Gates (1994) cites four variations of advocacy: legal advocacy, the representation of the user in a formal context, for instance a health-review tribunal; self-advocacy, where the individual or a group of individuals speak up for themselves, a form of empowerment; collective or class advocacy, the large organisations who speak for the interests and rights of a category of people; and citizen advocacy, the representation of the user’s interests by a competent advocate (eg a nurse).
So what of the disadvantages for the nurse in acting as advocate? Castledine (1981, cited by Gates, 1994) identifies several: that the nurse’s unique role forces the patient to be wholly dependent on him/her for fear of pain and suffering; that the nurse’s educational background may be inadequate; that the patient has no influence over who will act as his advocate; and that the nurse is continually responsible to the authority of the employer.
The writer has just completed a practice placement in a residential home for people with learning disabilities. Each of the seven residents of the house has their own room. One of the residents is a woman, aged 40, who is unemployed and has been a resident for 11 years. She visits a day centre three times a week, where she undertakes a variety of activities - her favourite is cooking. She has limited knowledge of financial matters and each week receives a small amount of money from the house’s caring staff. She needs assistance with maintaining her personal hygiene.
One year ago this user’s mother died. Since that event she has had a problem coping with the bereavement. The woman was very close to her mother and had initial difficulty coming to terms with the loss, a difficulty that still prevails. Her father is still alive, but both parties appear reluctant to make contact with each other. Her behaviour in the house became intolerable, and other residents have started to avoid her. She was referred to bereavement counsellors by her GP.
The partnership between this woman and her carers is collaborative, and she is increasingly involved in decision-making. The professionals offered their advice and encouraged the user to question and not always to accept their opinion. The woman’s opinion was always respected. This successful collaboration between user and carers is achieved by widespread use of two-way communication, a vital part of empowerment, particularly for users with learning disabilities.
The woman has the right to her views, and to demonstrate her feelings and needs. Staff are keen to involve these in care planning. Professionals working with patients such as this who have learning disabilities need to ensure that they keep all information confidential, in order that their opinions continue to be respected by the user. The user is involved in constructing and maintaining her care plan.
This successful nurse-client interaction demonstrates trust, empathy, mutual goal settings, participation, decision-making and overcoming organisational barriers, all indicators of successful client empowerment in this scenario (Gates 1994). If this user had stronger contact with the remaining members of her family, carers should seek to involve them as fully as possible in decision-making. Staff in this case were attempting to build up this user’s relationship with her family; they had made efforts to contact her father, keeping her fully informed of what they were doing and their motives.
The woman has had a meeting with a social worker and her keyworker to establish how far she has progressed in the past year. That her voice has been as loudly heard as others (staff, family) has been crucial. Professionals have given her time to say what she has wanted to say, and have deliberately maintained the same level of vocabulary as the user. Staff in this case also helped the user to develop personal self-advocacy skills. The user was encouraged to make the most trivial of decisions on a day-to-day basis.
One of the most difficult aspects for professionals dealing with empowerment to accept is the notion that the user may be able to deal with something on their own (McNally 1997). In the past, people with learning disabilities, particularly, were given limited opportunity to make their own choices or to speak up for themselves. This user is now involved in the planning and evaluating of services which affect her.
A lack of empowerment in patients with learning disabilities may cause them to feel powerless, which can diminish communication, feeling of knowledge and perception of power. In the writer’s experience while nursing in the Slovak Republic a commonly held belief was “Why should I talk? No one is listening”.
The government’s 2001 White Paper Valuing People: A New Strategy for Learning Disability for the 21st Century recognises the value of self-advocacy and empowerment to people with learning disabilities and outlines four key principles - civil rights, inclusion, independence and choice. It explicitly states that advocacy is an important way for people to have more choice and control in their lives. The government says it will be making money available over the next three years to develop advocacy schemes and hopes that every learning-disabled person will have access to one of these schemes.
I selected this learning outcome after a week working with the patient detailed above and recognising that needs and feelings needed to be heard. I saw widespread adoption of advocacy techniques by the professionals I worked alongside on this practice placement and noticed that it was significantly felt. I found that by studying this learning outcome I would be able to apply the skills and knowledge I have acquired successfully in the future, in many practice situations - in mental-health or general adult nursing.
Information was gained from books acquired from the university library and from a number of appropriate articles located using the Athens website reference system. The governmental White Paper referred to above, published March 2001, was eminently helpful and made a commitment to developing advocacy services for learning-disabled people. My initial enquires at the beginning of the practice placement were with staff at the placement - chiefly the manager. The enthusiasm demonstrated by this professional motivated me to locate more information - and as there is a great deal of currency to this topic, principally through the internet.
As I gained more information and experience first-hand during my five-week placement in this residential home I found I was starting to be able to articulate my personal beliefs and philosophy of nursing. Now I can clearly recognise attitudes, values and beliefs which guide my practice. This reflection has helped me to assess myself and my behaviour in this context.
In the middle of my placement, the patient had a meeting with her social worker, keyworker and carers. I was included, and I felt happy about this: my experiences working closely with the patient were being heard. I was also comfortable that I had played some part in her development into the community. I believed that the user was trying to find new meaning to her life. Every day she studied the news intently, trying to find reports of people who had died, like her mother recently had. She also loved babies in an exaggerated way - perhaps another reaction to her parental loss. It was obvious to me that the death of her mother and her inability to cope with and demonstrate this grief had affected her more than she was prepared to admit.
At the meeting the patient was encouraged to be as independent as possible, changing her bed on her own on a weekly basis. I found this experience difficult; as a student nurse I felt a strong urge to help her - or to regard myself as having failed. After careful thought, I realised that it is more difficult to watch people struggle with their things own their own than to help them, but that this process was necessary for the patient to develop some feeling of autonomy.
During the meeting I listened very carefully and took part in the debate. I was very aware of my professional responsibilities as a nurse. Being accountable and individually responsible to clients for my decisions and action, the notion that the client’s needs and opinions were paramount began to gather weight in my mind. I was helping the client to make her own decisions, which was very important to her.
The experience changed my attitude to empowerment and the need for people with learning disabilities to achieve some degree of independence. Having initially seen this section of society as wholly dependent on others, I began to recognise their feelings, choices and needs; to give them time to express themselves; and to talk about how they imagine their progress to be.
The manager of the residential home was instrumental in helping me achieve this perception, and I learned a lot from her and from other carers. The staff’s growing awareness of these two directly related principles was highly significant in helping me fulfil this learning contract. Working with both staff and users on a day-to-day basis, I really felt like part of the house community and was very sad to leave at the end of the placement, although I still maintain contact with individuals in the nursing team. It is clear that there is still much to be learned about advocacy and empowerment by today’s nursing practitioners, especially in the field of learning-disability nursing. These principles were crucial in enabling this patient to achieve some sort of independence, and are widely used elsewhere in the residential home. I have found studying and applying both concepts a highly rewarding experience.
2, 133 words
Adams, B. and Bromley, B. 1998, Psychology of Health Care. Basingstoke, Macmillan, p123
Brown, R. I., Brown, P. M. and Bayer, M. B. 1992. Choices and Quality of Life. Chapman and Hall, New York, p172
Conway-Welch, C. 1996. Empowerment: Activism in Professional Practice
In : Hickey, J. V. (ed). Advanced Practice Nursing: Changing Roles and Clinical Applications. London, Lippincott-Raven, pp206-211
Department of Health. 2001. Valuing People: A New Strategy for Learning Disability for the 21st Century. London, HMSO, p3
Gates, B. 1994. Advocacy: A Nurse’s Guide. Harrow, Scutari Press, p3-291
McNally, S. J. 1997. Representation
In : Gates, B. (ed). Learning Disabilities 3rd Edition. Edinburgh, Churchill Livingstone, pp239-256
Payne, S. and Walker, J. 2000. Psychology for Nurses and the Caring Professions. London, Open University Press, p122
Castledine, G. 1981. The nurse as the patient’s advocate: Pros and cons. Nursing Mirror, 15 (20), pp38-40
Clark, J. 1993. Into the Community
In : Dolan, B. (ed). Project 2000: Reflection and Celebration. London, Scutari Press, p116
Holm, D. and Stephenson, S. 1994. Reflection - A Student’s Perspective
In : Palmer, A., Burns, S. and Bulman C. (eds). Reflective Practice in Nursing. Oxford, Blackwell, pp53-137
Johns, C. 2000. Becoming a Reflective Practitioner. Oxford, Blackwell
Miller, C., Tomlinson, A. and Jones, M. 1994. Learning Styles and Facilitating Reflection. London, English National Board for Nursing, Midwifery and Health Visiting
Raps, C. S., Jonas, M., Peterson, C., and Seligman, M. E. P. 1982. Patient behaviour in hospitals: Helplessness, reactance, or both? Journal of Personality and Social Psychology, 42 (6), pp1036-41
Structured Reflection Model (Johns 2000)
1.0 Description of experience
1.1 Phenomenon – describe the here and now experience
1.2 Causal – what essential factors contributed to this experience?
1.3 Context – what are the significant background factors to this experience?
1.4 Clarifying – what are the key processes (for reflection) in this experience?
2.1 What was I trying to achieve?
2.2 Why did I intervene as I did?
2.3 What were the consequences of my actions for:
* the patient/family?
* the people I work with?
2.4 How did I feel about this experience when it was happening?
2.5 How did the patient feel about it?
2.6 How do I know how the patient feels about it?
3.0 Influencing factors
3.1 What internal factors influenced my decision making?
3.2 What external factors influenced my decision making?
3.3 What sources of knowledge did/should have influenced my decision making?
4.0 Could I have dealt better/differently* with the situation?
4.1 What other choices did I have?
4.2 What would be the consequences of these choices?
5.1 How do I feel about this experience?
5.2 How have I made sense of this experience in light of past experiences and future practice?
5.3 How has this experience change/developed* my knowledge/understanding*
* Adaptations from original
Student’s Own Framework for Reflection (Stephenson 1994)
What was my role in this situation?
Did I feel comfortable or uncomfortable? Why?
What actions did I take?
How did I and others act?
Was it appropriate?
How could I have improved the situation for myself, the patient, my mentor?
What can I change in the future?
Do I feel as if I have learned anything about myself?
Did I expect anything different to happen? What and why?
Has it changed my way of thinking in any way?
What knowledge from theory and research can I apply to this situation?
What broader issues, for example ethical, political or social, arise from this situation?
What do I think about these broader issues?