The relationship of trust between nurses and their patients has long been recognized as a critical aspect of health care. Patients’ favorable assessments of that relationship are directly reflected in their opinions about the nursing profession: In a 2020 Gallup poll, Americans reported feeling that nurses were the most honest and ethical of 15 different occupational groups — the 19th consecutive year for the honor.

The trust that patients place in their nurses is well founded. Nurses spend a great deal of time with their patients, and fulfilling their obligation under the nursing code of ethics to advocate for their patients can make a significant difference in patient outcomes.

Nursing advocacy can come in many forms and at various levels in health care, and nurses need to have a clear understanding of their role in advocating for patients. This is particularly true for nurses who wish to advance in the profession or aspire to leadership positions. Nurses who complete online Master of Science in Nursing (MSN) to Doctor of Nursing Practice (DNP) programs may find themselves at the forefront of patient advocacy, and they’ll need to keep that aspect of the profession in mind as they go up the career ladder.

Knowing exactly what advocacy in nursing is, how it fits into the profession, why it’s important, and its potential impairments are key elements in nurses’ understanding of their obligations to their patients.

A 2019 study published in the journal Nursing Ethics identified several overarching characteristics of nursing advocacy. After reviewing 46 articles and two books on the subject published between 1850 and 2016, the study’s authors highlighted the following attributes that characterize the concept of nursing advocacy:

Apprising encompasses responsibilities such as providing patients with information regarding their diagnoses, prognoses, treatments, and discharge, as well as discussing health care alternatives with them.

Championing social justice in health care includes responsibilities such as facilitating patients’ access to health resources, addressing inequalities in health care delivery, and identifying and confronting rules or policies in a health care system that are inappropriate.

Mediating involves responsibilities such as serving as a patient’s voice when necessary, acting as a liaison for patients with other health care professionals or patients’ families, and relaying the cultural values and preferences of patients to other health care professionals.

Safeguarding entails carrying out responsibilities such as tracking errors made in patient care and protecting patients if other health care professionals aren’t competent or have committed misconduct.

Valuing focuses on responsibilities such as facilitating patients’ ability to make decisions freely; maintaining patients’ right to privacy; and operating in accordance with patients’ preferences, beliefs, and culture.

Being patient advocates is a natural fit for nurses and nurse leaders. The sheer amount of time that nurses spend with their patients affords nurses a unique opportunity to build trusting relationships and an open rapport.

The nursing code of ethics also establishes the fundamental obligation of nurses to advocate on behalf of their patients. Specifically, the provisions within the American Nurses Association (ANA) Code of Ethics for Nurses contain important requirements that are directly related to nursing advocacy. For example:

• Provision 2 establishes that nurses’ primary commitment is to their patients and requires nurses to provide patients with the opportunity to participate in the development of treatment plans that patients deem acceptable.
• Provision 3 obligates nurses to protect and advocate for patients’ safety, rights, and health.
• Provision 4 requires nurses to provide optimal care and promote patients’ health.
• Provision 7 calls for nurses to uphold patients’ rights across the continuum of care and while patients are involved in research projects.
• Provision 8 requires nurses to work with other health care professionals in areas such as protecting human rights and reducing disparities in health care.
• Provision 9 establishes nurses’ obligation to include social justice principles in health policies.

Advocacy in nursing is important for many reasons. For example, the previously mentioned study in Nursing Ethics noted that nursing advocacy can:

• Improve public health
• Increase collaboration among health care professionals, patients, and patients families
• Enhance the quality of care
• Improve the safety of vulnerable patients
• Elevate patients’ sense of empowerment
• Improve patient access to health care

Nurses themselves can also get a morale boost from patient advocacy. Specifically, the study noted that nurses can strengthen their own self-concept, self-motivation, and job satisfaction by advocating on their patients’ behalf. However, the study also cautioned that health care organizations need to be supportive of nurses’ advocacy efforts; otherwise, nurses may experience feelings of isolation.

Certain barriers can impair nurses’ ability to advocate for their patients. A 2020 study published in the journal Nursing Open identified an overall lack of cooperation among patients, health care professionals, and health care organizations as the primary barrier to patient advocacy. As components of that overall lack of cooperation, the following more specific barriers to nursing advocacy were identified in the study:

• Health care organizations’ bureaucracy
• Working environment inadequacies, such as lack of support from doctors or limited supplies of medical equipment
• Inadequate communication and interpersonal skills among staff
• Lack of support from health care organizations’ legal teams
• Lack of support from patients’ families
• Limitations on patients’ financial resources
• Nurses’ fear of negative outcomes from advocacy, such as being fired or transferred
• Nurses’ lack of belief in patient advocacy
• Nurses’ limited knowledge regarding patient advocacy
• Patient-related factors or barriers, such as culture, limited literacy, or strongly held ideologies or religious beliefs

Nurses in leadership roles need to be aware of the barriers to nursing advocacy so that they can implement strategies to address them.

Several effective advocacy strategies in nursing exist at both the patient and the health care organization levels.

A 2018 article in the journal Oncology Nursing News offered these strategies that nurses can implement to advocate for patients:

Simply remaining in a patient’s room while a physician discusses a diagnosis and options for treatment can make the patient feel more comfortable asking questions.

Nurses can provide patients with important information regarding how to manage their health issues and improve their quality of life. For example, nurses can provide patients who are receiving chemotherapy with information about how to take anti-nausea medication most effectively.

Learning patients’ wishes and communicating them to others can be effective in protecting patients’ right to make choices about their health.

Taking the time to review for and correct errors in patients’ health care information is critical in advocating for them. By conducting reviews, nurses can identify errors, conflicting orders, or oversights in a patient’s care.

Developing an awareness of community resources, such as transportation, financial assistance, and support networks, and connecting patients with the resources are important elements of nursing advocacy.

Nurses who are in a position to influence policies and procedures or join committees where they work can promote advocacy strategies at the organizational level. For example, a 2021 article in ONS Voice suggests:

• Arranging patient care conferences
• Requesting ethics consultations
• Serving on an ethics committee
• Working with nurse mentors

A 2018 article in HealthLeaders explained that holding patient care conferences — in which health care professionals from different disciplines confer on patients’ health care — are particularly beneficial for patients with multiple morbidities. Holding these conferences can lead to enhanced collaboration and coordination and better prioritization of patients’ health goals.

The American Medical Association (AMA) notes that ethics consultations — in which parties such as patients, members of their health care teams, and ethics consultants confer to clarify ethical issues — can support informed decision-making about patient care. The AMA also notes that ethics committees can help facilitate decision-making regarding patient care, enhance organization-held ethics training, and help organizations develop ethics policies.

A study on in-service nurse mentoring published in the journal Global Health Action in 2020 noted the potential for the use of mentors in nursing to improve patient care. Particularly in rural areas, where there may be fewer opportunities for professional development, nurse mentoring can be beneficial in helping nurses develop their skills to enhance quality of care.

Advocacy in Action: Nursing Advocacy Examples

Patient advocacy happens in various contexts, and specific nursing advocacy examples exist at both the patient and the organizational levels.

Look no further than the COVID-19 pandemic for some of the most tremendous examples of how nurses advocate for their patients. A 2021 article in Issues in Science and Technology highlights several examples of nurses’ innovations during the pandemic, such as the following:

• Nurses moved hospitalized COVID-19 patients’ infusion pumps (which dispense fluids and medicines) from patients’ bedsides to hallways. This enabled the nurses to tend to those pumps and replace the bags much more efficiently. Limiting close patient contact enabled the nurses to help more patients and reduce the risk of COVID-19 transmission.
• Nurses played a significant role in turning hospitalized COVID-19 patients on their stomachs, improving the patients’ blood oxygen levels.
• Nurses used their personal cellphones and iPads to enable hospitalized COVID-19 patients to communicate with their loved ones, who weren’t permitted to enter hospitals.
• A psychiatric-mental health nurse practitioner (PMHNP) in North Dakota was instrumental in swiftly creating a program to help a homeless shelter assist individuals who were experiencing alcohol withdrawal during quarantine.

Beyond the pandemic, examples of nursing advocacy at the patient level demonstrate nurses’ dedication to patient care. Nurse advocate firm Healthlink Advocates Inc. offers the following examples:

• Double-checking for errors helped a nurse determine that a patient’s dosage of blood thinner was too high, leading to the patient’s transfer to a facility to treat signs of internal bleeding.
• Proactively communicating with members of the patient’s health care team enabled a nurse advocate to help a patient avoid errors in treatment.

Nurse advocate firm Guardian Nurses Healthcare Advocates Inc. offers the following examples:

• Interpreting medical terms for the family of a hospitalized patient enabled a nurse advocate to fully inform the family of the patient’s condition.
• Facilitating medical appointments and treatment for a patient with a rare form of cancer helped a nurse advocate to reduce the patient’s anxiety and allow the patient to make informed decisions about treatment.

Medical staffing firm Premier Medical Staffing Services offers the following examples:

• Nurses can teach patients how to advocate for themselves through activities such as helping a patient create a list of concerns or questions to discuss with medical professionals.
• Nurses can tactfully protect patients’ privacy rights by requesting patients’ permission before discussing their care in the presence of people or periodically reminding other medical professionals about patients’ privacy rights.

Examples of Nursing Advocacy at the Organizational Level

Nurses can work toward organizational approaches for advocating on behalf of multiple patients. Nursing advocacy can be woven into an organization’s operations, as the following examples demonstrate:

Cleveland Clinic Care Community reduced patient transmissions and trips to the emergency room by assigning registered nurses (RNs) as care coordinators for high-risk patients. After identifying high-risk patients using an algorithm based on claims information, demographics, and state of disease, the organization assigns RNs to those patients to assist them in managing their diseases.

The RNs also connect patients to resources in the community (such as social workers or exercise programs), ensure that patients receive routine health care (such as colonoscopies and eye exams), and encourage patients to participate in other health-related programs (such as smoking cessation or weight loss programs).

Assisting patients with multiple chronic diseases through a guided care model that Johns Hopkins University developed can help patients follow a care plan that encompasses all their health challenges. In the guided care model, RNs assess patients’ needs and coordinate with primary care physicians to develop care plans. The nurses also teach patients and caregivers ways of managing their diseases. In addition to improving the chances for positive outcomes, this model has reduced patients’ health care expenditures.

A Vermont hospital improved patient service by implementing a transitional care model to continue to assist patients after they transfer from one health care setting to another. By assigning advanced practice nurses to patients transitioning to other health care settings, Southwestern Vermont Medical Center significantly improved service continuity. The nurses help patients better understand their medications and physicians’ instructions; visit patients’ homes when necessary; and connect patients with social services, such as housing or treatment for addiction. The program is free to the patients who participate.

Nurses who have a strong affinity for nursing advocacy can consider working exclusively in patient advocacy nursing. Although nurses don’t need to follow any single career path to work solely in patient advocacy nursing, they need to know about certifications in the field. For example:

• The Academy of Oncology Nurse & Patient Navigators (AONN Plus) offers certification as an Oncology Nurse Navigator-Certified Generalist (ONN-CG). RNs who meet the eligibility requirements must pass an exam on topics such as community outreach, coordination of care, patient advocacy, psychosocial support services, survivorship, and ethics.
• The Patient Advocate Certification Board (PACB) offers certification as a Board Certified Patient Advocate (BCPA). The certification is available to individuals from many different backgrounds, including nursing. Candidates for certification must meet eligibility requirements and pass an exam on topics such as empowerment, autonomy, communication, interpersonal relationships, health care access, and ethics.

Nurses have also started establishing their own nursing advocacy businesses. Patients and families hire and pay these nurse advocates to help them through difficult health issues. Examples of their services are:

• Explaining a diagnosis
• Providing support when a patient makes medical decisions
• Coordinating medical care, such as medical appointments, hospitalizations, and surgeries
• Visiting patients in the hospital to ensure that their needs are being met
• Assisting patients in obtaining medical equipment
• Providing patients with health and wellness advice and coaching
• Assisting patients with health insurance billing and other insurance matters

According to the Alliance of Professional Health Advocates (APHA), independent advocates usually charge hourly rates of $125 to $350, depending on the advocate’s credentials, location, and services.

As with any endeavor to start a business, nurses who want to strike out on their own can benefit from studying the market for their services, creating a business plan, considering factors such as insurance, and pinpointing the precise services they intend to provide.

Nursing advocacy is a critical and rewarding component of any nursing career. Nurses or prospective students who aspire to leadership positions and promote nursing advocacy can explore Hawai‘i Pacific University’s online MSN to DNP program to learn more about how the program may help them achieve their professional goals. Start expanding your knowledge on patient advocacy and nursing today.