Advocacy is a term that has become increasingly popular in recent years. The word "advocacy" is a neologism that originated out of social concern to act on behalf of one's fellow man. Nursing has picked up the term because nurses have always acted on behalf of patients. Lawyers, social workers and nurses all see themselves as the original advocates. Original or not, nursing does have a stake in the term since nurses mediate between client and community resources, between client and medical services, and between client and the family. Gerontological nurses were among the first in nursing to embrace the concept of advocacy because of the many complex needs that older persons in our society have.
Many older persons are disenfranchised from a number of benefits enjoyed by the larger society. Although we are a nation of tremendous wealth and resources, these are limited. There are also competing forces operating to perpetuate inequities in thedistribution of wealth and resources. Older persons face some of the same problems minority groups face, for example policies that limit their freedom of choice to work as long as they desire and are capable of. Many older persons, like other minorities, may find themselves trapped in urban senior ghettos. They are more vulnerable to crime and victimization. Compared with younger persons, they suffer from a greater number of chronic health problems that have an increased negative impact. They face the injustices of negative attitudes held by society, themselves, and health care providers. Because of the many problems needing attention, nurses may be confused as to which problem to concentrate advocacy efforts on.
In order for nurses to be effective advocates, they must have a firm understanding of what advocacy means. Webster defines advocacy as "the act or process of advocating support."1 The advocate's role is one that defends, pleads the cause of, or promotes rights of or changes in systems on behalf of an individual or group. Advocacy involves activities that are aimed at the redistribution of power and resources to the individual or group that has a demonstrated need.
There are generally two theories of the power structure in the United States. The pluralistic perspective holds that America's power structure is a free and open system based on democratic and egalitarian ideals. In this fluid system, access to the power structure is readily available for a well-prepared individual or group. From this perspective, the system is relatively rigid, with power levers held by a few persons, making access difficult if not unattainable.2
One can infer that the reality of power in the United States possesses aspects of both these perspectives. A third perspective that should be considered is the nature of bureaucratic systems. Most advocates will sooner or later run into the frustrations of dealing with public agencies of various organizational levels, each often providing different and conflicting types of information. Although a primary objective of a bureaucracy is to provide administrative efficiency, this aim becomes questionable when endless rules and regulations interfere with access to resources. Communication problems seem characteristic of bureaucracies as clients attempt to obtain services. Remember that even when a system is designed to protect the public, because of bureaucratization, it can and does become insensitive to the very consituency it is expected to serve. The disappointing realities of the bureaucratic systems demand that advocates possess some knowledge of the system, a large degree of acumen, the ability to tolerate ambiguity and obstructions, and a bit of luck.
Nurses traditionally have been more familiar with change theory than advocacy theory and will find that the steps in the process are similar - if not interchangeable. Havelock3 looks at change as a series of stages some of which, because of overlap, go on simultaneously. The first stage involves relationship-building between the client and the advocate. To develop a good relationship, it is important to look at the client as a system and, as with all systems, to identify the internal dynamics of the system. A workable relationship will possess the characteristics of reciprocity and openness with a mutual understanding of realistic expectations for the advocate. It is important to identify closely with the older person or group of older persons that the nurse intends to help. This means identifying what the norms of the particular group are, who in the group are influential, and who are the gatekeepers.
Stage two is the problem diagnosis stage. A thorough diagnosis includes identifying underlying causes so that a historical evolution can be discerned. A diagnostic survey will look at all of the symptomatology of the problem and go beyond surface symptoms to underlying causative factors. The second stage focuses on acquiring the relevant resources. A review of the literature is performed during this stage. Resources can be individuals, legislative structures, or agencies and includes an ongoing expansion of awareness of the issues involved in the problem. Resources should assist in further delineating diagnosis of the problem. During this stage, advocacy activity trials are carried out to evaluate their validity and reliability. An information system must be built that enhances awareness of the problem as the advocate scans the literature, including periodicals and the mass media, to build a knowledge base that is up-to-date and broad. Included in the information system will be the development of a personal acquaintance network of relationships that extends in a broad sphere and does not terminate once a given problem is resolved. True advocates build a permanent capacity for resource acquisition, establishing resource bases whenever possible. When building a resource retrieval system, the advocate works to legitimize need which brings about official recognition.13
During the third stage, it is necessary to delimit the problem by honing in on a specific aspect of a larger problem. When the advocate is attempting an innovation, it is helpful to contact at least one person who has had direct experience or, preferably, to observe the innovation in action. Delimiting the problem involves setting longterm goals and short-term objectives, which will allow advocates to choose activities to fit the objective during stage four.
Stage four is concerned with choosing the solution. Selection of advocacy strategies are derived from all prior research. The selection should include a range of strategies or activities that fit the needs of the clients and the specific area. To do this, it may be necessary to test the feasibility of activities. For example, writing a letter to an editor may bring slight attention to the problem, but when the advocate discusses the problem on a talk show, greater evidence of support often is produced. When milder negotiating tactics fail, the advocate must resort to stronger tactics. Activities should be prioritized with a timetable worked out for their accomplishment.
During stage five, the advocate works to gain acceptance of goals and objectives. Advocacy activities are carried out with the intention of building interest and identification with the problem. As awareness of the problem and solutions is heightened, activities coalesce and the advocate builds a coalition of support.
The advocate must be wary of burnout syndrome and therefore should heed stage six, the final stage. After careful evaluation of the successes and failures of the entire project, it is vital to ensure a self renewal period. During this time, disengagement occurs as the advocate departs with a futuristic and external orientation. A positive attitude should be maintained if expectations were realistic to begin with.
A number of activities can be carried out by advocates in concert with or on behalf of older persons. In the past nurses have confined their efforts primarily to those involving health care problems and the health care system, however gerontological nurses rapidly are identifying themselves with broader issues and problems and entering into social and/or political spheres of activity. Activities may be both formal or informal. On the elementary level they involve health care of elderly clients, assessing needs, and providing interventions. As gerontological nurses branch out they have been carrying out advocacy activities on local, state, and national levels.
Communication systems are one of the most powerful levers of inducing support and identification with a cause, which means the advocate must develop writing and speaking skills. Through the media, a coalition of support can be built and pressure brought to bear against government and industries. The news media - newspapers, television, and news magazines - serve to legitimize concerns and consistently reach large audiences.5 Judicious use of media sources can garner support and sympathy for issues.
Newspapers offer a number of channels advocates should become familiar with. These channels include letters to the editors, editorials, syndicated columns, feature articles, and the local and news sections. Information forums include local small newspapers, which may or may not be independent, and large daily newspapers with a broad circulation base. Investigative reporters serve special functions and often their investigations herald change. Advocates are advised to become acquainted with media personnel, whom they can contact for information, promotion, or for investigation needs if that is sought. Lay and professional journals involve different types of writing and are targeted to different audiences. Lay news journals serve a large audience on a national level. Professional journals can be used to garner support through editorials or articles focusing on issues of concern.
Television news shows reflect many of the same concerns as newsprint. If a station has a health reporter, feature sections focusing on innovations or health concerns may be a regular part of the news show, making access to the show easier when the advocate's problem deals with health. Television also has investigative reporters who, when their interest is aroused, can serve as powerful tools for advocates. Both radio and television have talk shows where the advocate can be interviewed to discuss issues and problems. Usually it is easier to speak on radio than on television. Additionally, both of these media forms broadcast free public service announcements.
Influencing legislative structures involves activities such as campaign work, telegrams, telephone calls, letter writing, personal visits, appearances at public hearings, and in some instances, litigation procedures in court. It always is easier to change a rule or regulation if the statutory law is flexible enough to accommodate change by the governing agency. However, when the bureaucracy is unresponsive to changing or expanding a rule, then advocates must turn to legislative avenues to procure statutory change. The Federal law governing Medicaid serves as an example that permits latitude to the states in naming their own reimbursable health providers. Where state agencies have been reluctant to expand coverage, nurse practitioners have had to advocate for statutory changes.
Whenever the change sought involves additional cost allocations, advocates work hard to point out that qualitative changes are sought. When possible, the preferred route is for the advocate to stress or show that disbursement of monies should be moved from one category to another, rather than adding to the tax burden. Another method would be to provide for disbursement through an already expanded, but not targeted, funded source. Thus the work of advocates involves knowledge of competing forces for tax dollars.
When aiming advocacy efforts at legislative structures, remember there are a number of informal access points. Governor's aides, when sympathetic to a cause, can be influential in presenting needs to the governor. Likewise, state or federal legislative committee staffs exert a great deal of influence over their respective committee's interests and functions. Meeting with elected representatives to present problems only should be done when there is a well-prepared cause, preferably having something in writing to serve as reinforcement. When statutory change is sought, a bill draft is essential. In this case it is always helpful to have a copy of a well-written bill or law from another state. When appearing at a state or federal hearing, it is advisable to have a prepared, duplicated presentation to ensure the accuracy of recording your vested interest.
At local, state, and federal levels there are a number of committees and councils that engage in recommending or formulating policy. Some of these may have the authority to induce rule change, others feed into the legislature to promote statutory change. Advocates should learn the functions of respective groups and seek membership on those that hold promise to serve as conduits for advocacy activities. The committees often serve a reciprocal function of being an important information source. On the local level, the Health Systems Agencies' committees and boards are powerful groups providing policy change through local regulation as well as feeding into the umbrella agency, the State Health Care Coordinating Council. Nurses serving on a Plan and Development Committee of an HSA can provide expertise in expanding the staff's knowledge of the elderly and in seeing that the elderly are well represented in the HSA's Annual Implementation Plan. Even when advocates are not members of the committees or boards, they may present their point of view during the open hearing portion of each meeting.
Other local important boards are the areawide agencies on aging and the state's division of health and welfare advisory boards - the latter usually found at both the local and state levels. Most states have a Council on Aging. Some states have unique committees or councils that involve nurses, such as Florida's ombudsman system that involves nurses on both the local and state levels.6 Sadly, too often there is no nurse committee member or worse, the nurse representative is the "silent nurse." When nurses who have expertise in other specialties are appointed to serve on committees whose stated aims involve the elderly, it is highly likely their input will be limited due to their lack of a sound knowledge base. Therefore, it is up to gerontological nurses to see to it that we are visibly involved in activities that facilitate the older persons' access to power.
When advocating for any change, be sure that the change is congruent with the wishes of older persons. A great deal of effort can be expended wastefully when the perceptions of desired change differ between nurse advocates and clients. Partisan work involves close identification with the group. It means helping the group work for the cause.lt involves enabling the group to access power levers and identify and employ the necessary skills. Retired, knowledgeable gerontological nurses have inherent rights in providing partisan viewpoints by the reality of their age.
- 1. Webster's New Collegiate Dictionary. Springfield, Mass, G & C Merriam Co, 1977, p 18.
- 2. Berger M: An orienting perspective on advocacy, in Kerschner PA (ed): Advocacy and Age. Los Angeles, The Ethel Percy Andrus Gerontology Center, pp 4, 5.
- 3. Havelock RG: The Change Agent's Guide to Innovation in Education. Englewood Cliffs, NJ, Educational Technology Publication, 1973, pp 4245.
- 4. Horn L, Griesel E: Nursing Homes, A Citizen's Action Guide. Boston, Beacon Press. 1977. p 12.
- 5. Kalish PA, Kalish BJ: Perspectives on improving nursing's public image. Nurs and Health Care 1:10-15. 1980.
- 6. Brower HT: Ombudsman for nursing homes. Nurs Leader 2:5-13, 1979.