Given the historical context of nursing advocacy presented by Terri Brower, I will attempt in this paper to identify a variety of rules that might assist in the development of nursing advocacy in the future. In addition, I will give an example of nursing advocacy in the practice of gerontological nursing and suggest a simple framework for evaluating individual implementation of advocacy skills.
There are many rules that might be derived from experiential and theoretical models of change, all of which might help in the development of nursing advocacy in the future. A supreme rule is that "old solutions seldom work with new problems," and, of course, new problems are ever present. Other rules to help further the evolution of nursing advocacy are:
1) Nontraditional methods of practice are not necessarily good because they are new, but nontraditional methods of practice are needed if new questions are to be asked, new solutions described, and new problems identified.
2) The model for change in nursing should be the application of knowledge, not just the application of power.
3) Nursing must continue to strive for the return to the consumer of the tools of health care (drugs, research, licensing, schools, hospitals).
4) Nursing must continue to strive for the refinement of a philosophy of health, within which the roles of nursing can be described more fully.
As described by Brower, historically nursing often has been reactive to situations (crisis oriented) rather than proactive. There are several present determinants of nursing practice that illustrate this historical phenomenon. Many nurses have experienced some of these determinants, which are indicators of the poor stage of development of advocacy skills. The determinants are:
1 ) Power in health care rests with institutions. As nursing knowledge expands, its application is limited more by institutional inflexibility than by consumer acceptance.
2) Institutionally-based medical care does rather well in the diagnosis and treatment of disease, but less well in other areas of health care, namely prevention of disease and promotion of health. Nursing knowledge is more fully utilized in the latter two arenas.
3) The business model of service delivery in health care (illness care) leaves out the consumer and emphasizes the provider.
4) The needs of the institution are not necessarily congruent with the needs of the consumer; nurses, employed by institutions for the most part, are caught in the middle of conflicts.
5) Stereotyped communication (female nurses versus male physicians, for example) hinders mutual acceptance of one profession's knowledge by another profession.
6) There is a lack of proactive role models for nursing and the presence of anti-intellectualism.
7) Rewards are often for service to the institution rather than for excellence in the implementation of nursing knowledge.
8) More credentials mean more work, not more freedom to implement knowledge in new ways.
9) Staffing is often by the warm body principle, fostering the old ideas of "a nurse is a nurse is a nurse."
10) Nursing is alienated from decision making, perhaps because of a history of stereotyped communication and the stereotyped role of passive dependency.
11) Professionals are burdened with nonprofessional tasks (payroll, leave and vacation schedules, staffing) from a misguided sense that "I won't ask them to do what I won't do myself."
12) Access to nursing is through a physician's order.
13) A crisis care system rewards clients for NOT taking their own responsibility for health care.
14) Strawboss supervision is the rule for nurses, in which only nursing executives make decisions, delegate, and apply knowledge, leaving staff nurses only to "do the job."
Given that some or all of the determinants are in place to some degree in the nursing arena, it appears essential for nursing to change concomitantly with the nation's change in the idea (ideal) of health. New goals for the nation's health1 are promulgated by the Department of Health and Human Services and include goals for access to care: "Every person should have access to the full range of health care services."1 Regretably, disease prevention services and health promotion services are ill-defined, maldistributed, and poorly tested. Nurses, along with others, must move away from institutional bias in the delivery of health services.
Fortunately, several factors are working with respect to gerontological nurses, that help us move more quickly toward the application of new nursing knowledge in the two less tested arenas of health care: disease prevention and health promotion. Those factors include:
* We know that the aged have chronic diseases, often multiple and coexistent
* We know that algorithmic solutions to episodic, simple medical problems do not work with complex health, social, and economic issues that affect the aged person's health
* We know that there is an institutional bias in the system of service delivery, and
* We know that there is an enormous diversity and complexity of older people, meaning that no single solution will work for each person with the same problem.
Nurses long have been dealing with microsystem issues of one-onone or one-on-family, but here I'm advocating a move to consider macrosystem issues of a political and economic nature, since the determinants of nursing practice identified earlier inevitably are formed in the macrosystems of our culture. The Federal government is moving toward promotion of heal th as a viable concept in health care but in our nation, which has an ethic of states' rights, we are encouraged to look in our heads and our own backyards for new ideas and new methods of solving problems, since ideas flow best from the bottom up rather than from the authority on top then down.
Bits of data from the universe of general knowledge and nursing knowledge have been grouped to support one new approach to a gerontological nursing problem, which follows. Then, other new ways of approaching similar problems are suggested along with a simple framework to evaluate the state of the art of a given nurse's advocacy skills.
The problem is: given that nursing home residents are very likely to be single in the institutions of our country, a group of underserved aged might be older couples who are not institutionalized. That is, since only 0.8% of married older adults are nursing home residents, versus some 7.1% of unmarried older adults, then the concentration of nursing resources in the institutional nursing home sector may be inappropriate if nursing knowledge is to be applied to aged adults who live in families at home in the community. In other words, nursing efforts to refine institutional standards, to define institutional services, to plan funding and reimbursement strategies, and other efforts, still leave unserved the large number of older adults who live outside institutions. It does not appear to me from the literature or from my own experience that nurses have implemented enough nursing knowledge of self care and of the importance of establishing good life patterns early in life, which in turn is associated with good quality and quantity of health in later years.
As long ago as 1975 the American Academy of Nursing published a statement urging health promotion for long-term care (residents and atrisk adults).2 While the problems we, as nurses, are faced with in the delivery of illness care are real, the consumer is unwilling any longer to accept that the issues of equal access, reasonable cost, and high quality are irreconcilable. Consequently, each gerontological nurse might try to divert attention from his/her own work arena to decide how nursing knowledge is implemented for those older adults who neither need nor receive illness care. Does each gerontological nurse in fact contribute to the ideal of each older adult receiving a full range of services of health care, including prevention-of-disease measures and promotion-of-health measures? If we as nurses are to be advocates of older adults, each gerontological nurse should, in fact, assist the consumer to maintain self-identity in the face of awe-engendering health care authority and should try not to assume authority.
If most aged live in families, and have ten days or less of decreased activity due to chronic/acute illnesses per year, how are we as nurses accessing that body of older adults? If most visits for health care on the part of older adults in families are ambulatory visits, how are we as nurses implementing nursing knowledge with these groups? Some individual measures might be identified and tried out by the readers. A radio reading service for the visually impaired surely would welcome a series of short talks on health promotion by a nurse. Church groups would welcome a discussion of the myths of older adults that focuses on suggesting positive patterns for healthful living early in life. Preretirement programs are expanding in all industrial and municipal government sectors. Within those preretirement programs nurses are the logical professionals to define the health content and teach it. Nearby companies would welcome suggestions and help in the design of those programs.
Garden clubs gather an influential and articulate group of persons who might be "seeded" with the ideas of disease prevention measures and with proactive health promotion measures. Participation in community-based fitness programs might be another avenue of disseminating health promotion ideas. Elementary and secondary schools are natural avenues for blending of health promotion ideas with the standard health program curriculum.
These individual entrepreneural methods might not be useful to some nurses. But linking with employing institutions might well suit the styles of these same nurses as well as others who find more comfort with an organizational base of support. The host institution, be it a hospital or other employing agency, might be persuaded to sponsor any of the programs identified above, which would lend its name to the accessing of other professionals to assist. A hospital has nutritionists, pharmacists, physical therapists, and other professionals who could provide expertise and resources in the design of talks of an informal or formal nature. Long-term care institutions could be persuaded to sponsor discussion groups for those middle-aged adults who are in the middle - dealing with a failing older parent and their own retirement at the same time.
The knowledge that can be grouped to produce curricula and to clarify beliefs and values, which in turn helps support the ideal of promotion of health, exists. Nursing groups might be able to identify other ideas that can be used to access the population of older adults and to provide the support needed to test, evaluate, and report those newer methods to the larger nursing public.
Janet Storch3 reminded us of the four basic consumer rights identified by the late President John F. Kennedy in his 1962 consumer message to Congress: the right to safety, the right to be informed, the right to choose, and the right to be heard. We are convinced as nurses that professional registered nursing services are essential if each of the four basic consumer rights are to be realized by the consumer. Lack of adequate professional nursing staff has been identified as causal in the drug administration error rate of 30% in nursing homes.4 One can point to many causes of the longterm care scandals in our nation, well described in the literature and in the media5, one of which we are sure is the relative absence of adequate quality and quantity of registered nurses in long-term care.
Just as we're able to be convinced about the need for nursing to assure the consumer's right to safety, we might extend the need for nursing to ensure each older adult's right to be informed, to choose, and to be heard, particularly if we as nurses try to establish means of reaching older adults who live outside of institutions. Through influence by means of legislative, educational, and other means, as well as through community visibility, nursing and nurses can have a policy impact role that is proactive and insures the consumer rights of older adults, both inside and outside of institutions.
- 1. Institutional and Personnel Resources anil Systems of Care, Item 9. Access to Care. Federal Register. 45(229): 78560. 1980.
- 2. American Academy of Nursing: Longterm care in perspective: Past, present and future directions for nursing. American Nurses" Association Pub. No. G-120 2M, 1976.
- 3. Storch JL: Consumer Rightsand Health Care. Nursing Administration Quarterly January February, 1980.
- 4. CS. Senate Subcommittee on Long Term Care, of the Special Committee on Aging: Nursing Home Care in the U.S. - Failure in Public Policy, Supporting Paper #2: Drugs in Nursing Homes: Misuse. High Costs, and Kickbacks. Washington, DC, Government Priming Office, 1975.
- 5. Moss FE. Ha la man dar i s VJ: Too Old. Too Sick, Too Bad: Nursing Homes in America. Germantown, MD, Aspen Systems Corporation. 1977.