Advocacy – strengthening the foundation of caring

Warm greetings from the United States! First let me say that I’m honoured to author a guest editorial in the British Journal of Nursing. When Ian Peate extended this kind invitation, I immediately considered what subject matter would be relevant to a UK nursing audience. In full disclosure, although I’ve had some memorable trips to the UK, I’ve not yet spent time in a UK health system. With that said, I’ll venture that the essence of the nursing profession transcends the oceans and continents. An area of common ground is most certainly caring—a somewhat intangible construct that you can identify when you experience it. And yes, there are those among us who display more than others in their daily work. But is caring enough?

An objective aspect of caring with a very tangible impact is advocacy—taking actions to assure patient needs are met. Nurses can be advocates at the front lines, at the system level or in the political sphere. Advocacy is a skill that nurses gain through education, mentoring and even life experience. Some are more comfortable speaking up or out than others, but I’ll assert that those who are successful feel a much greater sense of control and ownership in their practice. These are the nurses who stand out in a crowd and are usually the ones we’d want to care for us.

Advocacy is relevant in all aspects of practice, whether it’s at the bedside, in the classroom or at the administrative level. Advocacy that arises from caring should have patient-centredness at the core. At the clinical level, it’s removing barriers and working the system to assure patient needs are addressed. In education, it’s advocating for a curriculum of relevant content and experiences interlaced with high standards to prepare nursing graduates for real-world success. At the administrative level, it’s negotiating for resources and system changes that enable nurses to provide timely, safe, competent and compassionate care. In the political realm, it involves motivating and influencing decision-makers in matters of regulation, reimbursement and law to better serve the health needs of a population. All of these activities represent nursing care.

Key to success in advocacy is the knowledge, skills and abilities that develop through nursing practice and continuing professional education. This is the ingredient that provides the unique nursing perspective to the problem at hand. Next, is the effective use of self. That includes appropriate verbal and non-verbal communication—conveyed in a way that leads to the desired objective. When we classify nursing practice as being both an art and a science, here is where the art is essential. Effective advocacy requires strong communication skills, including the ability to negotiate. At the end of the day, the goal, if at all possible, is to strengthen or at least preserve positive working relationships with the individuals or groups involved and come away with a ‘win-win’ outcome.

Over my nearly 30 years in nursing, I’ve witnessed the good, the bad and the ugly in situations where nurses have had to advocate for a desired change. On the good side, there are those who are seemingly born with negotiation skills. They approach difficult or challenging situations with the right combination of grace, strategy and skill that promotes collaboration with key parties and a successful outcome. The ‘bad’ situations often involve nurses who lack basic assertiveness or conflict-resolution skills. It is often evidenced in their desire to avoid or retreat from potentially tough encounters and protect themselves. This non-action might prevent a taxing interaction from occurring, but someone’s needs will go unmet. Clearly, the consequences of non-action can be significant, especially if patient safety or wellbeing is at stake. Finally, I’ll wager that all of us have seen the ‘ugly.’ In this state of affairs, bullies emerge. The desired objective may or may not be achieved in the long run, but relationships are severely damaged and there’s usually a wake of destruction that creates barriers that must be overcome going forward.

So, how do we optimise caring through advocacy in nursing? We focus on communication and negotiation skill development. Today, how many nursing programmes teach negotiation strategies to students? Do nurses fully realise the value of this aspect of professional growth and personal empowerment? We need to make the business case. Negotiation is typically taught as a standard component in a business curriculum, not a healthcare programme. We need to change that paradigm. When the stakes are high, nurses need a full repertoire of tools at their disposal and they need to know how to use them. That takes awareness, education, practice and effective coaching. Without these tools, nurses will consistently draw the short straw in the battle of wills. Given the challenges our profession is facing in being effective advocates for our patients, we need to establish a level playing field.