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Advocacy in nursing: Speaking truth to power?

      The work performed by nurses during the COVID-19 pandemic shone a light on the centrality of the nursing profession. Despite this increased public awareness of the importance of what we do, nurses continue to occupy subordinate positions within the healthcare system. There is a paradox here; where despite the essential contribution made by nurses, we are not driving forward health systems, not empowered to speak out on the critical issue of patient safety, not encouraged to draw attention to adverse events, nor raise our concerns when the system is simply not working. The regularity with which nurses' efforts to advocate are dismissed suggests that the nursing profession faces a major challenge. Nurses' subordinate positions in healthcare systems contribute to poor patient outcomes and prevent us from shaping a more rewarding and fulfilling profession (
      • Cole D.A.
      • Bersick E.
      • Skarbek A.
      • Cummins K.
      • Dugan K.
      • Grantoza R.
      The courage to speak out: A study describing nurses’ attitudes to report unsafe practices in patient care.
      ). We contend that when nurses occupy an inferior position in this context, it serves as an injustice to ourselves, our profession, and those for whom we are entrusted to care. Our view is that this injustice is symptomatic of a system that routinely ignores, resists or silences nurses who seek to advocate for their patients. The time has come to review the way that healthcare systems respond to nurses when they do speak out.
      There is a well-established history of unnecessary, preventable deaths in healthcare, where better responses to nurses who voice concerns could have saved lives. If you believe that nurses need to be more persuasive when advocating, you may be mistaken. We contend that, rather than blaming nurses who speak out, it is health care organisations that need to change, not nurses or nursing practices. It is crucial for modern healthcare to embrace nurse advocacy and respond to it in ways that better reflect the safety, quality, and patient-centred philosophy so often woven through policy-driven care.
      Toni Hoffman's attempts at advocacy were not embraced when she reported concerns over the negligent activities of Dr Patel (‘Dr Death’) in Bundaberg Queensland Australia. In response to voicing her concerns, Ms Hoffman was exposed to sustained and persistent ridicule and resentment from management (
      • Fedele R.
      BLOWING THE WHISTLE: What drives nurses and midwives to turn whistleblower and report wrongdoing outside their organisation? What ramifications surface personally and professionally in the aftermath?.
      ; ). Aishwarya Aswath's case at Perth Children's Hospital (Manfield & Perpitch, 2021), the Mid-Staffordshire Inquiry [and subsequently the Francis Report] (;
      • Donnelly H.
      Managers must listen to nurses in NHS crisis: Mid Staffs whistleblower Helene Donnelly says front-line staff know what's going wrong and can suggest solutions.
      ;
      Mid Staffordshire NHS Foundation Trust Public Inquiry
      Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary.
      ) and the Gosport War Memorial Hospital Investigation in the UK (
      • Evans N.
      Gosport scandal: What it means for older people's nurses.
      ) are all examples where nurses advocated for their patients but were ignored. The question must be raised as to whether any other professional would be treated this way.
      There has been growing, and frequently voiced concerns about patient safety among aged care nurses in Australia (; “Residents suffer most”, 2018). Even when the precise nature of these concerns echoed 29 of the Australian Government's own major reviews and inquiries into the sector, they were ignored. In February 2022, the then Minister for Aged Care and Senior Australians, Richard Colbeck, said the aged care sector had “performed exceptionally well” (
      • Daniel D.
      ‘I wasn't the only one’: Colbeck defends going to the cricket.
      ). This comment came on a background of tens of thousands of staff and residents testing positive to COVID-19, and over 400 aged care deaths in the first two weeks of 2022 (
      • Coulter E.
      • Kewley L.
      Aged care workers are facing a 'crisis level of exhaustion' as the COVID-19 pandemic continues.
      ). The nurses at Sydney Australia's Westmead hospital, still reeling from COVID-19, found themselves similarly in a system unwilling to acknowledge a problem. Authorities attempted to resist and ignore their safety concerns, when they obtained an order from the Industrial Relations Commission to ban industrial action (Ward, 2022). Are there any other professions that are also so powerless to shape the contexts in which they operate?
      Nurses in our society should be seen as the allies of the patients within the healthcare system, as professionals looking out for the interests of the patient, as a fundamental part of their work. Despite strong community expectations that nurses will speak up for the vulnerable, their voices continue to be silenced. When nurses speak out about the COVID-19 outbreak, they are threatened with disciplinary action (
      • Johnson S.
      NHS staff forbidden from speaking out publicly about coronavirus.
      ;
      • Miles J.
      Jeta Gardens nursing home threatens staff with legal action if they release information to media.
      ). Although hospitals may feel a need to limit scaremongering during the pandemic, many nurses feel that bans prevent them exercising their own autonomy and agency (Costa & Costa, 2021). As the pandemic persists, nurses continue to be threatened for indicating their refusal to work without proper protection and making comments about their fear of COVID-19 on social media (“Disciplinary action, terminations, gag orders”, ;
      • Scheiber N.
      • Rosenthal B.
      Nurses and Doctors Speaking Out on Safety Now Risk Their Job.
      ). In a time full of misinformation and conspiracy theories, nurses' rich contextual voices should be perceived as an excellent foil to the explosion of fake news.
      Within this context of the profession being silenced, resisted, or ignored, the Australian Medical Association National President Omar Khorshid called out the WA Premier Mark McGowan's alleged failure to prepare for COVID by describing him as a “one trick pony when it comes to COVID” (
      • Brown A.
      COVID WA: AMA slams Mark McGowan over border decision.
      ). Does the profession of nursing need to speak with the same candour and frankness to better engage with the wider political game within which our profession exists? The COVID-19 outbreak has been one of the biggest challenges facing healthcare in the last century, but it has also given the nursing profession the opportunity to examine the imbalances in power dynamics and coercive patterns of control it is experiencing in its relationship within the health care system. For the sake of the individuals and communities we serve, nurses, both individually and as a profession, need to work at making sure our voices are heard.
      A revaluation of the relationship between nurse advocacy and power is required. Rather than simply victim blaming nurses whose attempt at advocacy goes unheard, there needs to be better understanding of the complex, overlapping and often conflicting influences on nurses when they choose to advocate, or not, for their patients. Failure to invest in the profession's relationship with the system within which it operates risks continued acquiescence, even complicity in the historical ideological hegemony that pervades healthcare systems and continues to persist to this day.

      References

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        Mid Staffs nurses’ concerns ignored.
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        • Cummins K.
        • Dugan K.
        • Grantoza R.
        The courage to speak out: A study describing nurses’ attitudes to report unsafe practices in patient care.
        Journal of Nursing Management. 2019; 27: 1176-1181https://doi.org/10.1111/jonm.12789
        • Daniel D.
        ‘I wasn't the only one’: Colbeck defends going to the cricket.
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        • Disciplinary action, terminations, gag orders: ‘Avalanche effect’
        Medical Ethics Advisor. 2020; 36
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        Managers must listen to nurses in NHS crisis: Mid Staffs whistleblower Helene Donnelly says front-line staff know what's going wrong and can suggest solutions.
        Nursing Standard. 2017; 31 (29–29)https://doi.org/10.7748/ns.31.30.29.s25
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        Gosport scandal: What it means for older people's nurses.
        Nursing Older People (2014+). 2018; 30: 8-9https://doi.org/10.7748/nop.30.5.8.s7
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        BLOWING THE WHISTLE: What drives nurses and midwives to turn whistleblower and report wrongdoing outside their organisation? What ramifications surface personally and professionally in the aftermath?.
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        • Johnson S.
        NHS staff forbidden from speaking out publicly about coronavirus.
        The Guardian. 2020;
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        Australia's aged care workforce crisis.
        Perth Now. 2021;
        • Mid Staffordshire NHS Foundation Trust Public Inquiry
        Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary.
        2013
        • Miles J.
        Jeta Gardens nursing home threatens staff with legal action if they release information to media.
        ABC News, 2022
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        Nurses and Doctors Speaking Out on Safety Now Risk Their Job.
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