The Perceptions of Advocacy Behaviors in End-of-LIfe Nursing Care Among Novice, Experienced and Expert Nurses

Abstract

Nurses have difficulty describing the steps of advocacy to guide practice. In order to improve the status of end-of-life care, nurse educators need to be cognizant of the advocate role in nursing practice. The purpose of this comparative descriptive study was to describe nurses' perceptions of advocacy behaviors in end-of-life nursing practice. The novice to expert process and the seven domains of a caring practice as they relate to advocacy behaviors (Benner, 1984) provided a framework in which the nurse can move towards becoming an effective patient advocate.

This study used a naturally occurring practice setting of three regional hospitals with a convenience sample of 317 practicing nurses, with the majority reporting frequent contact with dying patients. Practicing nurses completed the 38-item Ethics Advocacy Instrument (Wlody, 1993), including two open-ended questions and a demographic survey, with 33.3% return rate by postal mail.

Despite the recent emphasis on end-of-life nursing education, practicing acute-care nurses report modest exposure to end-of-life training. The perception of hospital supports was modest with no significant differences among novice, experienced and expert nurses. Three substantial supports to advocacy practice identified by the participants included nurse managers, co-workers and multi-disciplinary services. The study participants described considerable barriers to their advocacy practice including the physician, the patient's family and fear. Novice nurses reported with great frequency that lack of communication and lack of time and/or support served as barriers to their practice.

This study added to the empirical data base and its findings were congruent with the literature in that the majority of nurse participants agreed that they practiced advocacy behaviors, despite the reported barriers. A cross-method triangulation served to strengthen internal validity by measuring the concept of advocacy from two approaches. This study did not confirm an over-all difference in advocacy behaviors among the novice, experience and expert nurse as measured by the APS and ABS combined score. However, it offered insight into the supports and barriers nurses at different skill levels experienced in the practice of advocacy.