Nursing is a challenging, rewarding and exciting career. The nurse’s role is not limited to changing bandages, giving needles and offering support, as the past has indicated. The role of the modern nurse is one of advocate, caregiver, teacher, researcher, counselor, and case manager. The caregiver role includes those activities that assist the client physically and psychologically while preserving the client’s dignity (Kozier, Erb, & Blais, 1997, p.129). In order for a nurse to be an effective caregiver, the patient must be treated as whole. Patient advocacy is another role that the modern nurse assumes when providing quality care. Advocacy is defined as the active support of an important cause, supporting others to act for themselves or speaking on behalf of those who cannot speak for themselves.
There is significant information written in the nursing literature about patient advocacy; however, not all that has been written is in the form of empirical evidence (Schroeter, June 2000). Concept analysis is a method of inquiry that produces a clearer meaning of words. Beth Rogers (2000) believes that concept analysis is the foundation for expanding nursing knowledge and developing nursing theory. The concept of patient advocacy has been referenced and studied in many articles because the definitions and principles of advocacy been loosely defined, leading to ambiguous interpretations (Bennett, 1999). The perioperative nurse’s role as a patient advocate has been described as: to inform patients of their rights in a particular situation, to support patients in decision they makes, and to intercede when there is a need to protect the patient’s rights (AORN, 2003).
Client advocacy is the application of skills, information, resources and action to speak out in favor of causes, ideas, or decisions to preserve and improve the quality of life for those who cannot effectively speak for themselves. Tyson (1999, p 64) defines patient advocacy as “the act of educating and supporting clients so they can make the best decisions possible for themselves. Nurses frequently encounter clients that feel powerless, vulnerable to assert their own rights. The role of client advocate is there to protect the rights of clients. Advocacy has become a concept in nursing practice that is misunderstood and often overlooked by nurses practicing in the role of the caregiver. Professional registered nurses have a duty to protect their patients and have an ethical obligation to act in any instance in which patients may be in danger. The aim of this analysis is to explore operational definitions of the theoretical concept of advocacy in the perioperative setting.
Advocacy is a contemporary nursing issue comprising three essential attributes, respect for patient value, education of patients, and respect for patients’ individuality. During the perioperative period there are several events that will necessitate the nurse acting on behalf of the patient because his/her altered state of consciousness during the procedure (AORN, 2003). Events such as: lack of respect for modesty and dignity during the procedure, inadequate or inaccurate consents for surgery, incompetent care providers and surgeons, compliance with do-not-resuscitate orders during the operative period (AORN, 2003). The nurses’ role as advocate is to facilitate, encourage or to enable patients to be involved in all aspects of their healthcare even when unable to do so.
One of the responsibilities of the perioperative nurse is to ensure all foreign items have been removed from the wound prior to closure of the incision. If there is a missing item, the RN is to take steps to prevent closure of the wound prior to the item being located or initiate steps to obtain an x-ray to locate the item in the wound if needed. Some surgeons continue to close the wound while there is a search for the item. Acting as a patient advocate, this may require that the RN refuse to provide additional sutures until the item is found. This action may prompt an unpleasant response from the surgeon, yet the nurse still takes the action as an advocate to prevent patient harm during the post-op period.
A pediatric patient’s parents have adamantly refused the use of blood products during the procedure. The cardiac procedure is notorious for intra-operative bleeding. During the procedure the parents have to rely on the intervention of healthcare professionals to respect his wishes even if the outcome is poor. The surgeon is aware of this, as is the nursing and operating room staff. However, once the patient is under anesthetic, the surgeon states he will use blood products. The nurse refuses to support the surgeon’s decision to go against the wishes of the patient’s parents. Although the nurse disagrees with the parents, he/she has to comply with their wishes.
Situations of coercion may occur in the OR environment because of poor communication and time constraints. An example: the patient changes his or her mind regarding surgery and surgical team members attempt to eliminate these concerns with the patient. The surgeon tries to answer questions of the patient and attempts to convince the patient to undergo surgery. “If the patient is on the OR bed with all the team members around, it may be considered a coercive situation” (Schroeter, June 2000). To advocate for the patient the nurse should have the patient sit up to converse with everyone at the same level.
An elderly female patient arrives to the operating room for a hip fracture repair. The patient’s chart contains the appropriate documentation for do-not-resuscitate orders. The patient verbally expressed the desire for these orders to be followed during the operative period. After induction of anesthesia the anesthesiologist intubates the patient. During the procedure the surgeon and anesthesiologist discuss leaving the patient intubated until she gets stronger. The nurse calls the Post Anesthesia Care Unit (PACU) and provides the staff with ventilator orders.
Antecedents are events that must occur before the concept (Walker and Avant, 1995). Advocacy for surgical patients has two preceding events. First there is the circumstance of vulnerability where simply being a patient is to be vulnerable. The patient in his or her susceptible state might be facing conflict or in a situation that requires a decision. Other antecedents include a willing and motivated nurse to take on the responsibility for patient advocacy. Advocacy for patient rights promotes provider accountability and motivates the nurse to be proactive in educating patients and upholding patient rights regardless of the consequences. Patient advocacy is applicable to the perioperative practice environment, for it is during this time that patients experience extreme vulnerability because they often are sedated or anesthetized (Schroeter, June 2000).
The consequences of acting as a patient advocate can be potentially negative or positive for patient and nurse. As a result of nurse advocacy the patient will benefit because increased knowledge regarding his or her health care choices. Knowledge should reduce the fear and anxiety patients experience because of fear of the unknown. Because the nurse has demonstrated integrity and willingness to protect the patient, there is an increased sense of trust and feelings of security for the patient during the perioperative experience.
Perioperative nurses work closely, and often for long hours, with surgeons and surgical technologists as members of the surgical team. Many peri-operative nurses acknowledge that their role is to advocate for patients; but they may not have the administrative power to achieve this goal (Schroeter, June 2000). Nurses acting in the patients’ interest may experience negative feedback from colleagues if the advocacy requires the nurse to go against a team member or physician order. Speaking up when an event happens that violates a patient’s rights may leave the nurse fearing they may lose their jobs, be harassed by others, be disciplined at work, or even sued in a court of law.
Patient advocacy is a part of the Patient’s Bill of Rights put forth by the American Hospital Association (AHA). This document states that “activities must be conducted with an overriding concern for the patient and recognizes his/her dignity as a human being.” There are in fact many perioperative practices that involve ethics and advocacy, such as lack of respect for the patient’s dignity, inadequate consents, do-not-resuscitate orders, withholding information or blatant lying to patients and incompetent healthcare providers.
The perioperative nurse is obligated to provide a care environment that supports the patient’s self- governance, personal safety and security, and dignity regardless of the values of the provider. Kathy Schroeter (2000) defines advocacy as part of the patient’s rights when seeking the services of health care. Many patients are anesthetized during operative procedure. This leaves them vulnerable and at the mercy of the providers performing the procedure. The peri-operative nurse should respond and act in the patient’s stead according to the patient’s wishes to prevent harm, injury, or unwanted procedures performed even if the nurse believes the care would be beneficial to the patient.
Advocacy is not as some people suspect: it is about making decisions for patients or acting ‘in loco parentis’. It is about ensuring that no one overrides the needs, rights and humanity of patients. Many perioperative practice issues involve ethics and advocacy. Advocacy is very applicable to the perioperative practice environment because it is during the surgical experience that the sedated or anesthetized patient is most vulnerable. Nurses develop relationships with patients that put them in a position of trust and they are often the first to identify a patient’s ethical concerns. Individually, each of the attributes is a helping strategy used in nursing: only when all three attributes are present can advocacy be appreciated by the patient and the nurse.
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