Patient Advocacy at The Aprn Level Assignment

Patient Advocacy at the APRN Level:
A Direction for the Future
Robert G. Hanks, PhD, Kristen Starnes-Ott, PhD, and Linda Stafford, PhD
Robert G. Hanks, is an Associate Professor, Assistant Dean and Department Chair, Family Health Department a
University of Texas Health Science Center–Houston School of Nursing, Houston, TX;Kristen Starnes-Ott, is an Associate
Professor, Assistant Dean and Chair; Acute and Continuing Care Department, Bette P. Thomas Distinguished
Professorship in Innovative Health Care Delivery at the University of Texas Health Science Center–Houston Sch
Nursing, Houston, TX; and Linda Stafford, is an Assistant Professor, Family Health Department at the Universit
Health Science Center–Houston School of Nursing, Houston, TX.
Patient advocacy isseen asa critical role for the nursing profession.
Although there is an existing body of literature surrounding the registered
nurse level of patient advocacy,little is known about the advanced
practice registered nurse (APRN)and patient advocacy.This article
examines the existing patient advocacy research literature and existing
APRN competencies to provide direction for further research.
Keywords
Advanced practice, education,
ethics, patient advocacy
Correspondence
Robert Hanks, Department of Family
Health, University of Texas Health
Science Center–Houston School of
Nursing, Houston, TX 77030
E-mail: [e-mail]
Advocacy for patients is a criticalrole for nursing
(Cole, Wellard, & Mummery, 2014) and the profession
has been willing to incorporate the advocate role
into the actual practice ofnursing. However, even
though patient advocacy is an integral part of nursing
care,little is known about advocacy at the advanced
practice registered nursing (APRN) level.The APRN
level of nursing, as defined by the National Council of
State Boards of Nursing (NCSBN) includes the nurse
practitioner (NP), clinical nurse specialist (CNS), nurse
midwife, and certified registered nurse anesthetist
(CRNA) who are educated and certified to “assess,
diagnose,and manage patient problems,order tests,
and prescribe medications” (NCSBN,2016). For the
purposesof this article, attention will be focused
on the two largest populationsof APRNs currently
graduating from programs in the United States
presently (American Association of Colleges in Nursing
[AACN], 2015): NPs and CRNAs.
Since the 1980s,numerousnursing articleshave
been published on patient advocacy but the literature
surrounding the confluence ofAPRN practice and
patientadvocacy isrelatively sparse.This deficit is
particularly relevantin light of the complexity of
current health care, variation and unique issues among
patients,as well as reimbursementissuesthat are
integralcomponentsof APRN practice. This article
synthesizesthe existing nursing research literature
surrounding patientadvocacy in conjunction with
delineating APRN patient advocacy competencies
coalescing into an impetus for further research.
Patient Advocacy
The meaning ofpatientadvocacy as practiced by
nursing aids in the examination of APRN-level patient
advocacy. The term advocacy emanates from the legal
term “advocate”and is defined as “a person who
assists,defends,pleads,or prosecutesfor another”
(Garner, 2000, p. 43). Although the concept of patient
advocacy has been implicitly practiced in nursing since
Florence Nightingale ushered in the modern era of
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Patient Advocacy at the APRN Level Hanks et al.
nursing (Hanks, 2013), the more explicit concept that
nursing was the ideal profession to lead in patient
advocacy did not appear in the literature until George
Annas (1974) posed the concept. From the mid-1970s,
nursing literature and nursing research embraced and
explored the conceptof patientadvocacy,although
the preponderance ofthe literature surrounded the
hospital-based registered nurse (RN) levelof practice
(Hanks, 2013).
The centralconcepts ofpatientadvocacy thatare
found in the literature are multidimensional. The
dimension of safety in patient advocacy included
protecting and speaking out for patients (Foley,
Minick, & Kee, 2000; Hanks, 2008, 2010; Sellin,
1995). Patient advocacy has an additional facet
that includes communicating with,informing, and
educating patients (Breeding & Turner, 2002; Chafey,
Rhea, Shannon, & Spencer, 1998; Hanks, 2010; Watt,
1997). In addition, patient advocacycan include
building relationshipswith patients, families, and
other healthcare providers (Hellwig, Yam, & DiGuilio,
2003; Lindahl & Sandman, 1998; Snoball, 1996).
External to the patient–nurse professionaldyad is
social advocacy that extends patient advocacy concepts
to include advocacy groupsof patientsor society
(Hanks, 2013).
APRN Responsibility to Advocate
APRN and Ethical Codes
The guiding principles that underpin nursing’s
conduct include ethical codes that identify core
professional behaviors for the entire profession. Since
all APRNs are included in the nursing profession, they
are obligated to advocate for patients as itis clearly
stated in provision 3, “The nurse promotes, advocates
for, and protects the rights,health,and safety of the
patient” (p.9) in the American NursesAssociation
(ANA) Code of Ethics (ANA, 2015). Except for CRNAs,
who have an additional code of ethics, the ANA Code of
Ethics is the foundation for the APRN to act as a patient
advocate.
The key componentsof the Code ofEthicsensure
that the nursing profession maintains and promotes
safe nursing practice and protects patients from harm
in the realms of practice and research.It is these
critical advocacy responsibilitiesthat transcend all
levels of nursing, including that of advanced practice.
Although the advocacy duty isexplicit historically,
there has been a lack of clarity for a definition of
patient advocacy for the profession (Cole, Wellard, &
Mummery,2014;Ronnebaum & Schmer,2015) and
the term needs to be differentiated from advocacy for
the profession of nursing (Hanks, 2010).
Distinct from the ANA Code of Ethics,the American
Association ofNurse Anesthetists(AANA) has had
a Codeof Ethics for practicing CRNAs for many
years (AANA, 2013). This code exemplifies the
nurse anesthesia community commitment to patient
advocacy and social justice. The first section is
entitled “Responsibility to Patients” and outlines eight
subcategories, which include “the CRNA protects the
patient from harm and is an advocate for the patient’s
welfare” (p.1). Another section ofthe AANA Code
of Ethics is entitled “Responsibility to Society,” which
includes “the CRNA works in collaboration with the
healthcare community ofinterest to promote highly
competent, safe, quality patient care” (p. 2).
APRNs and Social Advocacy
There are severalhallmarksof a profession that
separateit from other groups: education,formal
organizations,and dedication to public service.
An important attribute of any profession is that
its membersare dedicated to public service that
is also parallel to social advocacy.The advocacy
responsibilitiesfor nursing also revolve around the
concept of social advocacy. This is not a new concept
for nursing and has historicalroots extending to the
beginning of the era of modern nursing (Hanks, 2013).
An exemplar of this dedication to social advocacy is
seen in nurse anesthesia practice where commitment
to quality patient care has been a predominant
purpose,irrespective of compensation for more than
150 years (Bankert, 1989). Social advocacyand
dedication to service began with the Catholic nuns
who played an important role in the history of nurse
anesthesia. Many early hospitals in the United States
were established by religious orders, and in the process
of providing patient care the sisters were often trained
in the administration of anesthesia.Many of the
nuns created the early nurse anesthesia programs at
their hospitals,training religioussistersand nurses
(Bankert, 1989). While the nurse anesthesia profession
is no longer overseen by religious orders, social
advocacy in nurse anesthesiacare persiststoday.
CRNAs have continued to provide anesthesia care
to indigent and underserved patients, without regard
to healthcare insurance coverage orcitizenship.By
virtue of their social and pecuniary status,these
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Hanks et al. Patient Advocacy at the APRN Level
patients are often very illwith multisystem disease
that presents an incredible challenge to the CRNA as
an anesthesia provider in today’s complex healthcare
system.CRNAs offer their skills and knowledge to
care of patientswith needs for anesthesia services.
Additionally, these CRNAs advocate for the healthcare
resource allocation needs of these patients in the spirit
of socialadvocacy and notmerely for an economic
incentive.
In the broader realm, the evolution of social
advocacy has resulted in the concept being explicitly
stated in the International Council for Nursing
(ICN) The ICN Code ofEthicsfor Nurses(2012), “The
nurse advocatesfor equity and social justice in
resource allocation,access to health care and other
social and economic services” (p.2). Although the
preponderance of advocacy literature has been focused
on individual patients,this focus has been criticized
for not producing systemic change (Mahlin, 2010). In
the United States,the advent of the Affordable Care
Act has broughta compelling reason for nursing to
focus on the new array of healthcare options available
to patients(Ronnebaum & Schmer,2015) and for
nursing to adapt existing advocacy actions to the new
healthcare arena (Walker et al., 2015). This focus may
be of particular importance to the APRN engaged in
the primary care setting with patients seeking access
to health care.In addition,APRNs can be drivers for
change to reduce healthcare disparities and increase
accessto care by meansof education and political
action (Schroedl, 2012).
APRN Educational Competencies
In addition to the Code of Ethics,the importance of
patientadvocacy is reflected in the AACN Essentials
of Master’sEducation in Nursing(AACN, 2011) and
The Essentials of Doctoral Education for Advanced Nursing
Practice (AACN,2006) and the NationalOrganization
of Nurse Practitioner Faculties (NONPF) Nurse
PractitionerCore Competencies(NONPF, 2012). This
duty to advocate, combined with the demands of the
APRN role as a healthcare provider, expands the duty
of patientadvocacy in a realm where the APRN is
directing the patient’s diagnosis and treatmentplan
at a more independent level than that of a generalist
RN.
Specific to NPs,the NONPF Nurse Practitioner Core
Competencies(2012) state that the competency for
NPs is to advocate “for improved access,quality
and cost effective health care” (p.2) and “ethical
policies that promote access,equity, quality, and
cost” (p. 3). In addition to the NONPF competencies,
the AACN The Essentialsof DoctoralEducation for
Advanced Nursing Practice (2006) includes a competency
that the graduate will “advocate forsocial justice,
equity, and ethical policies within all healthcare
arenas” (p.14). For CRNA education, the Council
on Accreditation of Nurse AnesthesiaEducational
Programs (COA) incorporates advocacy, particularly in
light of health policy (COA,2016).The combination
of the Code of Ethics with the NONPF, COA, and AACN
educational competencies highlights the importance of
the advocate role, particularly at the APRN level.
The Quality and Safety Education for Nurses,
commonly referred to as QSEN (Cronenwettet al.,
2009), was originally developed for the generalist RN-
level nursing care in an effort to improve quality and
safety in the workplace. QSEN’s main objectives were
developed from competencies focused on prelicensure
education.The disconnectbetween the QSEN and
APRN practice provided a driver for examining APRN
education in terms of knowledge, skills, and attitudes
(KSAs) reflected by existing competencies (Pohl et al.
2009).The outcome ofthe combined effort resulted
in the 2012 AACN Graduate-LevelQSEN Competencies
Knowledge, Skills and Attitudes. Similar to the generalist
RN level, the graduate-level QSEN provides a platform
for assuring that competencies continue to be focused
on and driven by the patient (American Association
of Colleges of Nursing QSEN Education Consortium,
2012). Although not explicitly stated, patient advocacy
is implied in the document based on the central focus
on the patient or family member.
APRN Advocate Challenges
As mentioned previously, APRN practice is
differentiated from RN practice in that APRN
practice includes advanced assessment, diagnosis, and
treatmentof patienthealth conditionsthat include
prescribingmedications,ordering diagnostictests,
and directing medical management. In this advanced
role, APRNs face challenging circumstances related to
patienttreatmentissues,patientinsurance coverage
and limitations, healthcare bureaucracy, and ensuring
that healthcare resourcesare available to patients
(Ronnebaum & Schmer,2015). The APRN is now
being placed in a role of advocacy in an increasingly
changing healthcare environment, particularly in
helping patientsto accesshealthcare resourcesand
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navigate healthcare systems, thus reducing healthcare
disparities (Schroedl, 2012).
Patient Advocacy Research Literature Review
Although there is a relatively large body of
philosophical literature supporting RNs acting as
patient advocates,there has been little published
patient advocacy research (Hanks,2010). For the
purpose ofthis research literature review,the term
advocacy indicates a nursing professional advocating for
a patient, or a group of patients,not advocacy for
advancement of the profession.
Two databaseswere utilized in this literature
search,CINAHL and MEDLINE, to provide the most
extensivecoverageof patient advocacy literature.
The time frame selected was1974–2016 in light
of Annas’ sentinelarticle (Annas,1974) and search
terms included “patientadvocacy”in combination
with “nursing” and “research.” Furtherrefinement
of the article selection for this review included
narrowing the resultant literature to research studies
conducted using nursing participantsengagedin
patient advocacy.The preponderance ofpublished
nursing research examining patient advocacy is
focused on the generalist RN level of practice.
Patient Advocacy Definitions from the Research
A key component of exploring the concept of patient
advocacy is an awareness of what nurses view patient
advocacy to be.Early researchers,such as Millette’s
(1993) and Sellin’s (1995) exploratory research of
RNs, found that caring is viewed as central to patient
advocacy. Similar exploratory research by Watt (1997)
indicates that respect for the patient is part of the core
of patient advocacy.Severaladditionalexploratory
studiesof RN samplesdefined patientadvocacy as
speaking forand standing up for patients(Chafey
et al., 1998;Foley et al., 2000;Hanks,2008;Sellin,
1995) along with protecting patients and personhood
(Foley et al.,2000;Sellin, 1995).Similarly,Sunqvist
and Carlsson (2014) found Swedish registered nurse
anesthetists(RNAs) to view patient advocacyas
protecting the patient.
In addition to the more active protectiverole
of the patient advocate,empowering patientsis a
central theme in multiple patientadvocacy studies
involving nurses (Chafey et al.,1998;Hellwig et al.,
2003; Lindahl & Sandman, 1998; Mallik, 1997;
Vaartio,Leino-Kilpi, Salantera,& Suominen, 2006)
as are the more specific roles of educatingand
informing patients (Breeding & Turner, 2002; Chafey
et al., 1998;Watt, 1997).Patientadvocacy research
indicates that there is a relationship aspect to
nurses practicing patient advocacy.For example,
in O’Connor and Kelley’s (2005) study of RNs,
questioning traditionalhealthcare powerstructures
was viewed as a patient advocacy action whereas
McSteen and Peden-McAlpine’s (2006) research found
that acting as a liaison was viewed as a part of
patient advocacy.Relationship building,including
with patients and other healthcare professionals
combined with interprofessionalcommunication,is
found as critical aspectsof advocacy in multiple
research findings(Hellwig et al., 2003; Lindahl &
Sandman, 1998; Mallik, 1998; Martin, 1998a; Snoball,
1996; Thacker, 2008).
Educational Preparation for the Role
How nurses are prepared for the patient advocate
role is an interesting facet of the advocacy discussion.
Early studies by Pankratz and Pankratz (1974) and
Perry (1984) indicated thathigher levels ofnursing
education might be influential in the advocate’s
level of autonomy, thus lending a higher level
of confidenceto advocate, although the level of
education did not indicate APRN status of the
participant.The incorporation of nursing ethicsin
coursework was found to also elevate the advocate’s
level of autonomy in Altun and Ersoy’s research
(2003). Similarly, later studies by Kubusch, Sternard,
Hovarter,and Matzke (2003) cited higher levels of
education led to a higher degree of the advocate
to be assertive and Mallik (1997) found participants
with higher levels ofeducation felt they were more
able to advocate; however, this finding was not
supported by subsequentstudies by Vaartio,Leino-
Kilpi, Salantera,and Suominen (2006) and Thacker
(2008).In examining the explicit preparation ofthe
nurse for the advocate role, Davis, Konishi, and Tashiro
(2003) found preparation was lacking. Analogous
themes regarding advocacy was a skill learned on the
job after graduation was implicated in other research
(Foley, Minick, & Kee, 2002; Hanks, 2008).
Intrinsic and Causative Factors
An interesting concept from the research literature
is what compels nurses to act as an advocate. Patient
advocacy research from Penticuff(1989) and Sellin
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Hanks et al. Patient Advocacy at the APRN Level
(1995) has shown thatacting as an advocate relies
on intrinsic characteristics ofthe nurse.The specific
traits identified by research participants thatspur a
nurse to advocate can be summarized to include self-
concept,personalvalues, confidence,and personal
beliefs (Chafey et al., 1998; Foley et al., 2002;
Josse-Eklund, Jossebo, Sandin-Bojo,Wilde-Larsson,
& Perzall, 2014; Perry, 1984). Extrinsic causative
factorshave also been identified asthe source of
nurses acting as patientadvocates.One of the most
common extrinsicfactors identified in the studies
reviewed indicated vulnerable patientswith unmet
needs instigated the nurse to advocate (Hanks, 2008;
Josse-Elklund, Petzall, Sandin-Bojo, Wilde-Larsson,
2012; Mallik, 1998; O’Connor & Kelly, 2005; Segesten,
1993). Studies performed by Penticuff and researchers
Sundin-Huard and Fahy (1999) illuminated that
circumstances involving emotional and moral distress
can be causative reasonsto advocate ascan moral
obligation as was found by McGrath and Walker
(1999) and Ulrich et al. (2006).
Work Setting and Patient Advocacy
The work setting and organizationalstructures
clearly have a role in nurses atall levels acting as
a patient advocate.Nurse participantsin advocacy
research have consistently indicated that work settings
can influence both the nurse’s decision to advocate
and the effectiveness of the advocacy actions (Chafey
et al., 1998;Hanks 2008;Josse-Eklund etal., 2014;
Kubsch et al., 2003; Penticuff,1989; Sellin, 1995).
Deterrents to effective advocacy,as in Martin’s
(1998b) research,pointed to ritualized workplace
communication behaviors as one barrier to advocacy.
Analogously, Sorensen and Iedema (2005) cited
organizationalauthority as another impedimentto
nursesadvocating.Additional influenceson patient
advocacy included Sellin’s (1995) finding that acting
as an advocate can instigate discord in the workplace.
Additionalnegative impacts of advocating have been
identified by researchers Mallik (1998) and Segesten
(1993) that advocacy actions may result in punishment
or change in work status and Mallik (1997) found that
advocacy can be risky. The end result of the negative
aspects of the work setting upon advocacy can result in
frustration (Hanks, 2008; Hellwig et al., 2003; Mallik,
1998; Sundqvist & Carlsson, 2014) and anger (Mallik,
1998) for the advocate.
Future Direction for Researching APRN Patient
Advocacy
Gaps in the Knowledge
Although the concept of patient advocacy as
practiced by RNs has been the subjectof numerous
advocacy research studiessince the 1970s,the key
gap in the existing advocacy literature isthe lack
of specificity to the APRN level of practice.The
vast majority ofthe studies reviewed for this article
either did not specify the actual RN participant
educational level or provided generalized information
about the highest level of education. There are notable
exceptions such as Sellin’s (1995) work in which CNSs
were explicated as a small percentage of the research
sample. One of the most informative articles in
exploring the APRN level of patient advocacy exists in
Sundivist and Carlsson’s (2014) exploratory research
with a sample of Swedish RNAs as this advanced
practice role in Sweden contains some components of
CRNA level practice in the United States.
The lack of specificityabout APRN participant
samples lends to the discussion ofother gaps from
the synthesis ofthe advocacy research.The review
of the research revealed no clear information about
how APRNs define or operationalize patient advocacy
with the exception of Sundivist and Carlsson’s (2014)
study. Additionally, there are no clear findings in the
research literature that indicate how the APRN learns
to advocate, particularly in the light of the diagnosing
and prescribing responsibilities included in the APRN
role. Last, there is no cited outcome of patient advocacy
related to the APRN level of nursing practice.
Implications
This article accentuates thatlittle is known about
patient advocacy at the APRN level; thus, the
implicationsderived are a basisfor future research
with this specific levelof advanced practice nursing.
As Grace (2014) indicates in her work, Nursing
Ethics and Professional Responsibility in Advanced Practic
patient advocacy isa basic tenant of nursing care
regardlessof practice level.However, in order for
APRNs to provide effective patient advocacy in
clinical situations,research is needed to understand
what specific advocacy actions APRNs are currently
providing for patients and how this is differentiated
from the RN level. Specific APRN-level concern about
advocating for patients, particularly in the context of
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Patient Advocacy at the APRN Level Hanks et al.
potential impact on clinical revenue generation, is an
additional aspect to study and may contrast with other
levels of nursing. Additionally, since APRN education
competenciestout patientadvocacy asan expected
outcome,further research is needed on exactly how
educationalprograms are preparing APRNs to act as
patient advocatesin terms of didacticand clinical
learning experiences. However, without research that
provides an understanding of the APRN level of patient
advocacy, it is difficult to provide quality education to
APRN students to fully prepare them for the role of
patient advocate at that level.
Conclusion
The concept of patient advocacy is an integral
aspect of nursing and is constantly evolving as nursing
practice strivesto meet the patient needs in the
dynamic present-day healthcare system. The APRN is
in a position to directly manage patienthealth care
and improve health outcomes in this type of complex
environmentthrough patientadvocacy.Ultimately,
the ideal outcome of APRN patient advocacyis
improved patient health outcomes. However, in
order to be an effective patient advocate,the APRN
must have the educationalpreparation to effectively
advocatefor his or her patientsin terms of the
APRN-patientrelationship and atthe broad societal
level as well. This dilemma presentsthe challenge
to begin researching patientadvocacy atthe APRN
level of care to more fully understand the meaning,
educational preparation for, and operationalization of
patient advocacy.
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Nursing ForumVolume 00, No. 0, xxx 2017