Introduction

The nursing literature is saturated with research supporting an advocacy framework for the patient and family. However, little evidence exists to support a framework for nursing self-advocacy. The overall well-being of the bedside clinician can have a direct effect on the quality and safety of patient care. Thus, there is a need to develop an evidence-based practice framework to support self-advocacy research in the nursing profession.[1][2][3]

Function

Nurses are vital to the functionality of the health care system and play a crucial role in assisting the patient and the family to not only achieve but also to maintain functional well-being.[4][5][6]

Definition of Nursing 

The definition of nursing involves many aspects that include but are not limited to providing quality, safe patient care, protecting the patient and family, and creating an avenue for optimizing resources for all individuals. These principles build health equality for the patient, the family, and the community based on established evidence-based practice.[7][8][9]

Nurse-Client Relationship

The nurse-client relationship is rooted in trust and advocacy. Because of that trust and advocacy, multiple survey groups, including a 2018 study by Figuera et al., have noted that nurses are rated as one of the most trusted professions. Milton also noted in a 2018 report that nursing is frequently referred to as the most trusted profession. These high caregiving standards do not come without challenges for the nursing profession.

Issues of Concern

Affordable Care Act

Recent challenges have been posed by the passing of the Affordable Care Act (ACA) of 2010 which represents areas of concern for healthcare providers. The ACA has many excellent benefits, yet at the same time, it has increased the workload of healthcare team members who provide care for patients and their families. The ACA has increased the availability of health care coverage for millions. While very much needed, the coverage has created an abundance of newly insured patients with chronic disease diagnoses. Brindis & Freund reported approximately 133 million adults suffering from chronic diseases in 2018.[10]

Negative Healthcare Trends

Major negative healthcare trends identified in the literature include a shortage of primary providers, increased patient-to-nurse ratios, high turnover rates among nursing and ancillary staff, and difficulty finding primary care providers that accept Medicare, Medicaid, and the ACA insurance according to Dickstein, Duggan, Orsini & Tebaldi's 2015 report. 

The increase in patient-to-nurse ratios has significantly added to the work stressors for the bedside clinician. The bedside clinician continues to advocate for an increased load of patients and families regardless of whether additional help in staffing or an increase in benefits is received. The extra workload can lead to higher stress and burnout and drive higher turnover rates among staff clinicians, leading to the question: “Who is advocating for the nurse?”

Self Advocacy

A literature search was conducted to establish a framework for researching and promoting self-advocacy within the profession using the Cumulative Index to Nursing and Allied Health Literature (CINAL), Medscape, and Google Scholar. 

The reviews document only a few controlled studies on nursing and self-advocacy. In addition to the traditional curriculum, nursing does not necessarily include a predetermined theoretical framework for how to care for oneself but instead focuses on advocating for the patient as described by Fukada. While this statement holds great truth for the profession as a whole, there is an identified gap in the literature that addresses the need for the nursing profession to research the practice of self-advocacy. Before implementation is proposed, self-advocacy must be defined.

Nursing self-advocacy can be defined as the ability to communicate the needs of self to make informed decisions about the essential elements necessary to meet those needs. Success in any endeavor requires nurses to possess the tools to promote self-advocacy. One way to address the issue would be to establish a theoretical framework that is derived from evidence-based practice (EBP) and easily related to many health domains.[11]

Clinical Significance

Aligning the need for self-advocacy to different domains of health is pertinent as stress and burnout among nurses have a direct effect on their overall well-being and their ability to provide quality safe patient care in a clinical setting. The Seven Domains of Health (SDH) described by Kane et al can serve as an EBP theoretical framework for researching and promoting self-advocacy among the nursing profession.

Seven Domains of Health

SDH are noted as follows:

Physical Functioning

The physical domain measures physical health as it relates to the ability of the bedside clinician to carry out the physical necessities of performing the duties within their prescribed unit. 

Psychological Well-being

The psychological well-being portion of the scale measures the clinician’s emotions and whether they are positive or negative. According to Kane & Radosevich, “Much of the assessment focuses on feelings of anxiety and depression." Anxiety and stress can have a direct effect on the clinician's engagement with the organization as well as the functionality required to work with patients and families assigned to their care. 

Social Functioning

The social functioning domain measures and addresses the social roles of the clinician. These define the clinician's ability to perform a social responsibility as prescribed by society such as the ability to succeed in a role that involves working to advocate for the patient. The perceived social integration of the bedside clinician is also directly related to the clinician’s perception of how well they can perform their assigned duties within the role of being a patient and family advocate. This perception is also complicated or complimented by the roles that their own family and friends play in their support system as a whole. 

Pain

The domain of pain is usually addressed as physical pain, yet psychosomatic pain can be associated with great degrees of stress that a clinician may be suffering. Recent studies have shown that chronic pain might not only be caused by physical injury but also by stress and emotional issues, and this pain can interfere with daily living. 

Cognitive Functioning

The cognitive functioning domain measures an individual’s ability in three different ways: memory, reasoning abilities, and orientation. A bedside clinician must be able to remember, have the aptitude to reason, and have the ability to apply multiple critical thinking concepts during the work assignment when providing care for the patient and family. This skill set may determine how the clinician perceives their ability to succeed in this area. 

Vitality

Vitality refers to the domain of the fulfillment of basic human needs, such as sleep and rest, as well as the level of energy one possesses. A clinician will require adequate sleep and rest periods to maintain awareness of the impact of the prescribed duties associated with the assignments that they are expected to carry out during their work hours. The inability to keep a keen focus is preceded by inadequate rest, which can lead to a significant margin for errors. Sleep deprivation hinders the ability to perform tasks that require concentrated attention. Critical operational performance of duties can become unstable and result in an increase in errors of omission, such as failing to respond to a stimulus, and commission, such as taking action when a stimulus is not present.

Overall Well-being

The last domain, overall well-being, is a comprehensive appraisal of one’s sense of satisfaction with health and happiness. Contentment with overall well-being includes actions based upon a sense of value, dedication, and purpose. These actions may consist of going to work when ill, seeking direction from peers and leaders, as well as obtaining outside support to help decrease the stress associated with the role of a bedside clinician.

Other Issues

The SDH as described can address the overall biopsychosocial well-being of the clinician thus offering a guide with which to build a movement for the nursing profession to conduct research that focuses on self-advocacy. The focus on self-care is not at the forefront of nursing; however, it is imperative to address the overall well-being of the caregiver to provide patients and families quality care at the bedside and benefit the health care system as a whole.

Enhancing Healthcare Team Outcomes

Improving the overall well-being of the workforce is an essential requirement of the medical field. Optimizing the workplace environment and promoting a culture of self-advocacy among healthcare professionals will decrease burnout and turnover among nursing and allied health professionals, and eventually, extrapolate to better patient care.