Types of Advocacy and Definition
The author will give details regarding some forms of advocacy but will mention in passing others, however included in the assemblage is peer, self, and group advocacy, professional, citizen and legal. Also collective and individual and a new initiative locally ‘transitional advocacy’ aimed at young learning disabled making the ‘transition’ from education to work or employment.
We should commence by defining advocacy in terms that are meaningful to nursing although advocacy is more than relevant in other areas. The RCN (1995) defines advocacy as "The process of acting for, or on behalf of someone; the pledging of a cause of another as if it were your own but especially those who are particularly disadvantaged within the healthcare system, such as people with learning disabilities". We can continue by looking at the differing types of advocacy starting with Self-advocacy. Self-advocacy, in the author’s opinion is one of the most significant from a nursing prospective for are we not encouraged to empower and promote the autonomy of our patients. Self-advocacy is about people regaining the power over their own lives (MIND 1992). It could be also be described as having a say and being listened too and it’s about helping people who are disadvantaged or disabled to develop skills, knowledge and confidence so they can advocate on their own behalf. It’s about defending oneself, taking risks, choice and feeling stronger. However we should acknowledge Goodley (2000) when he states, "As the movement has grown, its relationship to the empowerment of people with learning disabilities becomes increasingly opaque".
Another type of advocacy applicable to the author’s branch of nursing is citizen advocacy. This is pairing an ordinary citizen with a disadvantaged, disempowered individual such as someone with learning difficulties, who then offers support via emotional support through friendship, spokespersonship, assistance with gaining services, representation etc. The partnership is based on a one to one relationship, which is visualised to be long standing rather then for one specific issue helping you to speak out.
Collective advocacy could be possibly described as politically minded. It could be tenant associations, charities such as MENCAP, trade unions, community care forums or self-advocacy groups fighting for a common cause.
Conflicts That May Arise When Advocating For patients
It is expected as well as accepted that nurses will advocate for their patients regardless of branch chosen, moreover advocacy is a role that the UKCC expects nurses to adopt even though the concept has not been clearly defined. The words ‘advocacy and autonomy’ are not strictly mentioned but a practitioner’s role is clearly outlined in clause 1 and 5 of the UKCC code of Professional Conduct when dealing with client/patient choice. However, Woodrow (1997) states, "While the principle of nurse advocacy is laudable the practice is fraught with potential conflict". These conflicts for a nurse are as many as they are varied and here we will discuss a few yet mention several.
We are taught to respect and promote a patient’s autonomy, but what transpires when a patient’s autonomous decision conflicts with the nurse’s own moral judgement. Impartiality on behalf of the nurse must prevail regardless of the nurse’s beliefs regarding the decision made by the patient. Even if that decision turns out to be a wrong one, we must offer support and encouragement to enable the patient to arrive at their own conclusion. A patient’s decision could also bring the nurse into direct contrariety with their employers or senior management. An activity advocated by the nurse that stretches resources and manpower of the service providers challenges the loyalty and professional obligation between patient and employers. The author has direct experience of this when a client asked to holiday alone instead of with another. Rather than the usual three staff with two clients the service providers needed to supply two staff with each therefore, putting pressure on resources to find extra finances and staff to accommodate his request. The house manager advocating for the client came into direct conflict with the scheme manager, which could have resulted in poor relations in the future. Attention should be given to ASIST (2001) when they say, "Service providers in many instances express their views in terms of, ‘best interests of the user’ although in an increasingly tight purchasing environment it may be in terms of obtainability".
Conflicts may arise when encountering advocacy services such as ASIST, a local advocacy agency who offer (amongst others) a service called ‘Watching Brief’ for clients whom are part of the Stallington Resettlement Project. The author witnessed such a confrontation at an IPP meeting where the representative disagreed with the clients named nurse regarding an activity requested by the client. The nurse felt the activity could lead to behavioural and emotional problems in the future due to past history whereas the representative thought it a reasonable request. Discussion took place between the three parties, client, nurse and representative and compromise prevailed. Providing care is a multi-professional, multi-agency activity which, in order to be effective, must be based on mutual understanding, trust and co-operation (UKCC 1996)
An example of ethical conflict which needs deliberation could be in the promoting of self determination by respecting a persons autonomy but the action taken by the client is determined not to be in their best interests this may then conflict with the principle of beneficence. Our evaluation of right and wrong, good or bad will be challenged throughout practice and how we encounter that conflict will depend on the individual but the author suggests that many will decide to ignore possible conflict since it is the easier option. Limitations on resources such as transport and staffing levels can leave the nurse torn between patient’s requests and the completion of the routine tasks presenting the nurse advocate with another example of ethical conflict. The writer speculates we have all encountered an instance where by patients have foregone an activity or as a consequence quality time spent with patients has suffered because of a lack of resources. Inter-personnel relationships could also come into conflict in this instance due to the fact of differing opinions to who will make use of the limited resources.
Other forms of conflict include, conflict with relatives or carers, with legal and professional requirements and in the aspect of respecting the patients autonomy.
Advocacy in clinical Practice, Process and Outcome
Some patients will lose their autonomy due to their illness or condition. It is at this instant when a nurse may be called upon to advocate their role being as a facilitator to achieve the best for the patient. Whilst looking at the process of advocacy some issues need to be contemplated, these include –
· Good advocacy depends on good preparation (Hyam 1992).
· Making every attempt, regardless of difficulties, to allow the patient to make an autonomous empowered decision.
· Every aspect of decision making, beneficial or detrimental, needs to be fully explained in language and terms and at an appropriate level of understanding to the patient involved.
· Must ascertain the beneficent and maleficent consequences of a decision/activity and seek to maximise beneficent outcomes.
· If we are acting as an advocate then it should be expected that we have sufficient knowledge and authority to be in position to initiate benefit to the client.
· A long standing ‘equal’ relationship between the nurse advocating and the patient is desirable thus giving a greater knowledge and understanding of the needs of the patient resulting in a successful outcome.
We must recall that the origins of advocacy derives from a legal background where the user would normally choose the representation themselves whereas in a health care setting the choice is often made for them
In the process of advocating the nurse must always consider the guidelines set by the UKCC for professional practice. We have a legal and professional duty of care and in law we could be found negligible if harm occurs to the patient. Consideration must also be given to our accountability when advocating, for we are as accountable to our employers as our patients. We must at all times safeguard and promote the interests of individual patients and whatever path we decide to take we must be able to justify our actions.
Advocacy does not have to be constantly on a grand scale, the author perceives we advocate proactively without actually recognising we are doing it. In a clinical setting an introduction of new staff usually requires us to advocate for the clients everyday needs. Simple but important considerations such as milk and sugar in drinks, how they like to be woken, preferences during bathing, how they prefer to be greeted etc., but non what would be considered ‘grand scale advocacy’ but all have important outcomes.
Throughout the process we need to be appreciative of the client’s self-autonomy, be aware of the relationship between a person’s choice of action and their character, their right to refuse treatment or actions, their self-determination and recognition of the values expressed through choice. We need to reflect upon these criteria if we are to move away from state paternalistic attitudes. Lindahl and Sandman (1998) suggest in avoiding paternalistic attitudes a more docile and careful manner may be a prerequisite for advocacy.
The writer reflects on advocacy observed and participated in practice at an IPP meeting that he chaired. Months previous to the meeting he engaged with the client in communication techniques to be utilised in ascertaining the requirements of the non-verbal client. An excellent mutual relationship had previously been built between the two through their work together initiating an ethical partnership for advocacy. The client also had the services of an independent advocate from a local advocacy service, unfortunately the representative left and a replacement drafted in shortly before the meeting. The writer used photographs, makaton and symbols to communicate with all present at meeting through the client making every attempt to ensure self-autonomy was respected and specifically advocating empowerment.
A greater period of time to work with communication techniques would have been beneficial to the client resulting in greater understanding. The author observed on numerous occasions that the conversation was directed toward himself rather than the client when actually discussing client concerns. At these points he intervened asking the questions to be first directed to his client and then if needed him and the staff team could assist with communication techniques hopefully empowering and respecting the client. He found this to be irritating to some of the multidisciplinary team presumably due to the length of time taken. Sharing information depends on effective communication skills (UKCC 1998). The representative from the local advocacy service made very little, if any contribution to the meeting failing their citizen advocacy status possibly due to having little time getting to know the client. However it could be argued that the representative might have felt that the best interests of the client had been met and no contribution was needed. But the writer feels this demonstrates the importance of building up a relationship prior to advocating for someone. These observations and others lead the author to the belief that if we are to achieve worthwhile outcomes for our patient’s, the advocates must first contribute considerable time and effort. Relationships need building upon and furthermore those offering assistance need to have a fundamental understanding of the principles of advocacy, empowerment and the respect of self-autonomy. Through our advocacy efforts, great or small we can make a difference (Manton 1998).
The RCN (1995) defines advocacy as "The process of acting for, or on behalf of someone; the pledging of a cause of another as if it were your own but especially those who are particularly disadvantaged within the healthcare system, such as people with learning disabilities".
Self-advocacy is about people regaining the power over their own lives (MIND 1992).
Goodley (2000) when he states, "As the movement has grown, its relationship to the empowerment of people with learning disabilities becomes increasingly opaque".
Woodrow (1997) states, "While the principle of nurse advocacy is laudable the practice is fraught with potential conflict"
ASIST (2001) when they say, "Service providers in many instances express their views in terms of, ‘best interests of the user’ although in an increasingly tight purchasing environment it may be in terms of obtainability".
Providing care is a multi-professional, multi-agency activity which, in order to be effective, must be based on mutual understanding, trust and co-operation (UKCC 1996)
Good advocacy depends on good preparation (Hyam 1992).
Lindahl and Sandman (1998) suggest in avoiding paternalistic attitudes a more docile and careful manner may be a prerequisite for advocacy.
Sharing information depends on effective communication skills (UKCC 1998)
Through our advocacy efforts, great or small we can make a difference (Manton 1998)