Authors

1. Munday, Judy RN, DipEd (Nurs), BA (Hons)
2. Kynoch, Kathryn RN, BN, MN (Intensive Care)
3. Hines, Sonia RN, BN, MAppSc (Research)

Abstract

Review question/objective: The objective of this review is to identify the meaningfulness of perioperative nurses' experiences of advocacy.

The specific objectives are to explore perioperative nurses' experiences as patient advocates, identify how perioperative nurses define advocacy and to explore the barriers to and strategies for promoting advocacy in the perioperative environment.

* What are perioperative nurses' experiences as patient advocates?

* How do perioperative nurses define advocacy?

* What are the barriers to and strategies for promoting advocacy in the perioperative environment?

Background: The concept of advocacy in health care has been described as "complex and fraught with dilemmas"1,^p444, and at the same time simple yet complex.2 Although some argue that the advocacy role is not 'new' to nursing and is actually rooted in nursing tradition,3 awareness of advocacy as a distinct concept has gradually increased in interest since its emergence in the 1970s. Literature focussing on the concept particularly grew during the 1990s,1, 4, 3 with the development of patient and consumer rights. Today, professional advocacy roles exist in some health care systems. The expectation and requirement that nurses are prepared to act as patient advocates as part of their role is formalized and embedded in international codes of conduct, such as the Nursing and Midwifery Council of Australia's Registered Nurse Competency Standards5, the American Nurses Association's Code of Ethics with Interpretive Statements6, and the Nursing and Midwifery Council's Standards of Conduct, Performance and Ethics in the UK.7 Various models of advocacy in nursing practice were proposed in the 1970s and 1980s2, 8, 9, 10 and the importance of providing information to patients, to empower them to make their own healthcare decisions and promote autonomy, is a central feature of these early models.2, 8, 9, 10 Different opinions still exist regarding what advocacy actually means for everyday nursing practice but despite this, advocacy is seen as a central concept of ethics in nursing practice.4 Acting as a patient advocate requires understanding of ethical principles, as well as the ability to communicate, listen to and understand patients' needs.11

Advocacy in nursing has been explored in relation to many different practice areas including critical care,12 public health,8 and perioperative care.11, 13, 14, 15,16 Nurses working in perioperative departments care for patients when they are in a highly vulnerable state. The ability of the patient to communicate during this time is usually impaired due to the nature of surgery and anesthesia. Nurses are ideally placed in the perioperative department to fulfil this role, despite the perioperative nurse-patient relationship being typically short-lived. It is argued that many practice issues in this speciality involve advocacy issues14 and the many hazards that surgical patients are exposed to in their journey through the perioperative department are recognized. The everyday necessity for perioperative nurses to advocate for patient's safety and wellbeing may be partly attributed to the particularly closed and restricted environment of the operating theater14 where no relatives or next of kin are able to take this journey with them. While it appears that there is a requirement for healthcare professionals in the perioperative environment to be able to speak up for patients, it has been argued that the assumption that nurses are the "only ethically orientated" group that has contact with the patient is erroneous.1, ^p444 The perioperative environment necessitates that many different professional groups work alongside each other in often highly-pressurized situations, therefore it is essential that collaborative working is maximized together with the common goal of guiding the patient safely through surgery. While it is true that nurses are not the only professional group in contact with patients in the operating suite displaying inherent ethical values, it remains true that they are ideally placed to fulfil the advocacy role, particularly when patients are undergoing medically initiated, rather than nurse-led, procedures. The benefit to patients of nurses and medical staff working collaboratively, rather than guarding their own territories, has also been emphasized.10

Patient vulnerability is cited as one of the central conditions that necessitates advocacy3 and this vulnerability is particularly evident for patients undergoing surgery. While knowledge of the patient is a central requirement within some nursing advocacy models,2, 10 perioperative nursing staff may have little if any knowledge of, or established relationship with, the patients for which they care. Caring for anesthetized patients, or 'silent patients'17 brings unique challenges in terms of advocacy. Gadow17 was the first to explore the challenges of advocacy in the population of patients that she termed 'silent patients' - those which are sedated, too young or unable to speak up for themselves and have reduced ability to make decisions for themselves.10 In practical terms, advocacy as a perioperative nurse can mean speaking up for these silent patients when they are unable to do so, or 'giving voice' as this has been described.14 This may involve some risk-taking on the part of the nurse who may have had no prior established relationship with the patient. The concept of risk-taking is also raised by the prospect of direct conflict between nurse, medical staff and organization when advocacy situations arise, often in high-pressure situations. There is also possibility that, instead of gaining support from other nursing professionals, perioperative nurses in advocacy situations may place themselves at conflict with other nurses. As Farrell points out, "who will protect the patient from the nurse?"18,^p25 Such conflict situations may mean that nurses themselves may have to draw upon reserves of professional confidence and knowledge to undertake this role and overcome the perceived powerlessness which was described by nurses in one study.11 It may also mean accepting the personal stress that may result from these situations.19 Assertiveness has been cited as a facilitator to enabling nurses to act as advocates in the perioperative environment13 when speaking up or conflict is likely, however covert strategies for acting as advocates have also been described in this environment.13 Mallik highlights the dilemmas that can arise due to conflicting loyalties and accountabilities of nurses and emphasizes that nursing authority in advocacy situations can be weak despite moral pressure to act3; whereas Kosik points out that if the patient is truly at the center of care, then no dilemma exists. 8

In practical terms, patient advocacy in the perioperative environment can also mean ensuring that patients are well-informed regarding their surgery, not purely in relation to giving informed consent, but that they also understand what interventions are involved and why (such as what medications are given and on what indication for example); situations where patients are not informed about what is happening to them and why have been described as an infringement upon autonomy.10 Full disclosure of information to patients, however, needs to be undertaken with care in some situations, with consideration and awareness of the patient's individual desire for information, as well as the possibility that in some cases nurses are not seen as free to disclose full information to patients,10 whether this is morally right or not. In addition, the many potential hazards in the perioperative environment necessitate that nurses are diligent in protecting patients' safety, which is an obligation of patient care.11 This can takes many forms15 from the purely practical in terms of positioning and minimizing physical hazards to promoting autonomy of the patient despite their silent state during surgery.

The protective dimension of the perioperative nurse's advocacy role has been highlighted,14 as has been the influence of the perception of an advocacy role upon nurses' ethical decision making.11 Literature exploring the advocacy role suggests that the protective aspect of perioperative nurse advocacy leads them to take action when patient safety is compromised and when there is a strong potential for adverse incidents to occur.14, 15 One ethnographic study amongst Australian perioperative nurses identified that nurse advocacy was prompted most often by the requirement to remind other professionals about their duty of care.13 Additional examples highlighted in the literature have identified how the perioperative nurse acting as advocate can seek to resolve patient discomfort when this is not recognized by medical staff,13, 20 and ensure that patients are not moved to ward areas until stable in the face of management pressure to do otherwise.20 Perioperative nurses have also used 'covert' advocacy to push for consultant assistance when less senior medical staff have had difficulties whilst operating13 and sought to protect patient dignity when this has been unnecessarily threatened by other healthcare professionals.13

Maintaining a vision of the human side of caring can be challenging within the perioperative environment, where technology and machines maintain a clear presence and the patient is often hidden from view underneath the surgical drapes.13 It has been emphasized, however, that if it is kept in mind that both healthcare professionals and patients are human beings, then advocacy is a 'natural' process.10,^p9 How nurses define and experience advocacy in the perioperative department, including the barriers they face and strategies they use to promote patient advocacy has not yet been explored by systematic review. This systematic review seeks to make recommendations for perioperative nursing practice based upon the findings of this review, in particular regarding strategies used by perioperative nurses as patient advocates in this setting. Although the literature surrounding patient advocacy and the discipline of nursing is increasingly abundant, with several literature reviews available,3, 4 this topic has not yet been explored by systematic review.