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Patient , Subordinate,

Workplace, And
Professional Advocacy
 This chapter examines the processes
through which advocacy is learned as
well as the ways in which leader-
managers can advocate for their
patients, subordinates, and the
profession. The role of “whistleblower”
as an advocacy role is discussed.
Specific suggestions for interacting with
legislators and the media to influence
health policy are also included.
Leadership roles and management
Advocacy=helping others to grow and self-
actualize-is a critically important leadership
role. Many of the leadership skills that are
described in the following chapters, such as
risk taking, Vision, self-confidence, ability to
articulate needs, and assertiveness, are used
in the advocacy role.
The term advocacy can be stated in its
simplest form as protecting and defending
what one believes in for both self and others
Nurses may act as advocates by helping
others make informed decisions, by acting
as an intermediary in the environment, or by
directly intervening on behalf of others.
Leadership roles and management function associated with
Leadership roles
1. Creates a climate where advocacy and Its associated risk taking
are valued.
2. Seeks fairness and justice for individuals who are unable to
advocate for themselves
3. Seeks to strengthen patient and subordinate support systems to
encourage autonomous, well-informed decision making
4. Role models the use of patient and family engagement strategies
5. Influence others by providing information necessary to empower
them to act autonomously
6. Assertively advocates on behalf of patients and subordinates when
an intermediary is necessary.
7. Participates in professional nursing organizations and other groups
that seek to advance the profession of nursing.
8. Role models proactive involvement in health-care policy through
both formal and informal interactions with the media and legislative
9. Works to establish the creation of a national,
legally binding Bill of Rights for Patients.
10. Speaks up when appropriate to advocate
for health-care practices necessary for safety
and quality improvement
11. Advocates for social justice in addition to
individual patient advocacy
12. Appropriately differentiates between
controlling patient choices (domination and
dependence) and in assisting patient choices
(allowing freedom)
Management Functions
1. Assures that subordinates and patients have
adequate information to make informed decisions
2. Establishes a work climate that prioritizes the rights
and values of patients in heatth-care decision making
3. Seeks appropriate consultation when advocacy
results in intrapersonal or interpersonal conflict.
4. Promotes and protects the workplace safety and
health of subordinates and patients
5. Encourages subordinates to bring forth concerns
about the employment setting and seeks impunity for
6. Demonstrates the skills needed to interact
appropriately with the media and legislators regarding
nursing and health-care issues
7. Is aware of current legislative efforts affecting
nursing practice and organizational and unit
management 8.Assures that the work environment
is both safe and conducive to professional and
personal growth for subordinates
9. Creates work environments that promote
subordinate empowerment so that workers have
the courage to speak up for patients, themselves,
and their profession
10. Takes immediate action when illegal unethical,
or inappropriate behavior occurs that can
endanger or jeopardize the best interests of the
patient, the employee, or the organization.
Kaplan (2015) found that younger professionals
engaged in higher levels of patient advocacy than
older professionals and that social workers
engaged in greater patient advocacy than did
nurses. In addition, the researchers found that
when hospitals are committed to patient
empowerment, those health-care professionals are
more likely to engage in advocacy.
Regardless of how or when advocacy is learned,
or the extent to which it is used, there are nursing
values central to advocacy. These values
emphasize caring, autonomy, respect, and
Nursing Values Central to Advocacy
1. Each individual has a right to autonomy in deciding what
course of action is most appropriate to meet his or her
health-care goals.
2. Each individual has a right to hold personal values and to
use those values in making health-care decisions.
3. All individuals should have access to the information they
need to make informed decisions and choices.
4. The nurse must act on behalf of patients who are unable to
advocate for themselves.

5. Empowerment of patients and subordinates to make

decisions and take action on their own is the essence of
Patient Advocacy
This patient advocacy is necessary because
disease almost always results in decreased
independence, loss of freedom, and
interference with the ability to make choices
autonomously. In addition, aging, as well as
physical, mental, or social disability, may
make individuals more vulnerable and in
need of advocacy. Thus, advocacy
becomes the foundation and essence of
nursing, and nurses have a responsibility to
promote human advocacy.
Patient and Family Engagement
In addition, in 2013, the American Hospital Association (AHA)
Committee on Research released a report entitled Engaging Health
Care Users: A Framework for Healthy Individuals and Communities,
suggesting that health-care user engagement is a key ingredient in
reaching the triple aim of better population health, enhanced patient
experience, and lower costs (AHA, 2006-2016). The report
suggested that hospitals must become more “activist" in their efforts
to engage patients and that a continuum for engagement from
information sharing to partnerships must exist. The report went on to
recommend entry points for user engagement at four different levels
of the health-care system.
 The Guide (AHRQ, 2013) outlines four strategies hospitals can
use to connect with patients and families, including the following:
=Encourage patients and family members to participate as advisors.
=Promote better communication among patients, family members,
and health-care professionals from the point of admission.
Entry Points for User Engagement in the
Health-Care System
Individual: The aim is to increase the skills,
knowledge, and understanding of patients and
families about what to expect when receiving care,
Health-care team: The-focus is to promote shared
understanding of expectations among patients and
providers when seeking care.
Organization: The objective is to encourage
partnerships and integrate the patient and family
perspective into all aspects of hospital operations.
Community: The emphasis is to expand the focus
beyond the hospital setting and find opportunities to
improve overall community health.
Common Areas Requiring Nurse-Patient
 End of life decisions
 Technological advances
 Health-care reimbursement
 Access to health care
 Transitions in health care
 Provider-patient conflicts regarding expectations and desired
 Withholding of information or blatant lying to patients
 Insurance authorizations, denials, and delays in coverage
 Medical errors
 Patient information disclosure (privacy and confidentiality)
 Patient grievance and appeals processes,
 Cultural and ethnic diversity and sensitivity
 Respect for patient dignity
 Inadequate consents
 Incompetent health-care providers
 Complex social problems including acquired immunodeficiency
syndrome (AtDS), teenage pregnancy, violence, and poverty
 Aging population
Patient Rights
Until the 1960s, patients had few rights; in fact, patients often
were denied basic human rights during a time when they
were most vulnerable. This changed with the adoption of the
Consumer Bill of Rights and Responsibilities, also known as
the Patient's Bill of Rights in 1998. This document had
three key goals: (a) to help patients feel more confident in the
US healthcare system, (b) to stress the importance of a
strong relationship between patients and their health-care
providers, and (c) to stress the key role patients play in
staying healthy by laying out rights and responsibilities for all
patients and health-care providers (American Cancer
Society, 2014).
List of Patient Rights in California
• In accordance with Section 70707 of the California Administrative
Code, the hospital and medical staff have adopted the following list of
patient rights to
• Exercise these rights without regard to sex; cultural, economic,
educational or religious background; or the source of payment for
• Considerate and respectful care
• Knowledge of the name of the physician who has primary
responsibility for coordinating care and the names and professional
relationships of other physicians who will see the patient
• Receive information from the physician about illness, course of
treatment, and prospects for recovery in terms the patient can
• Receive as much information about any proposed treatment or
procedure as the patient may need to give informed consent or to
refuse this course of treatment. Except in emergencies this
information shall include a description of the procedure or treatment,
the medically significant risks involved in this treatment, alternate
course of treatment or non-treatment and the risks involved in each,
and the name of the person who will carry out the procedure or
• Participate actively in decisions regarding medical care. To the extent
permitted by law. this includes the right to refuse treatment.
• Full consideration of privacy concerning medical care program. Case
discussion, consultation, examination and treatment are confidential and
should be conducted discreetly. The patient has the right to be advised of the
reason for the presence of any individual
• Confidential treatment of all communications and records pertaining to the
patient's care and stay in the hospital. Written permission shall be obtained
before medical records are made available to anyone not directly concerned
with the patient’s care.
• Reasonable responses to any reasonable requests for service
• Ability to leave the hospital even against the advice of the physician
• Reasonable continuity of care and to know in advance the time and location of
appointment and the physician providing care
• Be advised if hospital/personal physician proposes to engage in or perform
human experimentation affecting care or treatment. The patient has the right
to refuse to participate in such research projects
• Be informed by the physician 0; a delegate of the physician of continuing
health-care requirements following discharge from the hospital
• Examine and receive an explanation of the bill, regardless of source of
payment Know which hospital rules and policies apply to the patient’s conduct
• Have all patient’s rights apply to the person who may have legal responsibility
to make decision regarding medical care on behalf of the patient.
The Right to Die Movement and Physician-
Assisted Suicide
At times, individual rights must be superseded to ensure the safety of all
parties involved. It is important, however, for the patient advocate to know
the difference between controlling patient choices and assisting patients to
choose. Health-care professionals often have knowledge that patients do
not have but must be careful not to use paternalism at the cost of patient
It is important for the patient advocate to be able to differentiate between
controlling patient choices (domination and dependence) and in assisting
patient choices (allowing freedom).
 Casey Gallagher (2016) notes, however, that helping
patients make decisions about PAS, and supporting them
in their choices, is difficult even when impending death is
a certainty. “All anyone can do is guarantee each
individual the freedom of decision and to determine what
he or she deems best for his or her own body or mental
well-being” (Casey Gallagher, 2016, para. 5).
The bottom line is that patients are increasingly
aware that they have rights, and as a result, they are more
assertive and involved in their health care. They want to
know and understand their treatment options and to be
participants in decisions about their health care. Leader-
managers have a responsibility to see that all patient rights
are met, including the right to privacy and personal liberty,
which are guaranteed by the Constitution.
Subordinate and Workplace Advocacy
Subordinate advocacy is a neglected concept in management theory
but is an essential part of the leadership role. Standard 16 of the ANA
(2009) Scope and Standards for Nursing Administration suggests that
nurse administrators should advocate for other health-care providers
(including subordinates) as well as patients, especially when this is
related to health and safety.
Workplace advocacy is a critical role managers assume to promote
subordinate advocacy. In this type of advocacy, the manager works to
see that the work environment is both safe and conducive to
professional and personal growth for subordinates. For example,
managers should assure that Occupational Safety and Health
Administration (OSHA) guidelines for worker safety are followed. For
example, educating staff about proper body mechanics and assuring
that staffing is adequate for safely ambulating and turning patients can
reduce the incidence of back injuries in health-care workers. In
addition, occupational health and safety must be assured by
interventions such as reducing worker exposure to workplace
violence, needlesticks, or blood and body fluids. When these working
conditions do not exist, managers must advocate to higher levels of
the administrative hierarchy to correct the problems.
The following are suggestions for creating an
environment that promotes subordinate“ advocacy:
• Invite collaborative decision making.
• Listen to staff needs.
• Get to know staff personally.
• Take time to understand the challenges faced by the
staff in delivering care.
• Face challenges and solve problems together.
• Support staff as needed.
• Promote shared governance.
• Empower staff.
• Promote nurse autonomy.
• Provide staff with workable systems.
Whistleblowing as Advocacy
 Huston (2017c) also suggests that there are basically two
types of whistleblowing. Internal whistleblowing occurs
within an organization, reporting up the chain of command.
External whistleblowing involves reporting outside the
organization such as the media and an elected official. An
example of whistleblowing by a health-care provider might
be to report inflated practices of documentation and coding
that result in elevated cost reimbursement.
 Huston (2017c) notes that nurses as health-care
professionals have a responsibility to uncover, openly
discuss, and condemn shortcuts, which threaten the clients
they serve. It is important, however, to remember that
whistleblowing should never be considered the first solution
to ethically troubling behavior. Indeed, it should be
considered only after other prescribed avenues of solving
problems have been attempted. This is true, however, only
if patients’ lives are not at stake. In those cases, immediate
action must be taken.
Guidelines for Blowing the whistle
 Stay calm and think about the risks and outcomes before you act
 Know your legal rights because laws protecting whistle-blowers vary by stat
 First, make sure that there really is a problem. Check resources such as the
medical library the internet and institutional policy manuals to be sure.
 Seek validation from colleagues that there is a problem. But do not get
swayed by groupthink into not doing anything if you should
 Follow the chain of command in reporting your concerns, whenever possible
 Confront those accused of the wrongdoing as a group whenever possible
 Present just the evidence; leave the interpretation of facts to others.
Remember that there may be an innocent or good explanation for what is
 Use internal mechanisms within your organization.
 If internal mechanisms do not work use external mechanisms.
 Private groups such as The Joint Commission or the National Committee for
Quality Assurance, do not confer protection. You must report to a state or
national regulator.
 Although it is not required by every regulatory agency, it is a good rule of
thumb to put your complaint in writing.
 Document carefully the problem that you have seen and the steps that you
have taken to see that it is addressed.
 Do not lose your temper, even if those who learn of your actions attempt to
provoke you.
 Do not expect thanks for your efforts.
Professional Advocacy
Advocating for professional nursing is a leadership role.
Joining a profession requires making a personal decision to involve oneself in
a system of socially defined roles. Thus, entry into a profession involves a
personal and public promise to serve others with the special expertise that a
profession can provide and that society legitimately expects it to provide.
Professional issues are always ethical issues. When nurses find a discrepancy
between their perceived role and society’s expectations, they have a
responsibility to advocate for the profession. At times individual nurses believe
that the problems of the profession are too big for them to make a difference;
however, their commitment to their profession obligates them to ask questions
and think about problems that affect the profession. They cannot afford to
become powerless or helpless or claim that one person cannot make a
difference. Often, one voice is all it takes to raise the consciousness of
colleagues within a profession. C. A. King (2015) agrees, suggesting that
advocacy for the profession is a choice. Individual comfort level and skill in the
political world can be developed and improved, starting with accepting the
challenge to be an active advocate.
A professional commitment means that people cannot shrink from their duty to
question and contemplate problems that face the profession.
Tips for interaction with the Media
 Establish proactive, routine communication with local, regional,
and national media to promote cooperation and transparency.
 Attend media training and/or practice speaking in front of a camera
with a microphone.
 Dress professionally for interviews.
 Respect and meet the reporter's deadlines.
 Assume until proven otherwise, that the reporter will be fair and
accurate in his or her reporting.
 Have key facts and figures ready for the interview.
 Limit your key points to two or three and frame them as bullet
 Avoid technical or academic jargon.
 Speak confidently but do not be afraid. to say when you do not
have the expertise to answer a question or when a question is
better directed to someone else.

 Avoid being pulled into inflammatory arguments or blame setting
and repeat key points if you are pulled off into tangents.
 Provide the reporter with contact information for follow-up and
needed clarifications.
Thank youuuu !!!!!