What Patient Advocacy Really Looks Like

This post has been sponsored by Campbellsville University Online.

Please note: as many of you know, there was recently a rather controversial blog post about patient advocacy, written by a surgeon, which has since been deleted. Ironically enough, this sponsored post was written and scheduled before the post, response, and removal occurred.

If nursing is the heart of healthcare, patient advocacy is the coronary arteries.

Nurses simply cannot function, the heart of healthcare cannot beat, if we are not advocating for our patients. Otherwise, we’re simply pencil-pushers, task-completers, and yes-men/women.

As hands-on caregivers, we have the primary responsibility of ensuring quality, ethical care for our patients. If you haven’t already read the American Nurses Association’s Code of Ethics, I really encourage you to. It states, “the nurse promotes, advocates for, and protects the rights, health, and safety of the patient.”

Nurses see it all

Nurses oversee the healthcare of many patients and can be privy to concerning practices. Nurses can see the behind the scenes happenings… we know the protocols, procedures, the personalities, the tendencies, the barriers, the culture, the unwritten and written rules, what’s supposed to be done and what’s actually done.

It’s funny how the nurse is the one with whom many feel most comfortable being honest, unedited, frustrated, mad, relieved, and even literally and figuratively exposed. It can be quite a burden to bear at times, as a healthcare provider.

Hospitals are required to look after their own financial well-being, legal obligations and other factors that can sometimes cause patient care to deteriorate.  Occasionally the healthcare team makes mistakes and people miscommunicate. When this happens, someone who practices patient advocacy steps in and looks out for the patient’s’ well-being in a way that maintains professional composure.

Patient advocacy challenges

American Nurse Today (ANT) defines nurse advocacy as “using one’s position to support, protect, or speak out for the rights and interests of another.” This practice is vital in healthcare, because errors, miscommunication, and oversights can result in severe injury or illness, or death. A nurse patient advocate must not only catch these errors, but also argue for their correction in the future in order to promote safety and patient health.

However, patient advocacy is not without its challenges. Because nurses are the constant presence at the bedside, we’re the ones in continual communication. We set expectations, clarify what others have said, correct the patient when they’ve misunderstood, and facilitate many things throughout the day and night. Naturally, when a communication breakdown, error, or oversight occurs… the nurse is typically the one on the front lines dealing with it. And sometimes, we’re the ones who are at fault.

Being a patient advocate can mean going up against some of the most intimidating and challenging leadership at times.  Here’s an amazing example of two nurses going to bat for their patients, against all odds. And here is the American Nurses Association’s news release on the matter. Both their state board of nursing and the American Nurse’s Association stood with them and provided support.

If patient advocacy is the coronary arteries of healthcare, I think Vickilyn and Anne just put in some stents. I cannot imagine how difficult it must have been to be in that position in the first place, and then take those difficult, yet incredibly necessary steps that needed to be taken for the sake of their patients.

Preventing major communication breakdowns

Let’s face it: with so many moving pieces in healthcare delivery, communication breakdowns occur. I find that the most common breakdown is due to a failure to meet expectations.
When an expectation has not been met (and in healthcare, this can even mean life and death), frustration, anger, and even verbal assault can occur. The stakes are high, therefore tension can soar.

Hopefully, we can avoid this in the first place by empowering everyone around us (the new grad nurse we’re training, the first year medical resident, the seasoned surgeon, our patients) to be comfortable asking questions in a calm, respectful manner. We do this by providing a safe, non-judgemental space whenever someone does come to us with questions or appears as if they may not understand, and by simply asking someone to repeat what they understand about the situation.

• “Tell me what you heard me say.”
• “Tell me what you heard me say, because this can be kind of confusing and I want to make sure we’re on the same page.”
• “What’s your understanding of the situation?
• Or conversely, “So what I hear you saying is, ___________________, is that correct?”

These are great open-ended, nonjudgmental ways to assess understanding and provide an opportunity to correct. Asking if anyone has any questions while you’re halfway out the door is a terrible way to communicate. When someone does that, it can feel burdensome to ask even basic clarification questions. We must not do this to our patients or to one another. If we don’t get why the physical therapist recommends something, or why that physician put in that specific order, it’s helpful to use one of those open-ended questions to create dialogue. We must be comfortable and confident enough within ourselves to ask others questions, even ones that may seem obvious.  This is essential because this simple act of vulnerability in admitting I don’t know something can in turn inspire others to inquire when needed.  Asking someone we perceive as smarter, above, or more powerful than us is scary, whether or not they actually are who we perceive them to be. But if we can break through that and ask the questions we need to, and occasionally insist upon them, it facilitates communication and makes it less personal and more about what is best for the patient.

Remember, there is no such thing as over communication in healthcare. What’s routine for the healthcare team is typically not routine for our patients. Even if we know our stroke patient isn’t going to get water until they’re cleared by a speech therapist and that’s stroke care 101, our patient’s most likely don’t know that.  And maybe the doctor forgot to tell them they’re NPO… or maybe they said “NPO” and the patient had no clue what that meant.  Therefore, we must communicate, even the most basic things that we do without thinking, to prevent a breakdown.  Otherwise, that family member of the stroke patient may think we’re starving their loved one when really, we’re just following our protocol and forgot to tell them that aspect of the plan.

Furthermore, the American Journal of Critical Care suggests that the best way to avoid such conflicts while practicing patient advocacy is to embrace a spirit of collaboration with other healthcare professionals, rather than taking the attitude that it is the nurse’s job to protect patients from the mistakes of others. This team mentality instead of an “us versus them” mentality is crucial.  We cannot create or perpetuate sides, even if someone truly messed something up.  A house divided cannot stand.

If we’re all working together towards a mutually agreed upon goal with the patient at the center, checking our ego at the door, and feeling comfortable asking (and calmly insisting and activating your chain of command if asking isn’t working) questions, we can hopefully prevent many situations in which advocacy would have been necessary.

What to do when advocacy is necessary

While we’d like to prevent these scenarios from ever being necessary, it’s not always realistic… especially if things are happening at an incredibly fast rate (like the unstable or time sensitive patient in the emergency department).  So what do you do when you find yourself in a situation in which you need to advocate for your patient, or your patient is advocating for themselves to you?

It’s essential to first calm the situation, especially if tempers are high. If you feel unsafe, or are being verbally assaulted, stop the conversation until the other party has control over themselves. (And if we’re not calm, cool, and collected, we must also step away and gather composure.)  This may include interrupting them on the phone and saying, “I will not be spoken to in that manner. Please call me back when you can speak to me appropriately. (Click)” Or, it may include verbalizing this face to face and walking away. It may even include calling security or an administrator on-call. It may also be necessary to refer to your institutional policies and procedures to ensure appropriate action is taken and the correct chain of command is followed.

Once the situation is calm, it’s helpful to first ask the person what the understanding of the situation is. Then, empathize with how they’re feeling about the situation (and this may include a “I’m so sorry this has happened”) while hopefully they’re empathizing with how you’re feeling. Next, communicate your understanding of the situation, and rectify it to the best of your ability.  Circle back with the patient to ensure they fully understand what’s going on and their needs are met.  You may need to facilitate a conversation with multiple members of the healthcare team at once as well  if the situation is more complex.

This is like saying:

You and I are not on the same page. Let’s chat about specifically which page each of us are on, recognize and consider how one another feels, and then both get to the same page together. Deal?

And finally, if there was a system-wide, big-picture problem which was the reason behind this issue, or if something needs to be expedited but doing so is out of your control as the bedside nurse, pull in management and/or administration to see if we can avoid this in the future for others. It’s helpful to do this early than later, again facilitating the team mentality with the patient at the center.  Consider consulting your institutions policies and procedures, your state board of nursing, respective nursing specialties professional organization, as well as the American Nurses Association if needed, as they all have helpful resources for the bedside nurse in particularly challenging patient advocacy scenarios.

Ensure safety.  Identify the error, miscommunication, or need.  Empathize.  Leverage your resources.  Rectify.  Circle back.

Widening your knowledge base with a BSN

This post was sponsored by CU Online, who offers an online RN to BSN degree program which enables diploma or ADN nurses to further expand their nursing knowledge by completing their BSN degree. I encourage you to check them out. Thank you, Campbellsville University.