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 concept of patient advocacy, although
the preponderance of the literature surrounded the
hospital-based registered nurse (RN) level of practice
(Hanks, 2013).
The central concepts of patient advocacy that are
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 advocacy can include
building relationships with patients, families, and
other healthcare providers (Hellwig, Yam, & DiGuilio,
2003; Lindahl & Sandman, 1998; Snoball, 1996).
External to the patient–nurse professional dyad is
social advocacy that extends patient advocacy concepts
to include advocacy groups of patients or 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 it is 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 Nurses Association
(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 components of the Code of Ethics ensure
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 responsibilities that transcend all
levels of nursing, including that of advanced practice.
Although the advocacy duty is explicit 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 of Nurse Anesthetists (AANA) has had
a Code of 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 of the AANA Code
of Ethics is entitled “Responsibility to Society,” which
includes “the CRNA works in collaboration with the
healthcare community of interest to promote highly
competent, safe, quality patient care” (p. 2).
APRNs and Social Advocacy
There are several hallmarks of a profession that
separate it from other groups: education, formal
organizations, and dedication to public service.
An important attribute of any profession is that
its members are dedicated to public service that
is also parallel to social advocacy. The advocacy
responsibilities for nursing also revolve around the
concept of social advocacy. This is not a new concept
for nursing and has historical roots 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 advocacy and
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 religious sisters and nurses
(Bankert, 1989). While the nurse anesthesia profession
is no longer overseen by religious orders, social
advocacy in nurse anesthesia care persists today.
CRNAs have continued to provide anesthesia care
to indigent and underserved patients, without regard
to healthcare insurance coverage or citizenship. By
virtue of their social and pecuniary status, these
2
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