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From our readers…Practical approaches to patient advocacy barriers


Nurses know that patient advocacy is an expected and important role for their practice, but the practical implications of acting as an advocate are often left for the nurse to interpret. These include the meaning of advocacy and how to overcome institutional and educational barriers to fulfilling the role of advocate.

What is advocacy?

Being a patient advocate is integrated into nursing school competencies and is reflected in ethical codes of conduct, such as the American Nurses Association’s (ANA’s) “Code of Ethics for Nurses,” which states, “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” The “Code of Ethics for Nurses” from the International Council of Nurses also includes patient advocacy.

The word “advocacy” occurs frequently in nursing, but the actual meaning is less clear. Advocacy is derived from the legal term of advocate, which means “a person who assists, defends, pleads, or prosecutes for another.” The meaning for practicing nurses is more complex than the legal term, and advocacy has been the focus of many nursing articles and research studies.

Some important points based on the nursing literature to consider are that only the patient can decide what is in the patient’s best interest and your role is to support the decision-making process. Patient advocacy includes a therapeutic relationship and communication between you and your patient. As an advocate, you act as an informer to the patient’s decision-making, stand by your patient, and enable your patient to make his or her own decisions. Your advocacy can involve acting on the behalf of a patient, speaking, fighting for, and standing up for your patients. Additionally you might be a liaison that bridges the communication gap between patient, other professions, and the healthcare system.

Overcoming institutional barriers

Barriers may stand in the way of you acting as a patient advocate. A major barrier is the institutional barrier where the nurse may find difficulty in being supported in the advocacy role by administration, physicians, and nursing peers. Some nurses can view the consequences of nursing advocacy as a career dilemma or risk taking and can lead to punishment and lowering of status. Even effective advocacy is associated with by feelings of frustration, anger, and a disruption of peer relationships with some advocates being labeled as disruptive.

One way to overcome the institutional barrier is to use clear, effective communication when advocating for your patients. Your communication will be better received if you speak clearly and try to minimize your emotional reactions such as anger or frustration.

Be aware of your body language and the message it is sending when speaking to others. Your verbal communication will be facilitated if your body language does not appear fearful, hostile or confrontational.

Beginning sentences with phrases such as “in the patient’s best interest, I recommend that…” keeps the focus on the patient. If the patient has spoken to you about an issue, then use that information to support your advocacy actions, for example: “Ms. Smith has told me repeatedly she does not want a feeding tube.”

In addition, document statements that the patient has told you so there is a written record. Review the patient’s advance directives to help support your advocacy, such as, “Mr. Jones wrote in his living will that he did not want to be on a ventilator.” You may also need to remind other healthcare workers of the contents of the patient’s advance directives to facilitate a consistent approach to the care of the patient.

To support yourself internally, remember that your duty as a nurse is to your patient, not the institution or other healthcare workers. Keep the ANA Code of Ethics and your state nursing practice act in mind when faced with an advocacy situation to help to bolster your confidence while advocating.

Learn about and use the administrative structure of your institution, such as ethics committees, administrative chain of command, and institutional policies. Consider attending ethical rounds or ethics committees, if possible, and discuss with peers situations that have caused you to act as an advocate. The ability to access the correct administrative personnel and policies will help the advocacy process be smoother in the future.

Overcoming education barriers

Another barrier that you may have to overcome is lack of education about acting as an advocate. Even thought it is a basic nurse competency, studies have indicated that nurses lack specific training in advocacy.

To help improve your advocacy skills, find those nurse mentors who you feel are effective advocates and model your own skills from what you observe and hear. Attend continuing education regarding ethics and advocacy, particularly if it is directly related to your employer. In addition, share information you have learned about being a patient advocate to other nurses that you work with-your peers may have similar advocacy experiences that they will share with you.

After you advocate

After the situation is resolved, reflect on your reasons for why you felt the need to advocate, what was successful, and what areas you need to improve for the next time you act as an advocate. Consider that feelings of fear and frustration may be a result of your advocacy action.

Ethical and legal duty

As a nurse, you have an ethical duty to advocate for your patients, and it is an expected competency for practicing nurses. Your state’s nursing practice act may have additional legal requirements to act as an advocate for your patient. However, with the use of effective communication skills, educating yourself about resources, and increasing your own advocacy skills and confidence, you can overcome these barriers to being an effective advocate for your patient.

Robert Hanks is an assistant professor at The University of Texas at Health Science Center at Houston School of Nursing.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

Selected references

American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing, 2008.

American Nurses Association. The code of ethics for nurses with interpretive statements. http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html. Accessed January 4, 2012.

Benner P. From novice to expert: Excellence and power in clinical nursing practice. Commemorative Edition. Upper Saddle River, NJ: Prentice Hall Health; 2001.

Garner B. Black’s law dictionary (7th ed.). St. Paul, MN: West Group Publishing; 2000.

Hanks R. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics. 2010;17(2): 255-267.

Hanks R. The medical-surgical nurse perspective of the advocate role. Nurs Forum. 2010;45(2), 97-107

Mahlin M. Individual patient advocacy, collective responsibility and activism with professional nursing associations. Nurs Ethics. 2010;17(2), 247–254.

International Council of Nurses. The ICN code of ethics for nurses.
http://www.icn.ch/images/stories/documents/about/icncode_english.pdf. Accessed January 4, 2012.

2 Comments. Leave new

  • Mental Health RN
    March 11, 2013 9:38 am

    I run up against a system that is unrealistic in empowering individuals with mental illness on a regular basis who ‘do not have to take medication’, ‘ can deny medical treatment’ and yet when they die my charts still get reviewed, combed threw, critiqued (often by non nurses) etc. It is a rough place to be.. and I question why I’m doing this daily. I wish I could write in detail what goes on…

  • Our role as patient advocate is one of the most important qualities that sets the professional nurse apart from a task-oriented technician. It requires extra time and effort, often under circumstances where time is in short supply, but every patient (even the most difficult one!) is worthy of that extra consideration.


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