Patient Advocacy: Barriers and Facilitators
During the two recent decades, advocacy has been a topic of much debate in the nursing profession. Although advocacy has embraced a crucial role for nurses, its extent is often limited in practice.
An
Published 1 March 2006
Abstract (provisional)
Background
During the two recent decades, advocacy has been a topic of much debate in the nursing profession. Although advocacy has embraced a crucial role for nurses, its extent is often limited in practice. While a variety of studies have been generated all over the world, barriers and facilitators in the patient advocacy have not been completely identified. This article presents the findings of a study exploring the barriers and facilitators influencing the role of advocacy among Iranian nurses.
Method
This study was conducted by grounded theory method. Participants were 24 Iranian registered nurses working in a large university hospital in Tehran, Iran. Semi-structured interviews were used for data collection. All interviews were transcribed verbatim and simultaneously Constant comparative analysis was used according to the Strauss and Corbin method.
Results
Through data analysis, several main themes emerged to describe the factors that hindered or facilitated patient advocacy. Nurses in this study identified powerlessness, lack of support, law, code of ethics and motivation, limited communication, physicians leading, risk of advocacy, royalty to peers, and insufficient time to interact with patients and families as barriers to advocacy. As for factors that facilitated nurses to act as a patient advocate, it was found that the nature of nurse-patient relationship, recognizing patients' needs, nurses' responsibility, physician as a colleague, and nurses' knowledge and skills could be influential in adopting the advocacy role.
Conclusion
Participants believed that in this context taking an advocacy role is difficult for nurses due to the barriers mentioned. Therefore, they make decisions and act as a patient's advocate in any situation concerning patient needs and status of barriers and facilitators. In most cases, they can not act at an optimal level; instead they accept only what they can do, which we called 'limited advocacy' in this study. It is concluded that advocacy is contextually complex, and is a controversial and risky component of the nursing practice. Further research is needed to determine the possibility of a correlation between identified barriers/ facilitators and the use of advocacy.
Background
The role of patient advocacy is not new for nurses. Historically, patient advocacy has been a moral obligation for nurses. During recent years, nursing literature has been focused on the advocacy role and nursing professions has adopted the term 'patient advocacy' to denote an ideal of the practice [1]. Nurses assume that they have an ethical obligation to advocate for their patients [2]. They also frequently describe their judgments and actions on behalf of a patient as "being a patient advocate" [3,4].
An examination of advocacy in the nursing literature reflects broad and at times different perspectives. Advocacy has been described in ethical and legal frameworks and, more recently, as a philosophical foundation for practice. It has also been described in terms of specific actions such as helping the patient to obtain needed healthcare, assuring quality of care, defending the patient's rights, and serving as a liaison between the patient and the health care system.
Although multiple factors influence the need for advocacy, it is generally true that someone in the healthcare environment must assume the role of client advocate, particularly for the client whose self advocacy is impaired. Generally, advocacy aims to promote or reinforce a change in one's life or environment, in program or service, and in policy or legislation. In healthcare delivery, these activities focus on health conditions, healthcare resources, and the needs of patients and the public [6].
Advocacy is usually employed by someone powerful on behalf of someone who has no power [7]. In situations of vulnerability, powerlessness, or being involved in difficult circumstances, the individual needs to be advocated. Failure to do so may put the person's rights, welfare or basic needs in danger. Mallik (1997) concludes from her review that the core condition which demands advocacy action is the vulnerability of the client in two respects: personal vulnerability from illness and also vulnerability to risks inherent in the institutional processes to which the client is exposed in the health care system [8].
When nurses advocate for patients, they face certain risks and obstacles associated with the settings within which they work [9]. Therefore, there is always the possibility that attempts to advocate for a patient can fail, and that nurses can experience many barriers when addressing the rights, choices, or welfare of their patients.
As Nahigian (2003) noted, despite the fact that a variety of studies have been conducted in many countries, such as Sweden (Segesten, 1993), Korea (Cho, 1997), Australia (Breeding & Turner, 2002), England (Ingram, 1998; Mallik, 1997, 1988; Mallik & Fafferty, 2000; Snowball, 1996) and the United States (Chronkhite, 1991; Cole-Schonlau, 1991; Fetsch, 1991; Hatfield, 1991; Sellin, 1991, 1995); and additional studies in recent years by Hellwig, Yam and DigGiulio, 2003; Kubsch et al., 2004), the factors facilitating and inhibiting patient advocacy have not been completely identified [10,5,11]. This points to the importance of conducting research to obtain nurses' viewpoints on the facilitators and barriers for patient advocacy. This article reports the findings about barriers and facilitators that Iranian registered nurses perceive affecting their advocacy role from a large-scale grounded theory study.
Method
This research used a constant comparative method to analyze data collected through an extensive grounded theory study, enabling the researchers to discover, describe, and discuss the factors which influence nurses' patient advocacy role. The approach was selected for the study because patient advocacy takes place in a complex workplace relationship and social context [12]. Glaser (1998) believed that the grounded theory researcher sets out to discover patterns of behavior among particular groups of people in specific contexts. The key word is discovery; the research is exploratory allowing for identification of variables that will be integrated into a theory in a larger project where the purpose of research is to develop substantive theory. In a small-scale project, it is acceptable to describe and explain some underlying social processes shaping interaction and behavior [13].
Context
Nursing care in Iran before 1915 was carried out by household women or servants. Hospitalized patients were also cared for by untrained personnel. Due to the lack of basic education, social and cultural status, and some religious limitations for women, nursing did not have much advancement during that time. Iranian qualified nursing began in 1916, when a three-year nursing school was established in Tabriz. After 1916 there was a gradual increase in nursing schools across the country. Before the Islamic revolution in 1979, the majority of nurses were female and cared for both men and women. After the revolution, the government decided that nursing schools allow entry of male students up to 50 percent of those admitted, according to the belief that men should care for men and that women provide care for women. In 1980, when the war between Iran and Iraq began this point of view has been continued for many years. But due to the fact that the nursing profession could be more suitable for females in Iranian culture, the number of male students in nursing schools has been declined gradually. At present, nurses (male and female) can study at the university level from a bachelor's degree up to a PhD degree.
Sampling and data collection
The sample consisted of 24 nurses (staff nurses, head nurses and supervisors) working in a large university hospital in Tehran. Eighteen nurses, 3 head nurses and 3 supervisors were interviewed. The participants' age ranged from 23 to 50 with an average of 33.45. Nursing practice experiences ranged from 1 to 26 years with a mean of 10.59 years. Twenty three of participants had BS degree in nursing, and one participant had MS degree in physiology. Twenty one of participants were female and three were male. All the nurses who worked full-time in the period of study were considered as potential participants.
Purposeful sampling was used for the initial interviews and, according to the emerging codes and categories data was collected by means of theoretical sampling. We had planned to interview nurses with at least three years of work experience, however, emerging codes and categories, especially the codes related to desensitizing (working long time had made nurses grow desensitized), led us to interview a number of novice nurses. In total, 5 novice nurses were invited to be interviewed.
Interviews
The main researcher R. Negarandeh explained the aim of the study and the research questions for each potential participant. Upon accepting to participate in the research, and after signing the informed consent sheet, nurses were given an appointment for the interview. For the sake of participants' convenience, interviews were carried out at the time they felt their workload was lower and had enough time to be interviewed. Individual semi-structured interviews were conducted in a private room at the workplace. The interview guide consisted of core open-ended questions to allow the respondents to explain their own viewpoints and experiences as completely as possible. Each interview began with a broad question, such as "could you describe one of your working shifts?" Participants where then asked to explain their own experiences and perceptions of "patient advocacy", as well as "barriers and facilitators" that affected taking on the advocacy role. The interviews continued with the topic questions and probes in order to capture a deeper understanding of the phenomenon under study. All interviews were carried out by the same interviewer. Interviews were recorded by a digital sound recorder, transcribed verbatim and analyzed consecutively. The duration of interview sessions ranged from 40 to75 minutes, with an average of one hour, depending on participants' tolerance and their interest in explaining their own experiences.
Data analysis
Data analysis resembles a discussion between the actual data, the created theory, the memos and the researcher. Such discussion takes place when the data are broken down, conceptualized and put back together in new ways. The data give rise to the codes and the categories which combine the codes. The categories and hypotheses must be verified against the data by comparing the categories with each other, with the data and with the researcher's conclusions [13].
Data from the interviews were analyzed concurrently using constant comparative method. Data analysis started at the same time with the data collection and each interview was transcribed verbatim and analyzed before the next interview took place. In other words, each interview provided the direction for the next one. The process of interviewing was stopped when data saturation occurred. Data were considered "saturated" when no more codes could be identified and the category was "coherent" or made sense.
Open, axial and selective coding was applied to the data [14]. Through open coding, the interview transcripts were reviewed several times and the data reduced to the codes and then the categories were formed from the codes, in a manner that similar codes were grouped into the same categories. The focus of axial coding was on specifying a category in the context in which it had appeared. This process allowed links to be made between categories and their subcategories, and then selective coding developed the main categories and their interrelations. If the researcher is simply concerned with exploring or describing the phenomena being studied, axial coding completes the analysis. Hence data analysis was stopped at this phase for the aim of this article. However, grounded theory, as the term suggests, seeks to go further. For this you need to go on selective coding.
Regarding trustworthiness, credibility was established through member check, peer check and prolonged engagement. The participants were contacted after the analysis and were given a full transcript of their respective coded interviews with a summary of the emergent themes to determine whether the codes and themes were suitable to their experiences. Then three expert supervisors and two other doctoral students of nursing conducted the peer checking. Prolonged engagement with the participants within the research field helped the main researcher to gain the participants' trust and a better understanding of the research fields. Maximum variation of sampling (in terms of the type of ward, years of working experience and place of duty) also enhanced the confirmability and credibility of data. This sampling strategy enabled the researcher to capture a vast range of views and experiences carefully [15].
Ethical considerations
Ethical issues were concerned with the participant's autonomy, confidentiality and anonymity during the study period. All participants were informed of the purpose and design of the study and also the voluntary nature of their participation. The research proposal was approved by the Iran University of Medical Sciences Research Council. Informed consent was attained from the participants in writing and signed by them for all stages of the study. Moreover, an official permission was attained from the hospital director, nursing manager and head nurses in order to conduct the study.