Journal of Neonatal Nursing (2017) 23, 5e8
www.elsevier.com/jneo
Original Article
Advocacy, ‘defacto’ partner to neonatal nursing practice Mary Anne Ryan, B.Sc. Nursing (hons), M.Comm. (Public Admin), M.Sc. Ethics and Law, RGN/RSCN/RM Department of Neonatology, Neonatal Unit, Cork University Maternity Hospital, Wilton, Cork, Ireland Available online 9 July 2016
KEYWORDS Advocacy; Neonatal nursing; Ethical and legal
Abstract Advocacy is married to nursing practice in every sense of the word. Woven through the very fabric of our practice, it is the demonstration of our responsibility to those in our care in an area where it is paramount. Neonatal care facilities generally accept that parents/guardians are the best advocates for their children and act in their best interest. At times social and family demands make it impractical for parents to be with an infant throughout each day and hence the concept of an advocate is most relevant. The level of vulnerability of the infant and parents in the neonatal unit in all aspects of care further strengthens the call for advocacy. Being an advocate in nursing not only refers to those in our care but relates to a wider effort to improve accessibility, excellence, research and overall service delivery. Advocacy within the profession of nursing and our codes of practice refers to organisational/management support for its nurses extending their role at a local and national level alike. ª 2016 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Introduction Advocacy is inherent to neonatal nursing practice. In conjunction with our medical colleagues we aim to champion our families and infants as
we provide a second protector to ensuring the best interest of the infant and family are met. The family are an integral part of neonatal nursing akin to the team of health care professionals.
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[email protected]. http://dx.doi.org/10.1016/j.jnn.2016.06.003 1355-1841/ª 2016 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
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Advocating for parental autonomy There is potential for loss of liberty in the neonatal unit (Goering, 2009). The unfamiliar ‘high tech’ environment, encountering foreign and unfamiliar medical terminology, whilst potentially traumatised from an abrupt unpredicted turn of events compromises parental autonomy. In the tradition of the Hippocratic Oath, beneficence may be considered a duty to do only good or ones best for the patient, and has been identified as bound by other virtues such as justice and professional responsibility (Crisp, 2014). Beneficent actions also seek to protect autonomy whilst non maleficence is our duty to do no harm. Madden (2011) suggests that this ‘duty’ implies an obligation on the medical profession to ensure doctors/practitioners are adequately trained to provide care and no harm to the patient or family. This duty of care or duty to do no harm is not only pertinent to clinical aspects of care. The unanticipated admission of an infant to the neonatal unit gives newly made parents little time to adapt to the role of decision makers. For some of these couples parenthood is an event that is thrust upon them with little time to prepare and adapt, bringing with it anxiety and fear for their offspring amidst this unfamiliar environs of the neonatal unit. This environment can be intimidating when parents come to seek and understand details and implications of care. Irrespective of reason for admission we need to acknowledge the need for time to ingest and digest information, to ask questions, and to adjust to the situation and new environment. Let us not forget that the basis of parental autonomy is that the parent has the right to determine what happens to the infant’s body. Whilst acknowledging the infants best interest, there is potential for bias in a neonatal environment pending on the personal beliefs/attitudes of all neonatal health care professionals and perhaps potentially steering parents toward a specific path of care that is inconsistent with parents views. Respect for autonomy stems from acknowledgement of the unconditional worth of all persons with the ability to make ‘moral’ choices pertaining to their own destiny (Beauchamp and Childress, 2009). Potential peril exists amidst our most beneficent actions in neonatal care where despite the best efforts of doctors and nurses, time constraints can limit our enhancement of parental autonomy as we ‘assume consent’ and proceed with treatment/investigations/care. Allowing the
M.A. Ryan assumption of consent to erode the concept of informed consent does little to elevate parents to a position of power and confidence. Cultural variances must be acknowledged as a contributing factor to parent’s concerns and at times reluctance to get involved. The world is made up of many cultures and religions which may be considered to have minimal shared norms. A prima facie moral requirement is that this individual, and cultural variability is protected. The key to achieving this is acknowledging our own values and beliefs and respecting those who differ. If we are to provide holistic nursing, we require a good understanding variances amongst families in our care, in conjunction with information pertaining to emotional, spiritual, psychological and social implications of the infants medical condition for the family (Nurses and Midwives Board of Ireland, 2015).
Advocacy in nursing practice An emphasis on human rights and autonomy in nursing/medicine has led to the emergence of advocacy. Bu and Jezeweski’s (2007) theory suggests that ‘advocacy is a process or strategy consisting of a series of specific actions for preserving, representing and/or safeguarding patients’ rights, best interests and values in the health care system’ (p. 104). This broad definition focuses on safeguarding patient/parental autonomy, acting on behalf of parents in representing their beliefs, values and rights when unable (or does not wish) to attend to themselves, and to strive to recommend, promote, defend and reduce inequalities and inconsistencies. In turn advocacy reflects codes of nursing practice. It is acknowledged by codes of practice that we must protect and promote autonomy of service users, respect their choices, priorities, beliefs and values (Nursing and Midwifery Board of Ireland, 2014, p. 8). These codes advocate for service users rights and for best practice in neonatal and maternal health care. As a neonatal nurse I have a moral and legal obligation to act as each infants/parent’s advocate. However it may take courage and negative consequences may also develop for the individual professional concerned. Nurses are professionals responsible and accountable for their practice, attitudes and actions including inactions and omissions (Nurses and Midwives Board of Ireland, 2014, p. 16). Being neutral or
Advocacy, ‘defacto’ partner to neonatal nursing practice silent about an issue that implicates the infant/ family in your care does little to provide a voice for compassion, empathy, honesty and truth. The outspoken advocate may not win any popularity contests and may potentially lead to disagreement between health care professionals. The steering toward change or recognition of our deficiencies, questions and disturbs the status quo. Seeking to change ‘what is’ into ‘what should be or what could be’ is never easy to negotiate (with the ultimate aim of acting in the best interest of the infant), and is the road less travelled. This may carry with it an element of rejection and exclusion, from management and colleagues alike. If one is to act as an advocate for our patients we must be empowered and have the support of our organisation. Such support is a demonstration of advocacy on or behalf of the profession of nursing and the management style in which it is delivered (Nurses and Midwives Registration Board of Ireland, 2015). In the past this would have appeared quite aspirational and an unrealistic expectation to make generalities that nurses would be supported in this role by the organisation for which they work. It is however largely dependent on the organisational management style/ culture, and ethos of the clinical environment in which they work (cognisant that both may differ). Reconfiguration of our health services and its delivery provided leaders and management in nursing an ideal opportunity advocate for the advancement of the role of nurses. Political and organisational support and value for the ‘face’ of a health care organisation and front line work force continue to remain less than optimal in 2016. There are times when a practitioner’s proposed actions may not always be based on tradition, policy and authority but based upon reflection and experienced clinical judgement. Acknowledging that ‘doing the right thing’ may not be ‘the right thing to do’ as per organisation rules, can be difficult to navigate at times. Acknowledging deficits in knowledge and experience and knowing when to seek expert advice is incumbent upon all practitioners. Consideration for the weight of a decision frequently assists in determining the course of action.
Advocacy and the law The Irish Constitution advocates for the family, as the natural primary and fundamental unit group
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of society and as a moral institution possessing inalienable rights antecedent to all positive law (Bunreacht na hEireann, 1937: 41:1:1). Case law frequently utilises the ‘duty of care or best interest standard’ does not always equate with the preferences of the child or the family but seeks to protect the rights of the child (Law Reform Commission, 2011). Such a standard may not always be confined to medical issues but may also relate to the emotional, social and psychological benefits to the infant or child in the short or long term. However difficulties can arise with such standard as personal opinions are made on behalf of the infant/child that incorporate personal prejudice, bias and a potential conflict of interest. Medical and nursing professionals need to extend their education to ensure knowledge and advocacy for the law, embracing it in our daily practice. To say there is an element ‘jaundice’ pertaining to the law, is possibly more the order of the day. Institutions fear being sued as do doctors and nurses and hence there are concerns that the law is unduly intrusive and threatening, that it distracts the doctor from his real work of treating patients and that the maze of legal rules and procedures are designed to trip those up who are unfamiliar with the system (Madden, 2011, p. 49). Consideration and education must also be given to the weight of the law which needs to be balanced with a mix of ethical considerations. The ratio of content of these individual components of ethics and law on one side of the scale will vary pending the clinical issue in the balance. Ensuring this balance is, in itself a form of advocacy. Health care professionals need to advocate for fulfilment of our legal requirements and that our medical staff are competent to take on this responsibility. The process of informed consent is not unique to the neonatal environment, but the risk of dilution of this legal entitlement is possibly greater in neonatology than in any other area of care. There is much opportunity for on the job clinical learning in neonatal care but less opportunity to pause, change the tempo and discuss pertinent non clinical aspects such as communication and the ethical/legal issues at hand. It is incumbent on our educators to ensure an ongoing allocation of hours is provided to ethical/legal discussion as it is to clinical aspects of care. Undergraduate/post graduate training in these areas will empower nurses and doctors to a greater extent to fulfil their roles as advocates.
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M.A. Ryan
Conclusion Infants do not have a political voice of their own and hence advocacy is an essential component of neonatal care. In a highly specialised clinical environment caution must be expressed for the potential of an overemphasis on clinical findings and clinical skills. Through extending and broadening knowledge and education pertaining to the concept of advocacy, we can facilitate the development of ‘an advocacy team’ as well as a team of medical experts. Each professional’s ultimate and collective aim is to improve the quality of service in the neonatal unit. This involves collaboration and co operation between professionals that incorporates mutual respect, trust and openness to discussion. Nurses are team players, and need to be encouraged to practice to the full extent of our education and our codes of practice. If we are to truly act as advocates we need organisational support and extra chairs around the table to ensure a visible nursing presence at all levels of health care, especially in
the area of research and policy development, in partnership with our medical and political colleagues alike.
References Beauchamp, T., Childress, J., 2009. Principles of Biomedical Ethics, sixth ed. Oxford University Press, Oxford. Bu, X., Jezewski, M.A., 2007. Developing a mid range theory of advocacy through concept analysis. Journal of Advanced Nursing 57 (1), 101e110. Bunreacht na hEireann, 1937. The Irish Constitution. Government Publications, Dublin. Crisp, R., 2014. The duty to do ones best for ones patient. Journal of Medical Ethics 40 (3), 17e23. Goering, S., 2009. Postnatal reproductive autonomy, promoting relational autonomy and self trust in new parents. Bioethics 23 (1), 9e19. Law Reform Commission, 2011. Children, Medical Treatment and the Law. Government Publications, Dublin. Madden, D., 2011. Medical Ethics and Law, second ed. Bloomsbury Professional, Dublin. Nursing and Midwifery Board of Ireland, 2014. Code of Professional Conduct and Ethics. NMBI, Dublin. Nurses and Midwives Board of Ireland (NMBI), 2015. Scope of Nursing and Midwifery Practice Framework. NMBI, Dublin.
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