of last century, is that of the patient’s advocate. It is nurses who have embraced this role and claimed it as integral to their work. Advocacy could simply be seen as the act of beneficence in which nurses have an obligation to intervene for patients at risk, or of autonomy in which patients’ rights are protected. But the role of the nurse as the patient’s advocate has not only developed in many countries as a principle or ethical obligation, but also as part of professional codes of practice for nurses.

With advocacy espoused as a central tenet of the nursing profession and a professional requirement, the question can be asked, why is this role so pivotal to the nursing profession and not others? Terms including key, best, and ideal are those quoted to describe the unique position held by nurses to champion the advocacy role. Some argue that it is the sustained and intimate attendance of the nurse which results in the nurse developing a unique knowledge of the patient, which places nurses in an ideal position to advocate for patients. Other arguments that ‘nurses are in the best position to advocate for patients’ include that nurses have the most knowledge of the patient as a result of the time spent with the patients, and, that they are emotionally engaged in the patient’s experience.

The concept of the nurse as the patient’s advocate has three principal suppositions. Nurses are proactive in contrast to being passive and subordinate, that nurses speak up and act on behalf of patients, and that a form of difficulty, challenge or conflict has to be present- otherwise, advocacy would not be necessary. In terms of patient safety this form of advocacy would require nurses to intervene when they recognise a patient is at risk (beneficence), not solely in situations when a patient’s rights and wishes are being violated (autonomy), but in the face of unsafe or inappropriate management decisions which expose the patient to unnecessary risk. Therefore, the important role of the nurse as the patient’s advocate could be argued to contribute to a diminution of patient risk.

However, at what point does advocacy become paternalism? Does the role of the nurse as the patient’s advocate impact on the ability for patients to advocate on their own behalf? Does the role result in harm, as defined as an impact on a patient’s confidence? Does the nurse as the sole advocate not only bar other health professional from assuming this role, but also the patient from being able to self-advocate? Does it impact on a patient’s right to self-determination?

Perhaps the answer lies in the autonomy based model of advocacy in which paternalism and advocacy may coexist and nurses must carefully delineate the two in order to ensure that patient autonomy is paramount. Nurses must support an individual in the exercise of the individual’s right to self determination. There is an argument that it is that only individuals who decide what is in their own best interest, and the role of the nurse is to assist the individual in this process to make his or her own decisions about the best course of action.

So, maybe we don’t need to put down the banner, but change the sign to “Nurses, supporting patients to advocate for themselves”.

Dr Bernadette Eather