Factors That Influence Patient Advocacy by Pain Management Nurses: Results of the American Society for Pain Management Nursing Survey

Patients in pain are a vulnerable group who often need nurses to advocate on their behalf for the best possible pain management. Self-advocacy is difficult. Although advocacy is an expected responsibility of the nurse, how it is enacted and defined continues to be confusing and is interpreted in various ways by nurses worldwide. Advocacy is recognized as being a critical function of all nurses; but, in fact, there is limited empirical evidence to guide nurses in perfecting their role as a patient advocate.

Philosophical debate and conceptual information, on the other hand, are plentiful (Hewitt, 2002). What is the meaning of advocacy? How does it relate to the nurse who wants patients to experience optimum pain management? These questions and the lack of related empirical data provided the stimulus for the American Society for Pain Management Nursing (ASPMN) Research Committee to explore ASPMN members' beliefs, knowledge, and skills related to nurses' pain management advocacy activities.

Advocacy is frequently viewed from a triadic point of view that includes informing, advising, and counseling (Mallik & Rafferty, 2000). Thacker (2008) identified the following defining attributes of advocacy based on an extensive literature review: protecting the patient, listening to the patient's voice, moral and ethical decision making, and promoting patient well-being. Bu and Jezewski (2006) developed a midrange theory of patient advocacy through concept analysis and identified three core attributes of patient advocacy: safeguarding patients' autonomy, acting on behalf of patients, and championing social justice.

A survey of the literature reveals a variety of definitions for the word “advocate.” Representative of these definitions is: “one that supports or promotes the interests of others” (Merriam-Webster, 2008). Advocacy may occur through such acts as speaking or writing and may be focused on personal advocacy, public awareness advocacy, or policy/legislative advocacy (Duensing, 2004). In a 2006 meeting, the ASPMN Advocacy Task Force noted that advocacy is about helping patients to say what they want, assisting them to obtain rights, representing their views, and helping them to gain needed services while providing practical support. Dubler (1992) placed advocacy within the context of acting to provide for a client's interests and needs as those are defined by the client. Mallik (1998) recognized advocacy as an integral role within “good professional practice,” placing advocacy squarely within the realm of nursing practice. This is consistent with the American Nurses Association's (2001) Code of Ethics for Nurses, which states, “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (p. 12). Although the nurse functioning in concert with the Code assumes a variety of activities that relate to advocacy, the statement most relevant is that the nurse, as a patient advocate, “must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy” (p. 14).

The International Council of Nurses (2006) also draws attention to the need for nurses to advocate for a safe and healthy environment. According to Holley et al. (2005), believing the patient is critical to successfully advocating for a patient. Carefully listening to and observing the patient for signs of pain and changes in behaviors are important nurse advocacy actions.

Advocacy has had a number of interpretations and applications (e.g., patient care, professional practice, and public policy). Curtin (1979) emphasized the importance of the nurse's role in supporting patients when their vulnerability was increased or altered due to illness and institutionalization. The nurse's role in advocating for the patient in the delivery of patient care has continued to gain importance (Baldwin, 2003, Chafey et al., 1998, Gaylord and Grace, 1995, Mallik, 1997) along with the recognition of this role in pain management (Vaartio, Leino-Kilpi, Suominen, & Puukka, 2008). In some situations, it may be necessary to speak for the patient needing better pain management, whereas in others there is a need for a partnership between the patient and the nurse to achieve pain management goals (Vaartio et al., 2008). Organizations such as the American Chronic Pain Association (ACPA) and the American Pain Foundation (APF) have helped in establishing programs and methods to increase communication about pain between patients and health care providers. Examples include the “TARGET Chronic Pain Initiative” developed by APF to support better pain assessment and treatment by clinicians not specializing in pain management (Rhiner, 2004) and “Partners for Understanding Pain,” a consortium of organizations headed by the ACPA (ACPA, 2008). The program targets a wide variety of organizations and individuals, including health care professionals, those with pain, community leaders, and legislators.

Companies representing the health care industry have also taken an active role in assisting healthcare professionals to advocate for pain management. For example, Purdue Pharma (2008) has developed a comprehensive online resource, “In the Face of Pain: Advocacy Tool Kit.” It provides the professional with excellent resources related to advocacy through legislation, media, community groups, and professional organizations.

Advocacy for pain management in professional practice has been evidenced through the publication of a number of different guidelines and practice standards. One of the first of these was the Acute Pain Management Guideline published by the Agency for Health Care Policy and Research (Acute Pain Management Guideline Panel, 1992). This was followed by the Quality Improvement Guidelines for the Management of Acute and Cancer Pain published by the American Pain Society (APS Quality of Care Committee, 1995). The APS (2008) continued to publish guidelines specific to pain management related to different conditions (e.g., cancer, fibromyalgia, osteoarthritis, and rheumatoid arthritis). A major breakthrough occurred when the Joint Commission approved pain management standards that became part of the accreditation process in 2001 (Phillips, 2000). This action meant that institutions would make a commitment to the management of patients' pain, and it placed emphasis on the nurse's role in doing so. It emphasized the need for nurses who could provide leadership in addressing the adequate treatment of pain (Berry & Dahl, 2000).

Nurses' advocacy participation in the legislative arena has not received the same kind of attention as advocacy in the workplace. Magnussen, Itano, and McGuckin (2005) drew attention to the need for developing legislative skills related to advocating for patients. They conducted a project that was implemented by baccalaureate nursing students who served as legislative interns for the purpose of developing legislative advocacy skills.

Gosselin-Acomb, Schneider, Clough, and Veenstra (2007) surveyed 141 RNs in North Carolina who were members of the Oncology Nursing Society for the purpose of identifying the ways that these nurses advocated for patients and the resources they used to do so. Although nurses were found to be active advocates for patients, they frequently cited lack of knowledge about insurance reimbursement and financial issues. A discrepancy was reported between wanting to advocate and having the necessary resources. At the national level, only 23% of the nurses had written letters to Congress. Study findings indicated that nurses needed educational information about advocacy and how to stay current with available resources.

Ingram (1998) conducted one of the few empirical studies found in the literature. He surveyed 86 nurses at one British District General Hospital. The study aims were to determine the extent to which patient advocacy is practiced as part of daily routine, to determine the characteristics that distinguish those nurses who are active as patient advocates from those who are not, and to develop an instrument to measure patient advocacy among nurses. Data were collected using the Patient Advocacy Scale (PAS), a 28-item Likert-type scale based on Hatfield's (1991) Nursing Advocacy/Beliefs and Practice Scale. Findings revealed that educational level and attendance at an ethics course were predictive of advocacy behaviors. Ingram also interviewed a small subset of the sample regarding advocacy behaviors. Based on analysis of the interview data, four themes emerged: 1) upholding patients' rights; 2) speaking on behalf of patients; 3) protecting patients from harm; and 4) giving advice.

Other researchers suggest that advocacy is limited by barriers. A qualitative study was conducted at the University Hospital in Tehran, Iran, to investigate advocacy barriers and facilitators (Negarandeh, Oskoule, Ahmadi, Nikravesh & Hallberg, 2006). The researchers identified the following barriers based on interviews with 24 Iranian nurses: powerlessness; lack of support, law, code of ethics, and motivation; limited communication; physicians; risk of advocacy; loyalty to peers; and insufficient time. Facilitating factors were also identified: nature of nurse-patient relationship; recognizing patients' needs; nurses' responsibility; physician as colleague; and nurses' knowledge and skills. Another qualitative study conducted by O'Connor and Kelly (2005) found that the nurse advocate serves as an intermediary between the patient and the health care environment. They also found that conflict and confrontation with others were likely results of advocacy and could be detrimental to nurses. Nurse participants in that study clearly differentiated between clinical advocacy (acting directly for patients) and organizational advocacy (acting on an organizational level for one or more patients). Hanks (2008) also conducted a qualitative study that revealed the following themes: speaking out and speaking for patients; being compelled to act on unmet needs of patients; fulfillment and frustration; the patient is changed because of advocacy; advocacy is primarily learned on the job; and confidence is gained through practice.

Purpose 

Based on the lack of empirical data to date, the ASPMN Research Committee developed a survey to determine the advocacy-related knowledge, practices, and educational needs of nurses who focus on pain management. This study was the result of a charge, in 2006, from the ASPMN Advocacy Task Force to the Research Committee to determine how the ASPMN organization could facilitate advocacy related to pain treatment and management. The Association's 2007 Research Committee (Laurie Jowers Ware, PhD, RN, Chair; Patricia Bruckenthal, PhD, RN, ANP-C; Gail C. Davis, EdD, RN; Shalah Ferrol, RN,C, ARNP, ANCC; Margaret Fischer, NP; Lois Lagerman, EdD, ANP, BC; Susan K. O'Conner-Von, PhD, RN; & Patricia S. Shakhshir, MSN, RN,C, CNS) initiated a survey for the purpose of determining ASPMN members' advocacy-related activities, proficiency (i.e., knowledge and skills), and educational needs. Specific aims included:

1.Identify members' pain management advocacy activities.

2.Identify advocacy roles of pain management nurses and the willingness to expand current role.

3.Identify members' educational needs.

4.Identify barriers related to advocacy.

Before addressing these aims, developing and estimating the psychometric properties of the ASPMN Advocacy Survey Instrument (AASI) was a first step.

Methods 

Design 

This was a descriptive correlational study that used an online survey of the ASPMN membership. Approximately 20% of the ASPMN membership completed the online survey.

Instrumentation 

The ASPMN Advocacy Survey Instrument (AASI) was developed by the 2007 ASPMN Research Committee members. Sources used to develop pain management advocacy instrument included: 1) “Pain Management Nursing Role/Core Competency: A Guide for Nurses” (Maryland Board of Nursing, 2001); 2) “Advocacy Competencies” (Lewis, Arnold, House, & Toporek, n.d.); and 3) The Nurse as the Patient's Advocate and Ingram's PAS (Ingram, 1988). The PAS consisted of 28 items using a Likert-type response scale; its reliability was reported as .86.

The ASPMN researchers adapted items from the PAS and developed additional items using the competencies identified by the Maryland Board of Nursing (2001) and by Lewis et al. (n.d.). The final version of the AASI was a 33-item instrument that measured four domains of advocacy using a Likert-type scale: personal advocacy (12 items), public awareness advocacy (7 items), nurse perceptions about advocacy (4 items), and knowledge and skill proficiency related to advocacy (10 items). Content validity was determined by having a small group of ten ASPMN pain experts review the tool for relevancy, clarity, and content. In addition to the four subscales which were rated by the experts as content valid, the tool also gathered demographic data, involvement in social and political advocacy activities, educational needs, and barriers related to advocacy activities.

The AASI was found to have high estimates of reliability. Cronbach alpha reliability (i.e., internal consistency) coefficients for the four subscales ranged from .81 to .92. The interitem correlation means were all >.45 (Table 1).

Table 1. AASI Reliability Estimates

	Scale	No. of Items	Cronbach alpha	Interitem correlation (mean)
	Patient advocacy (n = 161)	12	.92	.495
	Individual patient needs	7	.89	.53
	Patient/family education and planning	5	.85	.55
	Public awareness advocacy (n = 165)	7	.92	.63
	Nurse perceptions about advocacy (n = 173)	4	.81	.56
	Advocacy knowledge and skill (n = 83)	10	.88	.45

Data Analysis 

Analyses were conducted using SPSS version 14.0. Cronbach alpha reliability (total alpha and interitem correlations) was performed for each subscale (i.e., advocacy domain). Descriptive statistics (e.g., frequencies, percentages, and measures of central tendency) were used to examine demographic characteristics and responses to individual items.

Results 

Respondent Characteristics 

Characteristics were calculated on a total of 188 respondents. The majority were female (97.9%) and white non-Hispanic (90.1%). Most were 40-59 years (79.7%), had 20-39 years of work experience (78%), and had obtained a bachelor's or master's degree (67.2%). Almost 60% were employed in a hospital setting. Fifty-eight (31%) were currently employed as pain management nurses, and 89 (47%) held pain management certification. Table 2 presents more specific sample characteristics.

Table 2. Sample Description (n = 188)

	Characteristic	n (%)
	Gender (female)	184 (97.9)
	Ethnicity
	American Indian/Alaskan Native	1 (0.5)
	Asian	3 (1.6)
	Black/African American	3 (1.6)
	Hispanic	1 (0.5)
	Native Hawaiian/Pacific Islander	0 (0)
	White non-Hispanic	170 (90.1)
	Mixed	2 (1.1)
	Other	5 (2.7)
	Age (years)
	20-29	2 (1.1)
	30-39	13 (7.0)
	40-49	57 (30.5)
	50-59	92 (49.2)
	60-69	23 (12.3)
	Years in practice
	0-9	12 (6.5)
	10-19	30 (16.1)
	20-29	75 (40.3)
	30-39	59 (31.7)
	40-49	10 (5.4)
	Highest degree
	Diploma	14 (7.4)
	Associate	26 (14.0)
	Bachelor	56 (30.1)
	Master	69 (37.1)
	Doctor	9 (4.8)
	Other	12 (6.4)
	Professional role
	Staff nurse	33 (17.6)
	Nurse manager	17 (9.0)
	CNS	19 (10.1)
	Academic educator	8 (4.3)
	Pain management nurse	58 (30.9)
	Staff development educator	9 (4.8)
	Patient education educator	1 (0.5)
	Other	43 (22.9)
	Place of employment
	School of nursing	9 (4.8)
	Hospital	111 (59.7)
	Long-term care	4 (2.3)
	Home health agency	2 (1.1)
	Hospice	5 (2.7)
	Outpatient services	25 (13.9)
	Other	30 (16.1)
	Pain management certified (yes)	87 (46.3)
	ANA member (yes)	60 (32.1)

ASSI Subscales 

The AASI demonstrated strong reliability (i.e., internal consistency) with this sample (Table 1). Reliability estimates for interitem correlations were calculated using Cronbach alpha. Reliability coefficients >.70 are considered to be satisfactory for a new instrument (Burns & Grove, 1997); all of the subscales' coefficient alphas were greater than this criterion: Personal advocacy (12 items), α = .92, factored into 2 dimensions: 1) Addressing individual patient needs (α = .89), and 2) Education and planning (α = .85); Public awareness (7 items), α = .92; Nurse perceptions (4 items), α = .81; and Knowledge/skill proficiency related to advocacy (10 items), α = .88.

Personal Advocacy 

This subscale indicates the degree to which nurses are able to perform patient-specific advocacy activities within two dimensions: 1) addressing individual patient needs; and 2) education and planning. Of the 165 nurses who responded to these items, the percentage who rated them 4 (almost completely) or 5 (completely) was high, indicating performance >50% of the time. These percentages ranged from 57.1 (“Disseminate materials regarding rights to assessment/treatment”) to 88.5 (“Continue to advocate if needs not met”). Four additional items were rated high by >80% of respondents; they used current evidence-based pain guidelines (87.4%), let patients know they were “there” for them (84.9%), consulted with team members to overcome barriers (83.3%), and informed the patient/family of right to pain care (80.8%). Activities such as pain-related material dissemination, identifying and confronting pain management barriers, and negotiating pain-related services were performed less frequently (i.e., rated as 4 or 5 by <50% of respondents). More focus might be given to assisting nurses (e.g., provision of resources and ongoing education) to perform them.

Public Awareness Advocacy 

Public awareness advocacy identifies the degree of nurse participation in pain management advocacy activities that address “public awareness” concerns. Again, the ratings of 0 to 5 show how completely these are performed. Responses (n = 165) of 4 or 5 ranged from 32% to 55%, indicating that nurses may need more education in how to participate in public awareness advocacy activities (Table 3). Most of these activities require involvement outside of the clinical agency.

Table 3. Public Awareness Activities Completely or Almost Completely Performed (n = 186)

	Activity	%
	Identify/collaborate with professionals involved in dissemination of pain information	55.5
	Provide education for community of patients experiencing pain	50.0
	Collaborate with stakeholders to develop effective pain management vision	47.3
	Develop alliances with organizations to promote awareness	37.3
	Disseminate pain management info through media	37.0
	Analyze sources of political power/social influences that affect pain management	36.6
	Provide and interpret pain management data for state and local health care policy	32.2

Nurse Perceptions About Advocacy 

This subscale identifies how nurses perceive their advocacy role. Nurses felt strongly that they could confront physicians if necessary to advocate for a patient (89%), and they were comfortable in assisting a patient/family in their pain management (82%). Pushing boundaries to obtain whatever the patients needed (66%) and being comfortable bending the rules/protocols if necessary to meet patient needs (53%) were less robust.

Advocacy Knowledge and Skill Level 

This subscale reflects the personal rating of the nurse's perceived advocacy-related knowledge and skills. These nurse respondents felt proficient in advocating for the pain management of patients regarding patient-family communication (85.3%), pain care management (84.8%), patient-family decision making (79.3%), ethical issues related to pain care (77.7%), interdisciplinary coordination of care (77.6%), and application of evidence-based care (74.3%). Less confidence was reported in legal issues related to pain care (62.3%), conflict management related to advocacy (61%), legislative issues (37.5%), and media training (22.3%)

AASI Social/Political Advocacy Responses 

Most nurses surveyed were registered to vote (94%), knew how to get a message to local political leaders (82%), and were prepared to deliver key messages related to pain treatment and management (97%). Yet only 68% felt they were sufficiently informed to vote on issues relative to pain treatment and management, and only 30% reported making an effort to contact legislators regarding pain management concerns. Likewise, the number who reported having volunteered for a candidate or issue surrounding political campaigns was low (n = 26, 14%). Most felt comfortable speaking with a physician (93%) or an administrator (91%) about a problem they encountered, even knowing that the individual might disagree.

Results indicated a lack of comfort or experience interacting with public media. Only 7% reported having had official media training, 17% reported having written an editorial or letter to the editor in print press, and 18% identified knowing who to contact in ASPMN if asked to do an interview. There was a greater comfort level with being interviewed by the press (34%); 43% had participated in a TV/radio interview.

Overall, nurses responding to this survey felt strongly about patient rights to information about their own pain treatment plan (98%). They encouraged patients and families to ask questions regarding the treatment plan (97%), were culturally sensitive to patients' pain treatment (97%), and adopted a “never quit” philosophy in an effort to promote pain relief (82%).

Educational Needs Related to Advocacy 

Nurses (n = 193) identified the type of instruction they preferred regarding education that would assist them in better advocating for patients and families. In response to the five options given, the format preferred by >50% (n = 116) was workshops. Individual study options were the next most highly selected, with 87 (45%) choosing online modules and 67 (35%) choosing independent study. The least attractive approaches were CD/DVD (n = 57, 29.5%) and classroom (n = 50, 25.9%).

Advocacy Barriers 

Respondents (n = 193) were presented with 11 choices of possible advocacy barriers they might experience. In addition, they could note others that existed. A few (e.g., some physicians, ergonomics, and insurance) were listed. Only one barrier—time—was selected by >50% (n = 99) of the nurses. Table 4 shows overall results.

Table 4. Advocacy barriers (n = 193)

	Barrier	n (%)
	Lack of employer/institutional support	47 (24.4)
	Lack of professional clinical experience	34 (17.6)
	Professional obligations	39 (20.2)
	Power struggles	41 (21.2)
	Lack of assertiveness	23 (11.9)
	Concern over disapproval from administration	14 (7.3)
	Family obligations	30 (15.5)
	No mentor/role models	42 (21.8)
	Time	99 (51.3)
	Cost	42 (21.8)
	Distance	23 (11.9)

Discussion 

The nurses in this sample perceived that they were strong advocates for patients' pain management. All “personal advocacy” activities were accomplished completely or almost completely by the majority of nurse respondents (57%-88.5%). Eighty percent of the group “continued to advocate for patients if patients' needs were not met” and remained “available to the patient.” These findings are consistent with those of Kubsch, Sternard, Hovarter, and Matzke (2004) that nurses advocate on behalf of patients and champion social justice. Attention to “social justice” is consistent with advocacy competencies (Lewis et al., n.d.) The findings in this study also support the position that nurses as professionals uphold patients' values in decision making and act as the patient's partner (Mailick, 1984; Webb, 1987).

Promoting public awareness of pain management activities was the weakest area of involvement by nurses in this sample, consistent with the findings of Gosselin-Acomb et al. (2007). Fewer than 40% were involved in local and state health care policy and in disseminating pain management information through the media. Although most of the nurses reported being proficient in many advocacy-related activities, they noted that legislative issues and media training were the areas in which they lacked knowledge. Magnussen, Itano, and McGuckin (2005) point to the need for integration of legislative advocacy skills in nursing curriculums, recognizing this as an area of weakness for nurses. Although it seems that supporting and intervening on behalf of a patient is second nature to the nurse, contacting a legislator or the media is not. A majority of respondents reported having a lack of knowledge concerning legal issues, conflict management, legislative issues, and media training.

Implications and Recommendations 

Health care providers should not expect patients in pain to advocate for themselves. Patients who are experiencing pain are a vulnerable population and are often in no position to advocate for themselves. Additionally, they may not understand what is available to them or their rights to pain management. Educating patients about their rights to ask for pain medication and to have their pain treated is an important nursing responsibility. Helping nurses to achieve this, along with other pain management advocacy responsibilities, is a function that can be addressed by ASPMN.

Increasing advocacy knowledge and skills should focus on the gaps identified by the nurse respondents in this study, as well as on ways to deal with the barriers identified. Even though the study sample was composed of only a small nonrandom sampling of the ASPMN membership, the results provide a starting place for education. In addition to providing education, ASPMN might appoint a liaison to facilitate members' letter writing, communication with the media, communication with legislators, and staying informed about current legislative issues.

The ASPMN leadership may want to consider development of online continuing education courses to address advocacy gaps in knowledge/interventions, as well as providing workshops at the ASPMN annual meeting. Workshops are needed to address media training, letter writing to legislators, and legal issues related to advocating for patients. Follow-up is needed with ASPMN membership to better understand the major barrier for advocacy, which was lack of time. Galer-Unti, Tappe, and Lachenmayr (2004) state emphatically that advocacy for health-related concerns cannot be put off because of lack of time, because it is nurses' ethical and professional responsibility to advocate for patients. Perhaps specific advocacy-related tasks should be addressed in job descriptions. Furthermore, support from administration, physicians, and other health care workers is essential for successful advocacy. Ensuring that members know where to go to find information is important, because much credible and useful information is available on websites such as those of APS, ASPMN ACPA, and APF and through such Internet resources as “In the Face of Pain: Advocacy Tool Kit.”

The following strategies are suggested to promote advocacy activities: 1) register to vote and encourage others to register and vote; 2) support or become a candidate, directly lobby, or integrate grassroots lobbying into direct lobbying activities; 3) use the internet to access and disseminate advocacy-related information; 4) get involved with the media via letters or opinion pieces and teach others to write letters and opionion pieces; and 5) be a resource person (Galer-Unti et al., 2004). As Hurley (2007) has stated so nicely, the ingredients for successful advocacy include passion, knowledge, skilled communication, vigilance, and perseverance. Armed with these skills, pain management nurses can continue to strive toward being the best advocates for pain management possible.