Nurses' advocacy in an Australian operating department

AORN Journal,  June, 2004  by Rosalind Bull,  Mary FitzGerald

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The complexity of the health care environment challenges the very people it is designed to serve and may magnify the vulnerability that accompanies illness and injury. Recognition of patients' vulnerability has encouraged nurses to undertake the role of patient advocate. (1) The adoption of advocacy into the nursing role, however, has sparked debate. This debate has tended to concentrate on appropriate definitions of advocacy and the preparation and authority of nurses to act as advocates.

Advocacy commonly is defined as pleading on behalf of another.(2) One author states that nurses must protect their patients and the facility from potential risks associated with new technology. (3) The author suggests that, in this light, acting as a patient advocate is a nursing responsibility. This highlights one of the tensions inherent in the advocate role, however, because the patient's and organization's best interest are not always compatible.

There also are arguments against nurses taking the position of patient advocate. Inadequate educational preparation for the role, potential damage to nurse-physician relations, and a lack of legal and organizational recognition for nurses acting as advocates have been cited as reasons for a cautious approach. (1,4-6)

Despite objections, growing professional confidence has added strength to arguments supporting the adoption of an advocacy role into mainstream nursing. (4) License to practice as an RN in Australia is dependent on meeting the Australian Nursing Council (ANC) set of competencies for RNs. Patient advocacy is identified as a core competency within this set (7) and, as such, it is of central concern to all RNs. Significant personal, professional, and organizational barriers exist, however, for nurses who attempt to act as patient advocates.

This article explores how nurses in an Australian OR experience the role of patient advocate. The lead author conducted an ethnographic study with nurses in an Australian operating department, known as the OR suite (ORS), during a nine-month period. Extracts from five semi-structured interviews conducted with ORS nurses and the lead author's field note observations are used in this article.

ADVOCACY AND THE PERIOPERATIVE NURSE

Despite ongoing debate, patient advocacy is recognized as an established part of perioperative nursing practice. (8,9) It is identified clearly as such in legislation and policy documents. (10,11) The simplified manner in which the role is addressed in these documents, however, belies its true nature. One author suggests that advocacy in the OR is both complex and challenging. (12) Nurses often are faced with conflicting loyalties and may not have the authority to act as effective advocates for their patients.

Perioperative nurses tend to have only a brief engagement with their patients. Despite this, pressure on them to act as advocates is intense because many of their patients are unconscious or in a particularly alien environment, which means they are likely to be in greater than usual need of an advocate. Perioperative conflicting nurses have assumed this responsibility for many years.

The ORS nurses who participated in this study believed that advocacy is a central concern, a belief that is reflected in the literature. (8,9,12-15) The meaning of advocacy to the nurses in the ORS differed significantly from definitions of advocacy found in the literature, however. Much of what the nurses interviewed in this study considered to be advocacy appeared to be standard nursing care. The following extract from an RN's interview highlights a range of activities she construed as advocacy.

   You make sure that what's done to
   them is done in a sale manner.... to
   ensure that the patient is safe and protected
   and all that sort of stuff when
   they're on the table. Also, that they
   definitely give consent, because often
   consent explained to patients, I think,
   is, by some surgeons anyway, in medical
   terms, and a lot of the patients
   don't understand exactly what's going
   on.... you book them in and you ask
   them, "what are you having done
   today?" and they reel off this big long
   word but they really don't know what
   it means. So, often, I say, "well, can
   you tell me what part of your body
   we're operating on," and then they say
   a gallbladder or whatever, you know,
   so you're acting as an advocate there if
   you don't think they really understand
   what's going on.... by limiting the
   number of people that are in the theatre
   just to protect the patient's own
   privacy, the decency, the confidentiality
   and just, you know, they can't do
   any of that. And if you've got lots of
   medical students hanging around, you
   often say, "look there's too many people
   in here, can we get a few out?" So
   you're looking after the things that
   they would normally do that they
   can't do because they're unconscious,
   perhaps. (16(p165)