Patient advocacy—nurses keeping patients safe

AORN Journal,  May, 2005  by Suzanne C. Beyea

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Nursing advocacy plays a critical role in keeping patients safe throughout their encounters with the health care system. This is especially true when a patient is undergoing surgery and anesthesia or is too ill or sedated to serve as his or her own advocate. In a recent edition of the National Patient Safety Foundation's newsletter, a scenario is presented that describes a surgical patient's distress when he discovered that bone tissue had been excised during his surgery. The patient had explicitly told his physician not to remove any bone. (1) It is apparent that after the patient was anesthetized, no one served as his advocate. This patient's expressed wishes and written consent were ignored.

Individuals familiar with the role of the circulating nurse in the OR might ask, "Where was the RN?" After a patient is anesthetized, the circulating nurse most commonly serves as the patient advocate, speaking up when the patient cannot. In most situations, the circulating nurse would simply have reminded the surgeon of the patient's preferences or prestated restrictions during the procedure.

BEING AN ADVOCATE

What does it mean to serve as a patient advocate? Advocacy is defined as "the act or process of ... supporting a cause or proposal." (2) Patient vulnerability often is the reason one serves as an advocate. (3) Since the time of Florence Nightingale, nurses have served in this important role, advocating for health care improvements related to infection control, practice and patient care environments, and access to care. Regardless of the practice setting, every encounter a nurse has with a patient provides an opportunity for that nurse to serve as a patient advocate.

Although nurse advocacy is discussed by nurse clinicians and educators, there is limited understanding of how to teach students or experienced nurses about this role. (4) Nurses generally learn the advocacy role by watching other nurses who provide positive role models by standing up for patients. Through their own experiences, nurses gain confidence in performing the advocate role. (4)

WHEN TO ADVOCATE

Clinicians may decide what is best for patients instead of asking or fully considering what the patient might want. This is most likely to occur in situations in which patients choose to rely on and give their complete trust to their health care providers. Other times, patients may be afraid to voice their concerns or preferences.

Nurses and other health care clinicians must remain alert to times when patients are hesitant or unable to speak up. Encouraging a patient to voice his or her wishes and desires or giving voice to a patient when the patient cannot speak is one of the nurse's most important roles. Nurses should consistently ask the questions, "What does this patient want? What are his or her preferences? What are his or her wishes and values?" This information serves as the foundation for the nurse's role as advocate. A nurse becomes an advocate for a patient by providing care that focuses on meeting the patient's specific wishes.

Nurses also must focus on ensuring that care is provided in the safest manner possible. A nurse serves as an advocate when he or she limits traffic in an operating suite or delays the start of a procedure until the correct instruments are available. Nurses in the perioperative arena play a critical role in monitoring the environment of care, providing safe care, and promoting best practices for infection control prevention.

ADVOCATING FOR PATIENTS' FAMILY MEMBERS

Patients' family members also may need an advocate during the perioperative experience. A perioperative nurse once told me the story of how she allowed family members of a severely injured patient into the OR when the patient appeared to be very close to death. This simple act of kindness also was an act of advocacy. The nurse supported the family members' strong desire to be with the patient if there was a significant change in her condition or if it appeared that the patient would die from her injuries. The nurse respected the family members' wishes and advocated with members of the surgical team to allow the family members into the OR just before what seemed like the patient's impending death.

Amazingly, when the nurse brought family members into the OR and allowed them near the patient's bedside, the patient's condition suddenly and dramatically improved. The patient eventually recovered from her surgery and her injuries. Members of the family later remarked that the patient might have died without this simple intervention and the nurse's commitment to both the patient and her family members.

CHALLENGES TO ADVOCATING

Working in complex systems can make it challenging for nurses to act as advocates. Other clinicians may not listen or respond in a timely manner. There also may be competing priorities for a nurse's attention and efforts, perhaps placing tasks before advocacy.

Nurses, however, must consistently place patients' safety first. This may involve having a difficult conversation with a colleague about practice issues or concerns that compromise patient care. For example, a nurse may observe that a member of the health care team does not routinely wash his or her hands before touching a patient or after providing patient care. In the OR, a nurse may see a colleague who regularly violates sterile technique or ignores other practice standards. The nurse may need to speak to a surgeon about breaking scrub or contaminating his or her gloves. Practice patterns that place patients at risk must be recognized and addressed.