Facilitators and Barriers for Advocacy among Nurses - A Cross-Sectional Study

Lizy Sonia Benjamin1, Sumathi Robert Shanmugam2, Savvato Karavasileiadou3, Yahya Showkan Ali Hamdi4, Saieda Fayez Moussa5, Amel Dawod Kamel Gouda6*

1Department of Medical-Surgical Nursing, College of Nursing, King Khalid University, 61421 Asir - Abha, Saudi Arabia.

2Department of Maternity and Pediatric Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, 13412 Riyadh, Saudi Arabia.

3Department of Community Health Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, 13412 Riyadh, Saudi Arabia

4Director of Nursing, Nursing Service, Aseer Central Hospital, 7663 Aseer, Saudi Arabia 5Department of Child Health Nursing, School of Nursing, Bader University, Cairo Governorate 4942340, Egypt.

6Maternity Nursing, College of Nursing-Riyadh, King Saud bin Abdul-Aziz University for Health Sciences, 22384 Riyadh, Saudi Arabia ; King Abdulaziz Medical City. King Abdullah International Medical Research Center , Ar Rimayah, 11481 Riyadh, Saudi Arabia

*Corresponding Author’s Email : goudaa@ksau-hs.edu.sa ; dawod@cu.edu.eg

ABSTRACT

Background: Nurses serve as patient advocates by protecting their autonomy, representing their interests, and promoting social justice in healthcare delivery. Healthcare advocacy has embraced a crucial role for nurses, but its extent is often limited in practice. Patient advocacy has not been completely clear. Objective: This study aimed to assess the facilitators and barriers to advocacy among nurses at selected tertiary care hospitals in India. Design: A descriptive study was conducted in tertiary care hospitals. Methods: A purposive sample of 150 nurses was recruited, and data was collected using the Modified Hans Protective Nursing Advocacy Scale (HPNAS) directly by the self-report method. The data were analyzed using SPSS, version 24. Results: The majority of nurses had mean facilitator scores of advocacy among nurses of 12.79, and the mean barrier score was 9.45. The item-wise facilitators of nursing advocacy that showed above 50% were communication skills (81%), problem-solving skills (69%), and the readiness of the nurses for patient care (60%). The item-wise barriers to nursing advocacy depicted were a risk to their job (81%), poor team coordination and cooperation (79%), and poor self-image (69%). Lack of job satisfaction, burnout, lack of time, and lack of confidence showed up equally (63%). There was no significant difference in the mean scores of nursing advocacy between male and female nurses, whereas there was a statistical association between advocacy facilitators scores and age and area of work and barrier scores with the gender of nurses. Conclusion: Nurses must be empowered by providing opportunities for them to speak up and break down barriers. Recommendations: The focus should be on coordinating institutional, national, and international effortsin order to conduct various nursing leadership and professional development programs, contributing effectively upholding and improving the nursing profile and status.

Keywords: Advocacy; Barriers; Facilitators; Nurses; Patients; Skills

INTRODUCTION

The term advocacy is widely used to characterize nurse-patient interaction in nursing practice. However, the term is ambiguous, as advocacy for patients is more than just defending patients' rights. Patient advocacy, according to registered nurses, promotes patient safety and high-quality care. It encompasses the following: patient protection; patient voice; high-quality care provision; building strong interpersonal relationships; and patient education. There are studies to prove that poor patient advocacy has negative consequences for their outcomes (Nsiah, Siakwa, & Ninnoni 2019). According to Abbaszadeh, Borhani, and Motamed-Jahromi (2013), the strong nurse-patient relationship that exists in healthcare facilities puts the nurse in a unique position to advocate for the patient.

Nowadays, nurses undeniably operate in a more sophisticated and demanding workplace than their predecessors. Hospitals primarily treat people with emergency or catastrophic health conditions; therefore, patients are increasingly gravely ill. As health advocates, nurses safeguard their patients' autonomy, advocate for their benefits, and thus promote social justice in healthcare. The quantity of administrative work that nurses are expected to do has increased dramatically. Furthermore, technological advancements have drastically altered the way nurses conduct several basic jobs (Gazarian, Fernberg, & Sheehan, 2016; Pratama, Yustina & Sudaryati, 2022).

A study conducted by Jeon and Choi (2020) concluded that nursing interventions should be developed to promote patient directivity and optimistic human rights toward people with disabilities among clinical nurses. Nurses require continual professional development to keep up to dateon their health advocacy role performance and to be empowered to speak out. Nurses should be encouraged to continue their professional education, as the existing data imply that the educational level influences a nurse's ability to advocate (Brickley et al., 2021).

Facilitators of patient advocacy in nursing practice refer to understanding, being sympathetic with, and feeling close to the patient and “protecting patients,” including patient care, prioritization of patients’ health, commitment to the completion of the care process, and protection of patients’ rights (Davoodvand, Abbaszadeh, & Ahmadi, 2016). On the other hand, barriers refer to inadequate communication and interpersonal relationships, patients' families, patients' religious and cultural beliefs, and the health institution as a whole, as well as the healthcare team and care recipients (Nsiah, Siakwa, & Ninnoni, 2019; Mandal, Basu, & De, 2020).

The assessment of facilitators for and barriers to advocacy is an important factor to improve the first and minimize the latter, to enhance the level and quality of patient support. It is mentioned that nurses who overcame barriers enjoyed positive experiences in their physical, psychological, and professional environments (Nsiah, Siakwa, & Ninnoni, 2020). Furthermore, nurses play a vital role in patient advocacy as they are accountable for patient care legally and ethically. A gap exists between nurses and other healthcare providers regarding the concept of patient advocacy and how it affects the intensity of advocating for their patients. Therefore, this study aims to assess the perceived facilitators and barriers to advocacy among nurses at the chosen tertiary care hospitals in India.

METHODOLOGY

Research Design and Population

This is a descriptive study design that used a purposive sampling technique among 150 nurses working in Apollo hospitals in Chennai, India.

Eligibility Criteria

The samples were recruited in the study with the following inclusion criteria: male and female nurses above 21 years of age who completed professional nursing courses, worked in general medical and surgical units and critical care units for at least one year, and showed a showed a willingness to participate in the study were included as study samples.

Sampling Procedure

The target population was 750 nurses working in various units of the hospital. The sample size was determined based on the findings of past studies using the Master software, with a margin of error of 5 and a confidence interval of 95%. The sample estimation was 142, but considering attrition, a sample of 150 nurses was included in the study. The nominal role of the registered nurses in every unit was considered to ensure a fair distribution of participants across the hospital.

Data Collection Procedure

The questionnaire had three main sections intended to capture data on respondents’ demographic characteristics, facilitators, and barriers to nursing advocacy. Experts in the field of nursing and research validated the tools. Data was collected from each nurse individually by one of the researchers and three volunteers, stating the purpose and the participant’s rights. The questionnaires were distributed and collected on the same day when the nurses attended a continuing nursing education program in the training center of the facility.

Research Instruments Demographic Assessment

The demographic profile is used to measure characteristics such as age, gender, marital status, qualification, current designation, area of work, and total years of experience.

Modified Hans Protective Nursing Advocacy Scale (HPNAS)

Data were collected using a standardized tool, Hans Protective Nursing Advocacy Scale (HPNAS) developed by Hanks (2010). The rating scales were scored to 3 levels with 15 items. Low = 1-5, medium= 6-10, and high= 11-15. The rating scale on perceived facilitators of nursing advocacy is a 7-items, 5-point Likert scale (5 to a large extent, 4- To a moderate extent, 3- No opinion, 2- To a little extent, 1-Not at all). The total score ranges from 7-35. Higher facilitator scores indicate more facilitators of advocacy and lesser scores indicate fewer facilitators. The rating scale on perceived barriers of nursing advocacy is an 8-item, 5-point Likert scale such as 1 is Not a barrier, 2 is Somewhat a barrier, 3 is Not sure, 4 is a Barrier, and 5 is a Significant Barrier. The total score ranges from 8-40. Higher scores indicated more barriers and vice versa.

Ethical Consideration

This study received ethical approval from Apollo Hospitals in Chennai, India with Reference No. ACON C/IEC/2021/016 on 5th February, 2021.

Data Analysis

Statistical analysis was performed using the Statistical Packages for Social Studies (SPSS), version 24. The gathered datawere entered and analyzed utilizing descriptive statistics such as percentages to determine the distribution of demographic profiles.

Mean scores and standard deviations were used to assess the facilitators, barriers, and level of advocacy of nurses. Inferential statistics (t-test and Annova) were used to determine the comparison of advocacy scores between male and female nurses and to identify the association between advocacy scores and demographic variables, respectively.

RESULTS

Demographic Characteristics of the Nurses

To begin with demographic characteristics, the majority (60%) was between 21 and 25 years old, and more than three-quarters were female nurses (70%). About 54% of them were undergraduate degree holders and were staff nurses, equally working in critical care units (51.3%). The average working experience exceeded less than one year (56.7%) (Table 1).

Table 1: Demographic Characteristics of the Nurses (n=150)

Facilitators and barriers scores of advocacy among nurses

The mean facilitators and barriers scores of advocacy among nurses were revealed as 12.79 and

9.45 respectively (Table 2).

Table 2: Facilitators and Barriers Scores of Advocacy among Nurses (n=150)

Item-wise percentage distribution of facilitators of nursing advocacy

The item-wise percentage distribution of facilitators of nursing advocacy highlights that most of the nurses felt communication skills would facilitate nursing advocacy (81%), followed by problem-solving skills (69%), and the readiness of the nurses for patient care (60%). Around 50% of the nurses expressed dedication and professional obligation (48%), eagerly waiting to facilitate advocacy (46%), and self-confidence and passion (53%), as facilitator items to improve nursing advocacy (Table 3).

Table 3: Item-wise Percentage Distribution of Facilitators of Nursing Advocacy (n=150)

Item-wise percentage distribution of barriers to nursing advocacy

The item-wise percentage distribution of barriers to nursing advocacy depicted that most of the nurses felt the risk to their job (81%), as one of the barriers to nursing advocacy, followed by poor team coordination and cooperation (79%). More than 50% of the nurses expressed that failed responsibility (60%), poor self-image (69%), lack of job satisfaction (63%), burnout (63%), lack of time (63%), and lack of confidence (63%) were barriers to nursing advocacy. Nurses are health advocates who safeguard their patients' autonomy, advocate on their behalf, and promote social justice in healthcare (Table 4).

Table 4: Item-Wise Percentage Distribution of Barriers to Nursing Advocacy (n=150)

Comparison of advocacy scores between male and female nurses

The comparison of advocacy scores between male and female nurses reveals p value = 0.02 indicating there was no significant difference in the mean scores of nursing advocacy between male and female nurses working at p < 0.05 (Table 5).

Table 5: Comparison of Advocacy Scores Between Male and Female Nurses (n=150)

Association between demographic variables of nurses’ advocacy facilitators and barriers scores

The association between demographic variables of nurses and advocacy facilitators scores p value=0.02 are significantly associated with age and area of work p value =0.02 which showed higher scores among nurses above 30 years and those working in general wards than critical care units at p < 0.05.

The advocacy barriers scores are significantly associated with gender p value =0.003, age p value=0.00, designation p value =0.008, and years of experience p value =0.00 which showed higher scores among male nurses, nurses aged above 30 years, working as nurses in charge, and with less than one year of experience at p < 0.05 (Table 6).

Table 6: Association between Selected Background Variables of Nurses’ Advocacy Facilitators and Barriers Scores (n=150)

Factors Associated with Advocacy Facilitators’ Scores Using Multivariate Regression Analysis

The multivariate regression analysis indicates that age and area of work (p value =0.002) are associated with facilitators’ scores, and gender was associated with barrier scores at p < 0.05 (Table 7).

Table 7: Demographic Variables Associated with Advocacy Facilitators and Barriers Scores Using Multivariate Regression Analysis(n=150)

DISCUSSION

The present study aimed to assess the facilitators and barriers to advocacy among nurses. The necessary skills such as communication, collaboration, dedication, self-confidence, problem- solving and self-interest that are required for nurses to promote advocacy are measured in this study as facilitators. It means that the nurse-patient relationship is the foundation for effective patient advocacy. The study findings about the advocacy facilitators are concurrent with the findings by Kolawole and Adejumo (2020) and Negarandeh et al. (2006) that the key factor for advocacy is the nurse-patient relationship; perceiving the needs of the patients and taking care of those needs are more effective in patient advocacy. Moreover, it is concurred by Nsiah, Siakwa and Ninnoni (2019) that the patient advocacy process involves establishing rapport and involving patients and their families in patient care.

The nurse advocating as a case manager needs to set their personal preferences aside and focus on the patient’s needs. This could be the reason that not every nurse in this study agreed upon self- interest (60%) as a necessary skill for advocacy, whereas all other necessary skills were agreed upon by the majority of nurses. The patient needs advocacy because of their lack of ability to decide what is in their best interest, or they may be unable to make any decisions due to a fall in their level of consciousness or mental state (Vaartio-Rajalin & Leino-Kilpi, 2011). Automatic decisions tend to be self-interest-driven. A study in Poland supports this claim, in which a decision that was made by certain health professionals without considering the patient’s perspective is considered to place self-interest before the patient’s interest (Tomasik, 2018). Nurses should perceive that avoiding the drive of self-interest during patient advocacy leads to more patient- centered decision-making. Studying the event of a pandemic (Ediz & Uzun, 2024). Roddy and Muehlbauer (2020) argued that self-interest without consideration for the patient leads to a worse outcome and, in extreme cases, sabotages the patient’s interest. Nevertheless, this study reported that self-interest might as well benefit the advocacy process. That is because reframing self-interest in the hospital setting might enlighten the nurse on how to use it in a good way (Ucar et al., 2024).

Patient advocacy will be successful only if information about the patients is communicated effectively to other healthcare providers. Indeed, nurses require collaboration skills and teamwork. These findings in this study are confirmed by an integrative review by Souza (2022) that oral communication skills of health professionals are an attribute in the relationship between professionals and patients. Similar results were obtained in the study conducted by Rainer (2015) on speaking up factors and issues in nurses advocating for patients in jeopardy. He reported that for health advocacy to be more productive in such cases, nurses need to be assertive rather than aggressive in their communication style. These facilitators were mentioned as nurses with positive attitudes and abilities (Oranta, Routasalo & Hupli, 2002) and representing patients or speaking on behalf of patients (El Seesy & Al Nagshabandi, 2016 ; Adjei et al., 2023).

Regarding barriers to advocacy, the majority of the nurses in this study agreed that poor team coordination and cooperation were one of the barriers. A similar finding by Nsiah, Siakwa, and Ninnoni (2019) states that a lack of cooperation between the healthcare team, care recipients, and health institutions was one of the barriers to patient advocacy. More than 50% of the nurses felt that job satisfaction, burnout, lack of time, and confidence were the most significant barriers to nursing advocacy. Similar results were obtained as limitations in the workplace (Figueira et al., 2018; Laari & Duma, 2021) and as time pressure (Alexander et al., 2022; Brennan et al., 2023).

The barriers to patient advocacy have been addressed as wrong labeling and vindication by employers, coupled with the possibility of losing their job (Black, 2011). In addition, few qualitative studies (Abbasinia, Ahmadi, & Kazemnejad, 2020; Choi, 2015; Josse-Eklund et al., 2014; Mortell, Abdullah, & Ahmad, 2017) reported that jobs might be at risk, unlike a study conducted in Saudi Arabia that found that job were not at risk (Alanezi, 2022). This will lead to a lack of job satisfaction, which was well perceived as a barrier by the nurses in this study. While advocating for patients, nurses need to be secured or protected (Dadzie, Aziato & Aikins, 2017; Davoodvand, Abbaszadeh & Ahmadi, 2016) in their job, which will increase nurses’ confidence and positive attitude toward patients, be committed to completing care, and more importantly, protect patient rights and drive advocacy properly (Josse-Eklund et al., 2014). Burnout, which was found as another barrier in this study, was mentioned as fatigue and frustration that hinder advocacy (Dadzie, Aziato, & Aikins, 2017).

In the current study, the results indicate no significant difference between male and female nurses on perceiving advocacy, as the average scores of both genders were quite similar. This varies from a study conducted in Saudi Arabia that found female nurses showed a higher score in a positive attitude toward patient advocacy than male nurses (Alanezi, 2022), which also confirmed that gender is a potential barrier to advocacy (Mortell, Abdullah, & Ahmad, 2017).

With regard to the interpretation of the finding, the authors are confident enough to say that there is no difference that needs to be addressed between the perceptions of advocacy across genders. Advocacy turns out to not be a gender-sensitive activity. It is safe to say that both genders would perceive and act on advocacy to thesame degree. Although gender is closely related to differences, especially in mindset and behavior, according to this study’s findings, such differences were not a concern, yet the existing research could be used as a deductiveapproach to explaining this finding.

The present study showed that the facilitators’ scores had a significant association with nurses’ age and area of work, which was also seen in the regression analysis. The barrier scores had a significant association with gender, age, designation, and years of experience, but regression analysis showed only a gender association. There was a statistical correlation between nursing interns’ perceptions of patients’ rights and advocacy and their clinical area; there was no other statistical relation between gender and age (Elewa, ElAlim, & Etway, 2016).

The nursing literature notes that the description of a nurse's advocacy function still contains deficiencies, differences, and contradictions and that nursing education is critical in preparing nurses for patient advocacy. The nursing profession views nurses as ethically and morally committed to serving as advocates. As a generally female-dominated profession, nurses are anecdotally regarded as being in traditional subservient roles to surrogate roles. To enhance nursing advocacy, an upgraded public view of nurses, which will provide them with the necessary confidence to raise their voices among other health professionals, relatives, and administrative staff and stand up for patients’ rights, is of paramount importance.

Future Implications to Nursing Practice and Education

The findings of the present study strengthen the professional role of nurses as direct care providers and policymakers in caring for patients and families with education and support. Thus, nurse administrators need to practically review advocacy roles in each unit regularly. The nurses' knowledge and skills are thought to be crucial in providing nursing care. It can be developed through continuing education programs that provide them the chance to get the necessary skills to combat situations that call for protecting patients' rights throughout their work experience. Nurses can use knowledge obtained through professional qualification to resist circumstances that they deem to be ethically unacceptable, promoting the use of power in their working environments and strengthening patient advocacy initiatives (Gazarian, Fernberg, & Sheehan, 2016). The concept of advocacy must be emphasized in the undergraduate and postgraduate nursing curricula to prepare them to play advocacy roles effectively. Short-term courses with clinical scenario-based training on nursing advocacy roles and their application can be conducted in nursing educational institutions.

Limitations

The study sample consisted of nurses employed by a single hospital, and thus the findings cannot be generalized. Moreover, many nurses were reluctant to share their responses due to fear of their career prospects, as their opinions would be marked in their annual appraisals.

CONCLUSION

In summary, the current study highlights that the that the facilitators of nursing advocacy were communication skills, problem-solving skills, and the readiness of nurses for patient care. In contrast, the barriers to nursing advocacy as a risk to their job are poor team coordination, cooperation, poor self-image, lack of job satisfaction, burnout, lack of time, and lack of confidence. Hence, the study determines that nurses must be empowered by providing opportunities for them to speak up and break down barriers. The focus should be on coordinating institutional, national, and international efforts to conduct various nursing leadership and professional development programs, contributing effectively to upholding and improving the nursing profile and status. It is recommended that further research studies are needed to explore the nurses’ perspective of facilitators and barriers to patient advocacy, as nurses working in different cultures and workplaces may influence the findings of this study. Future research should explore nurses' perspectives on facilitators and barriers to patient advocacy across diverse cultures and workplaces to validate and expand these findings. The study underscores the need for coordinated efforts in nursing leadership and professional development programs to empower nurses and enhance their advocacy roles.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors are thankful to the institutional authority for completion of the work.

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