...changes can challenge resource allocation decisions and adversely affect the work environment [and] can also create opportunities for nurses and the nursing profession. These are challenging times in which to be employed in healthcare. Unprecedented changes in the healthcare system are impacting care in all practice settings. These changes include financial pressures, uncertainty of the direction of healthcare reform, mandates from regulatory agencies to improve quality and patient safety, advancing technology, looming workforce shortages, and changes in the patient population. These changes can challenge resource allocation decisions and adversely affect the work environment. However, these forces can also create opportunities for nurses and the nursing profession. These opportunities include a greater voice for nursing in healthcare policy, expanded employment opportunities, and an enhanced image for nurses and the profession (Benner, Stephen, Leonard, & Day, 2010; Institute of Medicine, 2011; Page, 2005).

In order to successfully capitalize on these emerging opportunities, it is important for nurses to work together, across employment settings and roles, to advocate on behalf of colleagues and the profession. Nurses comprise the largest professional group within healthcare and have been recognized by the public as the most trusted profession (Gallup, 2010; Jones, 2010). Despite nursing’s strengths inherent in its size, diversity, and unique relationship with the public, the full potential for influence by the nursing profession has yet to be realized (Buresh, Gordon, & Benner, 2006).

Although nurses in the United States anticipate future benefits resulting from healthcare system reform, the stress of today’s workplace falls squarely on the shoulders of nurses at the point of care. To reap these future benefits, nurses need to advocate for the profession’s desired future. It is important that all nurses engage in, and become involved in developing processes in their respective work settings to advocate for realistic changes that meet the needs of both patients and staff.

Other articles on advocacy in this topic have addressed the role of the nurse in patient advocacy and the advocacy role of the professional association. The purpose of this article is to explore strategies that enable nurses to successfully advocate for themselves and the nursing profession. Whether working within one’s own employment setting to advocate for a safer work environment, or at the state level to achieve prescriptive authority for advanced practice nurses, the process and skills required for successful advocacy are the same.

Advocacy Defined

Advocacy often requires working through formal, decision-making bodies to achieve a desired outcome. Advocacy is defined by the Merriam-Webster Collegiate Dictionary (2009a) as the act or process of supporting a cause or proposal. An advocate is defined as one that pleads, defends, or supports a cause or interest of another. Much of the literature on advocacy comes from non-profit and special interest groups that prepare potential advocates to influence public policy. Strategies promoted by these groups are also applicable for nurses and the nursing profession. Amidei (2010) has described advocacy as "seeing a need and finding a way to address it" (p. 4). Sharma (1997) defined advocacy as "action aimed at changing the policies, positions or programs of any type of institution” (p. 4). Family Care International (2008) promoted advocacy as "the process of building support for an issue or cause and influencing others to take action" (p. 3); while the Worldwide Palliative Care Alliance (2005) identified advocacy as "a process that can lead to change through influence" and a "way of directing decision-makers towards a solution" (p. 4). These definitions all suggest that the role of an advocate is to work on behalf of self and/or others to raise awareness of a concern and to promote solutions to the issue. Advocacy often requires working through formal, decision-making bodies to achieve a desired outcome. This process could include the 'chain of command' within a healthcare organization, a commission, a state legislature, or other groups at the healthcare system's policy level.

While most nurses readily embrace the mandate of the professional nurses’ advocacy role as it applies to patients, the expectation for advocacy on behalf of colleagues, the profession, or even oneself may not be so clear or consistently noted. The professional responsibilities of the nurse to work with colleagues to promote safe practice environments are described in the American Nurses Association’s (ANA) foundational documents, including the Nursing Scope and Standards of Practice (2010) and the Code of Ethics for Nurses with Interpretative Statements (Code of Ethics) (2001). The ANA Scope and Standards of Practice identifies advocacy for safe, effective practice environments as a responsibility of the professional nurse (ANA, 2010).The Code of Ethics describes the responsibility of the nurse to work through appropriate channels to address concerns about the healthcare environment. In addition, the Code of Ethics identifies a range of advocacy skills and activities that nurses are expected to demonstrate. These activities promote the profession and form the basis of the advocacy role for the professional nurse. The skills include service to the profession through teaching, mentoring, peer review, involvement in professional associations, community service, and knowledge development/dissemination (ANA, 2001). These activities and skills form the basis of advocacy role of the professional nurse.

Advocacy Skills

The ability to successfully support a cause or interest on one’s own behalf or that of another requires a set of skills that include problem solving, communication, influence, and collaboration. Each of these skills will be discussed below.

Problem Solving

...it is important to take the time to develop a compelling request and to identify the appropriate time and individual to whom to make the request. Advocacy is focused on addressing problems or issues in need of a solution. The steps in the advocacy process are first to identify the issue(s) to be addressed and develop goals and a strategy to address the issue(s). Once the strategy is identified, a plan of action is developed to organize advocacy efforts and establish a time line for completing each activity that supports the strategy. Most advocacy initiatives involve approaching decision makers with requests for action to address the identified issue. Before approaching decision makers, however, it is important to take the time to develop a compelling request and to identify the appropriate time and individual to whom to make the request. Patience and a sense of timing are necessary in order to achieve a successful outcome. Few victories are achieved on the first attempt. Most advocacy initiatives are accomplished through collaboration, negotiation, and compromise; they may require a series of actions over time in-order-to achieve a desired outcome.

Communication

It can be helpful to put a ‘human face’ on the issue by using ‘word pictures’ to make the communication more compelling. Successful advocacy requires effective communication skills. Most advocacy initiatives involve bringing individuals and groups together to address an issue or concern. Advocates need to communicate clearly and concisely and to structure the message to fit both the situation and the intended audience. Advocates must be comfortable with verbal, written, and electronic formats. Communication regarding the issue should be factual and consistent. While it is important to be prepared to discuss the specific facts and data associated with the issue, it is equally important to discuss the impact of the situation on those involved. It can be helpful to put a ‘human face’ on the issue by using ‘word pictures’ (words that create a picture in another’s mind) to make the communication more compelling (Amidei, 2010).

One way to help to formulate a consistent communication message is to prepare a ‘Sixty- Second Speech.’ This is a brief, practiced speech used to introduce the issue and proposed solution. Distributing a one-page fact sheet or brochure is an excellent way to close the speech, and ensure that the listener is walking away with the key points (Amidei, 2010). The following Box describes the content to include in a Sixty-Second Speech.

Influence

Influence is built on competence, credibility, and trustworthiness. To facilitate change or solve an issue, the advocate must be able to influence others to action. Influence is the ability to alter or sway an individual’s or group’s thoughts, beliefs, or actions; it is essential to the advocacy process (Merriman-Webster, 2009b). Influence is built on competence, credibility, and trustworthiness. Keeping the best interests of those involved in the situation builds trust and credibility. An effective advocate influences decision makers by building a case for the desired change, backing the case with facts and data, and putting a human face on the issue using a compelling visual image. Persuasion is a stronger form of influence that makes use of an appeal or argument to make one’s point. While effective in small increments, persuasion can elicit defensiveness in others, thus undermining the overall success of an initiative.

Collaboration

Collaboration is working with other individuals or groups to achieve a common goal. It differs from cooperation which involves groups working together to achieve their own individual goals. In addition to demonstrating the skills described above, the advocate must also establish positive, collaborative relationships with others to garner the support necessary to address the issue. Collaboration is working with other individuals or groups to achieve a common goal. It differs from cooperation which involves groups working together to achieve their own individual goals. In collaboration, the individuals or groups involved develop common goals, along with common strategies and activities that will achieve that goal (Denise, n. d.). Collaboration is built on trust, mutual respect, and credibility. The end result of groups collaborating to achieve a common goal can be greater than that which each group could accomplish independently. Successful collaboration requires careful communication with the groups involved in the process, seeking input when appropriate, and providing ongoing reports related to progress on achieving the goal.

It is necessary, during the advocacy process, to work with those people (the stakeholders) who are affected by the issue. In addition, the advocate may collaborate with others in the organization interested in solving the issue. These individuals often have expertise that would be beneficial to the effort. Developing a collaborative relationship with professionals in support departments, such as infection prevention, employee health, or human resources, will be invaluable when addressing issues that involve these departments. Likewise seeking out support staff in other venues, such as a legislative aid or the assistant to a commissioner, can be equally helpful.

In summary, advocacy is a complex process that requires skillful use of problem solving, communication, influence, and collaboration to achieve a solution to an issue. Often, advocacy is an incremental process of achieving change through a series of efforts that may take months or years to accomplish.

Point of Care Nurses as Advocates for Nurses and Nursing

Never before has the voice of the nurse at the bedside been so critical...The impact of registered nurses on patient outcomes is increasingly evident... It is essential that point-of-care nurses develop and use advocacy skills to address workplace concerns, promote positive work environments, and advocate for the profession. Never before has the voice of the nurse at the bedside been so critical to patients, colleagues, and healthcare facilities. An increasing number of facilities have, or are developing shared governance structures to ensure that nurses at the point of care have a voice in decisions related to patient care and the work environment. The impact of registered nurses on patient outcomes is increasingly evident; and nursing input into organizational decision making related to safety and quality initiatives is invaluable. Nurses are increasingly positioned to advocate more effectively than ever before not only for patients, but also for themselves and the nursing profession.

Opportunities for Point-of-Care Advocating

While the time an employee invests in completing a survey may be only a few minutes, the outcome can be very significant for improving working conditions for all staff. Membership on committees, councils, and quality improvement teams provides opportunities to advocate. When serving on a committee, council, or team, it is important to represent the needs of both colleagues and patients. Sometimes this means considering the impact of an issue or proposed solution on nurses and staff in other departments as well as one’s own workgroup. The best way to work through the needs of multiple groups is to consider what ultimately is best for the patient, client, or population served.

Engagement in organization-wide activities provides opportunities to advocate for colleagues and for the profession. Many organizations conduct periodic, employee satisfaction or opinion surveys that are used to develop plans to promote staff engagement. While the time an employee invests in completing a survey may be only a few minutes, the outcome can be very significant for improving working conditions for all staff. Often a comment or recommendation will focus the attention of decision makers on a specific issue or possible solution. Being as specific as possible about the issue or potential solution will help organizational leaders to more appropriately address the concern. Nurses can also use employee forums or town hall meetings to raise awareness of their concerns. When making use of these opportunities, it is important to use good advocacy skills, which include communicating with credibility and promoting a sense of trust. Identifying an issue, proposing a solution, and/or offering to be involved are very effective ways to serve as an advocate.

Modeling positive professional behaviors and helping those new to the profession to acquire these behaviors is a form of advocacy. Nurses have an opportunity for advocacy when involved in teaching nursing students and new nurses at the bedside. Students and new nurses are excited about the profession they have chosen. They see practicing nurses as role models and mentors. Modeling positive professional behaviors and helping those new to the profession to acquire these behaviors is a form of advocacy. Providing guidance during a difficult learning situation, such as the first time a novice performs a procedure, can advocate for both the patient and the novice.

Nurses can help to portray a more accurate picture of nursing by talking specifically about what they do, describing the complexity of their work, and explaining the types of clinical judgments they make. Nurses also have opportunities to advocate for the profession by describing the strengths of the profession whenever they are asked about their work. Although nursing is consistently rated as the most honest and ethical profession, the role of the nurse is not well understood by the public (Buresh et al., 2006). Another opportunity to advocate for the profession is by promoting public understanding of the nursing role. Many individuals do not comprehend that nurse have an independent practice responsibility beyond following the doctor’s orders. There is an important need to educate the public that a nurse’s role is to assess, plan, and intervene to address healthcare issues. Nurses can help to portray a more accurate picture of nursing by talking specifically about what they do, describing the complexity of their work, and explaining the types of clinical judgments they make. Developing a sixty-second speech to describe the nurse’s role and share the consequences of nurses not being available to attend to patient concerns or complications prepare a nurse to respond effectively to any advocacy opportunity that might arise during working or non-working hours (Buresh, 2006).

Examples of Point-of-Care Advocacy

In one hospital a committee was established to address patient ‘throughput’ in the acute care setting, so as to expedite patient transfer from the emergency department to the nursing unit. The committee was comprised of nurses from the emergency department, intensive care, and medical surgical units, in addition to managers and admitting staff. The team was charged with developing a process to limit extensive waiting in the emergency department. One important area of discussion among the nurses was mitigating the disruption caused by patient transfers during shift change. Following a lengthy, heated discussion about the issue, the impasse was solved when the group agreed to focus on what was best way to get the patient to the most appropriate venue for care. Once this was established, the rest of the plan fell into place, and a strategy for minimizing the impact on inpatient areas was developed, thus improving the working conditions of staff nurses as well as addressing the needs of the patient.

Opportunities for advocacy occur at many levels: some occur in the work setting and others may occur in the grocery store. In another agency nurses were concerned about the increasing incidence of back injuries among the nursing staff. The staff approached the hospital risk manager who organized a task force to develop a program to reduce back injuries. Nurses, nursing assistants, physical therapists, and transporters were all involved in developing the program and testing products. They reviewed the lift and transfer devices available to facilitate safe patient handling and ensure staff safety. In addition, they assisted with training on the use of the equipment, which over time included ceiling-mounted lifts and transfer devices. The committee members also served as champions for eliminating manual patient lifting. As a result, the incidence of staff injuries decreased significantly.

In summary, every nurse can play a role in advocating for nurses and the profession. It is through day-to-day collective action that nurses work together to advocate for improvements in the work environment and for the advancement of the profession. Opportunities for advocacy occur at many levels: some occur in the work setting and others may occur in the grocery store. The key is to promote the profession with every advocacy opportunity that arises.

Manager/Administrator Role in Advocacy

Leaders advocate for patients, nurses, and the profession in a number of ways. This advocacy can include actions both to ensure appropriate resource allocation and to promote positive work environments.

Advocacy for Appropriate Resources

Today’s work environment is increasingly stressful, and competition for resources is keen. Nursing leaders can advocate for staff by actively involving staff in decisions that directly affect the practice environment. Advocacy is enhanced when scheduling and staffing are a collaborative process that involves staffing committees and self-scheduling approaches. Staff involvement can help to ensure balanced schedules and flexible staffing approaches that meet the needs of both patients and staff. In addition, proactive planning to formulate solutions to unpredicted staff shortages can facilitate patient and staff safety in unforeseen situations

Staff involvement in the budgeting process promotes an understanding of the challenges operating in today’s healthcare environment. Leaders also fulfill the advocacy role by protecting nursing resources during times of budget scrutiny, work process redesign, or work flow change. Staff involvement in the budgeting process promotes an understanding of the challenges operating in today’s healthcare environment. Staff can be included in a number of ways, for example by providing input on and prioritization of equipment and supply purchases. Increased staff knowledge of the costs associated with procedures also promotes effective usage and cost containment. When staff are involved in organizational initiatives, they are more likely to advocate for, and foster adoption. Collaboration between nursing managers/administrators and staff nurses is essential for maintaining adequate resources.

Staff input on purchasing decisions for supplies and equipment is now the norm in many healthcare agencies. Nurses sitting on purchasing committees serve as advocates by testing products and providing input on behalf of colleagues. Nurses involved in product decisions ensure that selection is based on patient and nurse safety, usability, and value, rather than being based on cost alone. In one agency a nurse attended a national conference and talked with a vendor about an IV catheter that appeared to be less likely to cause needle sticks. She brought samples and brochures home with her and took the information to her nurse manager and the unit’s representative on the new product committee. The committee contacted the vendor and worked with the staff to evaluate the IV catheter, which was eventually adopted by the institution. This nurse advocated on behalf of colleagues by working within the organizational structure to promote staff safety.

Advocacy for a Healthy Work Environment

When leaders support open communication, collaboration, and conflict resolution skills, staff are able to advocate more effectively for themselves and for colleagues. Managers play a pivotal role in developing the advocacy capabilities of staff. When leaders support open communication, collaboration, and conflict resolution skills, staff are able to advocate more effectively for themselves and for colleagues. In contrast conflict undermines effective teamwork and jeopardizes patient safety. Much has been written about the negative consequences of nurse incivility (Bartholomew, 2006; Longo, 2010). Fostering the development of conflict resolution skills and addressing unprofessional behavior, including incivility, promotes an environment in which advocacy can flourish.

Leaders promote advocacy when they enable staff to autonomously address concerns. They foster staff ownership of issues when they refer a concern to staff councils and form task forces, involving other departments as appropriate. In such situations the role of the leader becomes primarily a coach who provides guidance, helps staff navigate within the organization, and removes barriers to the process.

Leaders promote advocacy when they enable staff to autonomously address concerns. One hospital recruitment and retention committee, comprised of staff from a variety of nursing units, plus recruiters, staff development educators, and human resource professionals, met regularly to plan and evaluate recruitment and retention programs. The committee had already implemented a comprehensive nurse retention program that included recognition for national certification, incentives for nurse preceptors, and strategies to improve communication between nurses and physicians. One staff nurse on the committee felt that recruitment and retention could also be improved by providing an on-campus RN-to-BSN program. Prior to approaching the committee with this idea, he talked with nurses from across the organization to determine the level of interest and the program features that would accommodate working nurses. When he presented the idea to the recruitment and retention committee, he was able to identify the potential number of nurses interested in the program and volunteered to serve on a planning committee.

The nursing education director then sent a call for proposals to all baccalaureate nursing programs in the community, and the most appropriate program was identified by a selection committee comprised of bedside nurses. The faculty assigned to this program worked closely with these students to accommodate scheduling issues and to construct meaningful class assignments to facilitate learning. Through this program the hospital achieved a significant increase in the proportion of baccalaureate-prepared staff. In addition, many of the staff graduating from this program moved in to leadership positions within the facility which benefitted the facility as well as the staff. Advocacy was demonstrated as the university faculty provided convenient and meaningful learning experiences.

...it is important to help nurses at all levels of the organization understand the current reality of the healthcare system and engage them in designing a preferred future state. In this time of change, it is important to help nurses at all levels of the organization understand the current reality of the healthcare system and engage them in designing a preferred future state. Quality improvement activities and process redesigns often create anxiety and disrupt the patient care environment. New construction, implementation of new technology, and redesign to improve work flow are opportunities both for disruption and for nursing leadership to involve staff in creating the future of their healthcare setting. Changing the dynamic from panic and dread to challenge and opportunity can have a profound effect on staff buy in and morale. Advocacy during times of change includes using positive language when communicating about controversial issues, listening carefully to staff concerns, and acting to address these concerns. In today’s healthcare environment, change is a given. Leaders set the tone regarding reactions to change; they can make the difference between stress and success during the implementation process (Kotter, 1996; 2008). Managers and administrators can show their commitment to advocating for nurses and nursing by the manner in which they facilitate change.

Nurse Educator’s Role in Advocacy

...faculty in academic settings and nurse educators in professional development roles serve as the culture carriers for the profession. These educators are pivotal in the formation and continued development of nurses’ professional identity as advocates, an identity that transcends their entire career. One trend in healthcare over the past twenty years has been the active involvement of the nursing staff in decision making. This involvement increases the need for staff with more fully developed leadership skills and the ability to advocate effectively. No one plays a more critical role in developing the capacity and capability for professional advocacy than do nursing educators who model advocacy behaviors for students in both education and practice settings. Nurses in staff development roles contribute to this process of role formation by providing ongoing mentoring to nurses in practice. In many ways faculty in academic settings and nurse educators in professional development roles serve as the culture carriers for the profession. These educators are pivotal in the formation and continued development of nurses’ professional identity as advocates, an identity that transcends their entire career (Benner et al., 2010).

It is expected that the future will bring expanded nursing roles, enhanced opportunities for collegiality, and a greater voice for nurses at the organization and system level. It is essential that we prepare nurses now with the advocacy skills they will need to bring about this new world of healthcare. In 2006, the American Nurses Association invited academic nursing programs to serve as pilot sites to test a curriculum for safe patient handling. One component of this curriculum included the teaching of advocacy skills to prepare the students to use advocacy in overcoming barriers to the use of equipment that enhances the safety and quality of care.

Another example of teaching advocacy skills occurred in a hospital in which the Nursing Shared Governance Council was tasked with addressing the nurse-to-nurse incivility prevalent in some areas of the facility. Council members worked with staff educators to develop an educational program to address this issue. The council members developed case scenarios and role play activities and served as facilitators for classes designed to help nursing staff respond to situations of incivility. This teaching project heightened awareness of incivility and introduced new communication skills that promoted healthier ways of interacting within the nursing division. In addition, staff became more comfortable confronting difficult situations. Through this process, the council members learned to advocate effectively for a healthier work environment.

Educators involved in forming the professional identity of nursing students and shaping the capabilities of the nursing workforce are pivotal to advancing the profession. Healthcare is changing. Achieving the best possible future requires that nurses be prepared to advocate for nursing and for their professional roles.

Summary

Every nurse in every setting has the opportunity to make a positive impact on the profession through advocating daily for nurses and the nursing profession. It is an exciting time to be a nurse. Healthcare is changing and the role and practice of the professional nurse is changing along with it. Advocacy skills are becoming increasingly important in this ever-changing world. Opportunities abound for point-of-care nurses to advocate both for nurses and for the profession. Point-of-care nurses have an opportunity to build on their public image of being the most trusted profession by communicating and advocating for a more accurate view of their contributions to healthcare and society. Managers and administrators work daily, advocating to obtain adequate resources for their nursing staff and to promote positive work environments. Nurse educators play a critical role in preparing nurses to strengthen the profession through advocacy. Every nurse in every setting has the opportunity to make a positive impact on the profession through advocating daily for nurses and the nursing profession.

Author

Karen Tomajan, MS, RN, NEA-BC
E-mail: karen-tomajan@comcast.net

Ms. Tomajan is Director of the Nursing Practice/Magnet Program at John Muir Health, an American Nurses Credentialing Center Magnet Recognition Program^®-designated facility in Concord, California. Her nursing career includes a variety of roles that have focused on advocacy for patients and nurses, including staff nurse, nurse manager, patient advocate, and nurse educator roles, along with leadership roles in nursing education and quality management. She has published in the areas of nursing staff development, the image of nursing, and safe work environments. She lectures on lean thinking, team training, patient safety, nurse retention, and healthy/safe work environments. Ms. Tomajan is active in her state nursing association as well as the American Nurses Association (ANA) where she currently serves as Chairperson for the ANA Congress on Nursing Practice and Economics. She is a past president of the Oklahoma Nurses Association. Ms. Tomajan serves on community college advisory boards and precepts graduate students in nursing administration programs. She also serves as a Program Evaluator for the National League for Nursing Accrediting Commission and an Editorial Advisory Board Member of OJIN: The Online Journal on Issues in Nursing. Ms. Tomajan received her Bachelor and Master of Science Degrees in Nursing from the University of Oklahoma (Oklahoma City).

© 2012 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2012