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The ethics of advocacy
Nurses explore how advocating for change outside of work is part of RNs’ ethical code
Marcia Frellick
Marcia Frellick is a freelance writer.
Although most nurses embrace advocating for patients on the job, the duty to advocate outside work may be more ambiguous to nurses. That was among the reasons the American Nurses Association themed 2018 the
Year of Advocacy
, said
Liz Stokes, JD, RN, ANA Ethics Center Director.

Advocating for the health, safety and rights of patients at the bedside is discussed in Provision 3 of the
Code of Ethics

Provisions 9.3 and 9.4 address advocacy outside work in terms of social justice in nursing and health policy. Those policies indicate that nurses have a duty to promote open and honest communication that advances the agenda for health. Under that umbrella is global health, Stokes said. “That’s way beyond our bedside, but it recognizes the effects issues in the world have on our patients.”
Provision 9.4 reads, in part, “Nurses must promote open and honest communication that enables nurses to work in concert, share in scholarship, and advance a nursing agenda for health. Global health, as well as the common good, are ideals that can be realized when all nurses unite their efforts and energies.”

Those issues can include topics such as climate change, pesticides in food, decreasing harmful emissions, preventing violence and building community immunity through wider coverage of vaccinations.  Specifically, Stokes said, under interpretative statement 9.4, the code says nursing should advocate for policies that "maintain, sustain and repair the natural world." 

In the late 1980s, she worked for the only physician in Maine who specialized in treating abused children. That work required substantial hours in court and work with law enforcement and child services organizations.
“You have to have a real interest in trying to make a difference to do that kind of work,” she said.
Wall saw the need for advocacy beyond what could be contained to the office, so she started to serve on the board of a family violence project. “I became very educated and very facile at understanding domestic violence and how it played into child abuse,” she said.
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Nurses must promote open and honest communication that enables nurses to work in concert, share in scholarship, and advance a nursing agenda for health.”
— ANA Code of Ethics, Provision 9.4

Rising above politics

Some of those issues have become bitter political dividing points, and that may turn nurses off to advocating for change — but the challenge is to rise above the politics and focus on the science, Stokes said.

Because nurses treat people with a range of different belief systems and political leanings, they are accustomed to focusing on improving their patients’ outcomes without regard to politics, she said.
“I think most people recognize that issues like pollution and gas emissions negatively affect people,” Stokes said. “But when you say climate change, discussions of scientific evidence get drowned out by the politics."
Another barrier to nursing advocacy is the thought that such advocacy will take too much time for nurses who already believe their profession is all-consuming. That’s where sense of duty comes in, Stokes said.
“When you become a nurse you do create this social contract with society and in that there’s this piece to advocate beyond the day-to-day care of your patients,” she said.
Advocacy can start small. The ANA encourages nurses to start within their local communities, Stokes said. That may mean joining a neighborhood association or supporting a local candidate who supports the issues you care about.

She added nurses could also sit in on a local state legislature during open session or volunteer at a local organization that serves disadvantaged people, such as low-income, homeless or undocumented people.
Sometimes it’s also hard for nurses to see the direct benefit of advocacy. With direct patient care, nurses can actually see patients improve over time, witness how a patient lights up when a nurse holds his or her hand or see their relief when a nurse intervenes in an insurance dilemma.
But seeing the direct result of advocacy may not be as clear and may take longer to realize.
Education is key in helping nurses learn what advocacy is, how to do it and how to take pride in their attempts to influence outcomes that may not be seen for long periods of time, Stokes said.
A recently released Gallup poll serves as a reminder of how much Americans value the nurse perspective.
For the 17th consecutive year, nursing ranked as the honest and most ethical profession
, according to the poll.
“When nurses say something, people listen,” Stokes said.
With a workforce of 3.6 million, nurse advocacy can come with substantial power by sheer numbers. But she points out nurses can’t do this alone.

While advocating for children, Wall saw a bigger need for prevention. Although providers were focused on treating abuse victims, “No one wanted to do the necessary prevention work,” she said.
At the time, she also was simultaneously working in high school counseling as part of an internship for her master’s degree. The teens she worked with expressed how they needed a place to gather safely away from their home environments.
She began to work with the governor’s office to educate communities, with the help of police and social workers, on what was happening with the highest-risk kids and eventually helped establish a teen center in Augusta, Maine, where teens could gather safely and talk to counselors about the challenges they were experiencing at home.
The teen center,
Boys & Girls Club of Augusta
, is still thriving 18 years later, she said.
Her next area of focus was “nursing the environment,” she said, and she became CEO of Maine Lakes Resource Center.
In 2017, she stepped down as CEO and was elected to public office as a selectperson, part of a board that makes decisions about environmental and health issues in the town of Belgrade. Her term runs until 2021.
“Nurses have a unique perspective to offer because they know about health,” Wall said. “It’s not something you shut off when your shift ends.”
nursing ethics
Lifelong career as an advocate

Kathi Wall, RN,
of Belgrade, Maine, a Robert Wood Johnson Executive Nurse Fellow, has felt the call to advocate outside of work her entire career, she said. Wall, 74, has worked in many capacities, including as a renal transplant nurse and on a cancer ward.

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