Exploring the Implications of Patient Advocacy Outcomes among Practicing Nurses within the Hospital Context: A Qualitative Research ()
1. Introduction
Patient advocacy encompasses a range of activities aimed at safeguarding patients’ rights, promoting their autonomy, and advocating for their best interests within the healthcare system [1] . Nurses, as frontline healthcare providers, play a critical role in patient advocacy and have the potential to influence patient outcomes significantly [2] . Patient advocacy is known to be beneficial [3] , and nurses are expected by their codes of ethics to advocate for patients to enhance safety and quality care [4] [5] . The demand for nurses to advocate for patients has increased, especially during the COVID-19 pandemic, where family members of patients on admission have limited access to the health facility to provide support [6] .
While some studies have examined the concept of patient advocacy in nursing [6] [7] [8] , limited research has focused specifically on nurses’ experiences of patient advocacy outcomes in clinical practice. Understanding the outcomes resulting from nurses’ advocacy efforts is crucial to determine the effectiveness and impact of their advocacy role. Nurses’ experiences of patient advocacy outcomes refer to the effects or consequences of their advocacy actions on patients, families, and the healthcare system as a whole and on the nurses themselves [9] . These outcomes may include improved nurse job satisfaction, enhanced patient safety, increased patient engagement, reduced healthcare disparities, and better healthcare outcomes [6] [7] [8] . Davoodvand et al. [3] suggest that nurses can experience fulfillment and frustration as outcomes of their advocacy. The authors noted that nurses felt fulfilled and satisfied when advocacy for patients was successful. However, failure in the advocacy process can be frustrating and stressful for nurses in their clinical practice [3] .
Choi [10] noted that previous experiences of negative advocacy outcomes could hinder nurses from speaking up for vulnerable patients due to fear of the social consequences of being labeled as whisperers, troublemakers, and disloyal to their colleagues in the clinical setting. Notwithstanding, there are reports of negative emotional experiences such as feeling guilty, fear of failure, helplessness, anger, and strained relationships among colleague nurses and other healthcare team members [10] [11] [12] . However, positive outcomes among nurses can promote equity in accessing healthcare and the implementation of effective policies that enhance the quality of care in the clinical setting [12] [13] . Mamaril [14] concluded that a culture of patient advocacy among nurses exposes unsafe conditions and subsequently influences patient safety. Thus, the author advises that healthcare institutional authorities assess patient advocacy activities and offer the necessary support to create positive outcome experiences among paranaesthesia nurses.
Additionally, Munday et al. [11] conducted a literature review of several studies conducted in the United States of America, the United Kingdom, Australia, and Sweden. They concluded that patient advocacy promotes quality for patient health outcomes. However, acting as a patient advocate can create workplace conflict and moral distress among nurses. Nevertheless, understanding nurses’ experiences of patient advocacy outcomes could create awareness and practical steps for mitigating unwanted outcomes [11] . Moreover, Sundqvist et al. [12] suggest that nurses are emotionally involved in their advocacy role for patients, which sometimes makes them experience vulnerability. These authors explained that nurses’ experiences of vulnerability can include verbal abuse, disrespect by their own colleagues, feelings of rejection, and moral distress. The experience of moral distress, as noted by the authors, is because of their own convictions about what is right for their patients being ignored by higher authorities in care settings [12] .
On the contrary, some authors believe that the nurses have brought guilt on themselves, thinking they must advocate for patients, contending that patient advocacy is part of the nursing profession and not a unique role [12] . Mamaril [14] suggests that some nurses are loyal to their employers and institutional authorities. Hence, they may not be committed to accomplishing patient advocacy activities. On the other hand, Sundqvist et al. [12] revealed that advocating for patients is perceived by nurses as problematic due to limited understanding. Hence, they suggest the development of nursing theories that could explain patient advocacy within the nursing context with effective outcomes and positive experiences for both nurses and patients.
A study by Water et al. [9] in New Zealand reveals a gap between the ideal of patient advocacy and what is practiced and experienced by nurses. These authors contend that some healthcare professionals are confused about what it means to practice patient advocacy. Hence, differentiating the experiences of their usual nursing outcomes and patient advocacy outcomes is challenging and, in some cases, interchanged [9] . Moreover, the expectation for nurses in Ghana to advocate for patients began in 1992 when the Ghana Health Services (GHS) developed the Patient Charter that mandate all practicing nurses to advocate for their patient in the health care setting [15] . A study by Dadzie et al. [2] in Ghana suggests that nurses are the best advocates for patients. However, nurses are often faced with several challenges including staffing shortage, inadequate supplies, and infrastructure for patient care, as well as physicians’ control over decisions regarding patient care, which often hinders successful patient advocacy activities among nurses [2] [16] .
Our understanding of patient advocacy of patient advocacy in this study aligns with the existing definitions in literature. However, the nurses’ experiences of their advocacy activities in the Ghanaian healthcare setting are unknown. Studies that have explored the outcomes, and implications of patient advocacy, in the Ghanaian context are lacking. Numerous studies on nurses’ experiences of their patient advocacy activities occurred in developed and other countries outside Ghana, which makes it difficult to compare and contrast the situation in Ghana against that of other countries.
To date, limited research has explored nurses’ experiences of patient advocacy outcomes comprehensively, hindering our understanding of the broader impact of nursing advocacy on patient care in the Ghanaian healthcare context. Hence, conducting a comprehensive exploration of nurses’ experiences in this regard is essential to bridge the existing knowledge gap and inform evidence-based best practices that could promote the quality of patient advocacy in the healthcare setting and the well-being of patients and the nurses themselves.
Therefore, this research aims to delve into the subjective experiences of nurses about patient advocacy outcomes in clinical practice within the Ghanaian context. By gathering nurses’ perspectives, experiences, and insights, this study seeks to provide a comprehensive understanding of the impact of patient advocacy on nursing practice and patient outcomes. Thus, the findings of this research can contribute to developing policies and educational initiatives that foster effective patient advocacy and enhance the quality of care nurses provide across various healthcare settings. Consequently, nurses can identify effective strategies and interventions that contribute to positive patient outcomes, enabling them to refine their advocacy skills and improve patient care delivery.
Purpose of the Study
The study aimed to explore and describe the implications of patient advocacy outcomes experienced among practicing nurses in the hospital context.
The research question was:
What are the implications of patient advocacy outcomes experienced among practicing nurses in the hospital?
2. Research Design and Methodology
A qualitative approach and a descriptive study design were employed for this research. The research was conducted from the perspective of the post-positivist paradigm. Thus, the researchers assume the existence of multiple and subjective realities [17] . Creswell [18] revealed that the chosen approach could enhance an in-depth exploration and understanding of participants’ experiences. The design enabled the researchers to gain insight into the phenomenon from different perspectives of the study participants to meet the set objectives [17] [18] . Additionally, the study design is appropriate because there is inadequate information regarding how nurses experience the outcome of their patient advocacy activities in the Ghanaian context [19] .
Additionally, the researchers had no personal relationship with the study participants. The first author who conducted all interviews is a registered nurse with more than ten years of working experience, but she had never worked in the facility where the study occurred. Neither had any of the researchers supervised or had any authority over the study participants. Reflexivity was maintained; thus, the researchers identified their assumptions and biases, wrote them down in a diary, and remained open-minded to the participants’ views [17] [20] . Moreover, the authors use the methods of [16] [21] ; however, the content is different, as each research article sought to answer a different research question.
2.1. Setting, Sample, and Sampling Method
The study occurred in a large metropolitan hospital in Ghana that admits young and older adult patients with medical and surgical conditions. The study population involves all registered nurses working full-time in various units (Surgical, medical, children, and maternity wards, including theatre and outpatient departments) within the hospital at the time of the research.
Purposive sampling was used to select specific registered nurses who have worked in the hospital for at least one year and have gained some experience regarding the patient advocacy outcome phenomenon under study [17] . Specific nurses deemed “experience” in patient advocacy and selected for inclusion in this study were those who have had an exposure of engaging in advocacy from start to finish for a minimum of one patient in the selected hospital. Nurses who fell outside the inclusion criteria and those who were unwilling to provide informed consent were excluded from the study. Participants were selected by first obtaining permission from the hospital management.
An information sheet indicating the researchers phone numbers, the intent of the study, and invitation of voluntary participants were posted on all the notice boards of the hospital. The nurses were informed that participation is voluntary. Individual nurses within the inclusion criteria who called the researchers on the phone, willingly showed interest in the study, and consented to participate were recruited [17] [22] . Twenty-five participants were finally selected from the total population of 51 registered nurses in the health facility. The themes identified were frequently mentioned by most participants. Thus, data saturation was achieved as the mentioned themes became redundant without new ideas from the participants’ responses [17] [18] .
2.2. Data Collection
Semi-structured interviews and audio recordings were used to collect data from the study participants concerning their experiences of patient advocacy outcomes in the hospital. An interview guide with probing questions was developed to facilitate the collection of in-depth information from each participant during the interview process, which lasted for about 30 to 45 minutes [23] . The interviews were conducted in private rooms identified by the participants within the hospital at agreed times. Each participant was given a pseudonym at the start of the interview for their confidentiality [24] . The interviews were conducted in English, transcribed verbatim by the researchers, printed, and stored anonymously in a locker with a key accessible only to the researchers for further analysis. The interview guide was self-developed by researchers for data collection. Questions that were asked include, “Tell me more about your experiences of successful and unsuccessful patient advocacy outcomes in the clinical setting and the implications.” “Tell me more about the necessary qualities and skills for success in advocating for patients based on your experience.” Probing questions that were further asked depended on the participants’ responses. The researchers reviewed the interview questions separately, and necessary revisions were made to reflect the study’s purpose.
2.3. Data Analysis
The researchers employed an inductive method of qualitative content analysis to understand the content of the data from the participants’ responses regarding their experiences of patient advocacy outcomes [18] [25] . The verbatim transcripts from the semi-structured interviews were first read several times while listening to the audio recordings for accuracy and to make a general sense of the participants’ narratives. Next, the data was broken into segments, followed by line-by-line coding of each segment of the transcripts, identifying statements, sentences, phrases, or words describing participants’ experiences as the unit of analysis. Through this process, codes were derived directly from the raw data to capture participants’ experiences and grouped into categories based on their interconnectedness. Related categories were further grouped into subthemes, themes, and the main theme describing the phenomenon. The analysis occurred together with data collection until the attainment of saturation [19] [25] . In addition, the authors identified their values, beliefs, and perceptions about the phenomenon under study and documented it prior to the data analysis to promote open-mindedness and minimize bias [17] . Moreover, the authors frequently reviewed the emerging themes separately for confirmation and discussion and needed amendments to avoid research bias [19] .
2.4. Ethical Considerations
The University of Cape Coast’s ethics review committee granted ethical approval (ID NO: UCCIRB/CHAS/2015/40). The healthcare authorities also granted permission to the hospital where the research occurred. Participation in the study was voluntary. Each participant voluntary signed an informed consent form prior to the commencement of data collection. Pseudonyms were used to protect participants’ identity and confidentiality. The participants were told that they could withdraw from the study at any time without any penalty.
2.5. Trustworthiness/Rigor
Trustworthiness describes the steps researchers take to promote integrity, believability, and quality of the entire research process [26] . Lincoln and Guba [26] recommend four main criteria for trustworthiness: credibility, transferability, dependability, and confirmability. In this study, the characteristics of study participants, sampling procedures, data collection methods, and analysis are documented to promote credibility [17] . The use of purposive sampling enabled researchers to select participants who could provide credible and in-depth information on their experiences of patient advocacy outcomes to answer the research question [19] . One professor in nursing, together with two expert supervisors, reviewed the methods of data analysis, study findings, and interpretation separately. Differences were discussed, and necessary revisions were made to avoid researcher bias. The authors have provided direct quotes from participants’ narratives to support themes and subthemes to ensure authenticity and confirmability. Member checks were accomplished by verifying responses and confirming the findings with study participants after the analysis before drawing final conclusions from the data. The participants’ feedback indicated accurate findings reflecting participants’ experiences of the phenomenon understudy. Field notes were kept from the onset and throughout the research process to track the decision-making process during the data analysis to ensure dependability [17] .
3. Results
3.1. Study Participants
Twenty-five registered nurses, three males and twenty-two females, aged 20 to 51 years and above, participated in the study. These participants’ years of work experience as registered nurses also ranged between 1 to 21 years and above in the facility where the study occurred. Fifteen nurses had 1 to 5 years of working experience, six nurses had worked between 6 to 10, and two had 1 - 15 work experience. The remaining two confirmed their years of work to be 21 years and above. The nurses voluntarily participated because they felt it was a timely opportunity to share experiences that could contribute to creating awareness of nurses’ well-being, safety, and quality of care of patients.
3.2. Description of Themes
The Researchers explored Registered Nurses’ experiences of patient advocacy outcomes in the clinical setting. In the quest to achieve this objective, participants were asked to share their experiences concerning the outcomes of their patient advocacy activities. Analysis of the study data yielded three main themes based on participants’ responses. The first theme was “positive outcomes of successful patient advocacy activities”. The second theme emerged as “negative outcomes of unsuccessful patient advocacy activities”. The third theme was “qualities and skills nurses require for successful patient advocacy”, as presented in the following sections.
3.3. Positive Outcomes of Successful Patient Advocacy Activities
The nurses indicated that their experiences with positive outcomes of successful patient advocacy benefited the patients, nurses, and the health institution. These experiences include satisfaction and fulfillment, patients’ conditions are positively changed, promotion of effective health care and quality nursing care of patients, and positive emotions, as presented in the subsequent sections.
Satisfaction and Fulfilment: The nurses indicated that they experienced inner satisfaction and fulfillment as an outcome of successful patient advocacy, as revealed in the direct quotes from participants below:
“…there is job satisfaction, and when the patients go, they talk about it and inform others. I always say that it’s our jobs that sell us. I felt satisfied; at least I have been able to at least make one of my patients laugh, and that is what we are here for.” (Mrs. E1, over 21 yr work experience)
“…If things go through, you become fulfilled…” (Mrs.M2, 6 - 10 yr work experience)
“…when you are able to help your patients, there is this inner satisfaction…” (Mr. O 3, 1 - 5 yr work experience)
Patients’ Conditions are Positively Changed: According to nurses, when they succeed in advocating for their patients, the outcome includes quick recovery and discharge as well as an improved patient health outcome, as expressed below:
“Generally, it has always been positive. Because you use the evidence base, you have the facts; you have the data of what you are doing. It is just difficult pushing it, but it has always been positive. It saves lives; because of all referrals that were able to occur, you have a discharge and quick recovery.” (Mrs. F 2, 6 - 10 yr work experience)
…She could have got worse. But me hearing that she were recovering made me happy. The family was happy that I took that challenge… (Mrs. OP-1, 1 - 5 yr work experience)
Promotion of Effective and Quality Nursing Care for Patients: The participants disclosed that in the event of success in their advocacy activities for patients, safety and quality care were achieved. Patients and families had trust in the health care system, which yielded a positive image of nurses and the nursing profession, as stated in the following examples:
“…when you are done with one patient, and he is satisfied, they will even announce it to the hospital or the institution…” (Mrs. E 1, 21 yr and work experience)
“…it does have outcomes on the facility and on the nursing profession. Because mostly patients have this perception that nurses are wicked, they don’t know how to talk. But me showing this act of love, I have changed some perceptions about nurses…” (Mrs. OP-1, 1 - 5 yr work experience)
“…that the baby would have been lost…so for the patient, I know there has been an improved outcome. And then, the facility as a whole, the patient will always feel good to come back to the facility because she will have developed the confidence that if I go there, I will get somebody who will help me.” (Mrs. T 1, 6 - 10 yr work experience)
Positive Emotions: The positive emotions theme includes good feelings of nurses and positive feelings of patients and family as indicated below:
“…Sometimes, I am happy; at least I have achieved something for the day, and I have made somebody smile…” (Mrs. C2, 6 - 10 yr work experience)
“Hmm, hmm, emotionally, it does affect, because when you are able to help your patients, there is this joy…” (Mr. O 3, 1 - 5 yr work experience)
“…the family also felt happy, especially the woman. She was very thankful. Because we saw that when we were explaining, she was also naïve about the issue and was blaming herself rather, but after the education, she said, ‘Auntie Nurse, God bless you all.’ They felt good without blaming themselves.” (Mrs. M 4, 1-5 yr work experience)
3.4. Negative Outcomes of Unsuccessful Patient Advocacy Activities
The analysis further showed that in the event where the advocacy actions of nurses became unsuccessful, it resulted in experiences of negative outcomes. The outcomes include increased patient health, complications, lack of quality care for patients, loss of confidence in the health care system, negative emotions, psychological effects, as well as physical and professional consequences. Excerpts from participants in support of these outcomes are provided in the following sections:
Increased Health Complications: Unsuccessful outcomes of patient advocacy yielded negative consequences contributing to increased health complications and deaths of some patients, as shown in the excerpts from participants’ responses:
“…we lost the mother! It was a very sad issue…” (Mrs. O, 1 - 5 yr work experience)
“…sometimes, too, the consequences might be devastating. In terms of quality of life, the patient might not get back to the original state of life again she was in before coming to the facility…” (Mrs. T 1, 6 - 10 yr work experience)
“…it also has negative consequences. It leads to a rise in mortality. Because you know that when a patient is moved to the right or left, he can survive, but this patient is being kept here. There is nothing much you can do than to just keep quiet and just watch on the patients and do your best for them…” (Mrs. M 1, 6 - 10 yr work experience)
Lack of quality care for patients: The nurses stated that the outcome of their inability to advocate for the patients involved poor patient care and failure to render required care that meets the patient’s needs, as revealed in the following statements:
“…when such things happen, I see it as a failure on the part of the facility and the nurse because we have failed to render quality service. At the end of the day, we are not able to help the patient; that is how I feel. We have failed the patient…At the end of the day, there is morbidity or delay referral…” (Mrs. T-3, 11 - 15 yr work experience)
Loss of Confidence in the Healthcare System: The nurses believed their inability to succeed in advocating for patients may have contributed to decreased attendance to the health facility, a negative image of the health facility, and a loss of confidence in the health care system.
“Sometimes patients go and do not come back; they go and sell our name very bad outside…it also diminishes the image of the facility. People wouldn’t trust the facility anymore...” (Mrs. M 4, 1 - 5 yr work experience)
“…They also turn to lose confidence in the facility…” (Mrs. T 1, 6 - 10 yr work experience)
…on the patient, sometimes patients feel like, was it worth coming to the hospital? Especially if it is a delivery issue and she feels she could have been helped at home… (Mrs. O, 1 - 5 yr work experience)
Negative Emotions: The negative emotions, according to the nurses, included bad feelings, feelings of helplessness and powerlessness, painful feelings, and unhappiness, as shown in the excerpts from the participants’ speeches below:
“…As a nurse, you will be helpless, and sometimes you are forced to go along with what they are insisting you do. Sometimes, you go ahead and do what is right. If everything goes on well, then everything becomes quiet, but if it goes the other way, other colleagues will make you feel worse. They will say you didn’t do according to my instructions and now see this and this, and you end up feeling helpless. Because you know what will help the client, but your hands are tied, and you can’t do much…” (Mrs. CH 1, 6 - 10 yr work experience)
“…Oh, you know, under such circumstances, when you want to see that things are done, right, and it does not go that way, you feel bad; as human as you are, you will not be happy, so we really feel frustrated….” (Mr. P 2, 1 - 5 yr work experience)
Psychological Effect: The nurses indicated that they went through negative psychological experiences as they carried out their patient advocacy activities. These experiences ranged from persistent thinking and pondering over the patients’ unresolved problems after working hours to continuous negative thoughts of guilt. In addition, some nurses said they experienced psychological pain, especially after observing their patients die in situations where they thought a remedy could have helped. The experiences that frequently occurred after nurses strove to advocate for patients without positive results were enumerated as follows:
“…To date, over four years, I feel bad. Sometimes you will be thinking about the client…” (Mrs. O 2, 1 - 5 yr work experience)
“…so, at times, you would be thinking about it even at home, saying this woman could have survived…” (Mrs. M 3, 6 - 10 yr work experience)
“…depending on the outcome, I feel sad, especially where it involves life; sometimes we lose a life, or there are complications or bad consequences to the patient. You are going home, and at the back of your mind, you keep thinking I could have done something. I conceive that I have failed. In those instances, it’s a bit depressing.” (Mrs. M 1, 6 - 10 yr work experience)
Physical and Professional Consequences: Participants in this study revealed that their patient advocacy outcome experiences included physical and professional consequences when they could not succeed in their advocacy activities. These consequences involved losing interest in doing the nursing job, which affected their professional work output. In some cases, participants narrated that they were physically angry.
“…we lost the child, and it affected me physically because that was the patient’s first child…” (Mrs. O 3, 1 - 5 yr work experience)
“…It is very tiresome…” (Mrs. F 2, 6 - 10 yr work experience)
“…sometimes, I get angry because I am of the notion that we all choose to do something. For example, if the problem is with a pharmacy, you chose to do a pharmacy, and I chose to do nursing. But we are all looking for the common good of the patient, so I don’t see why because you work in a certain area, and you take an entrenched position that will not help the patient…” (Mrs. T 1, 6 - 10 yr work experience)
“…but when you are not able, your mood changes, and you get a bit of heartbreak, wishing that you could change things, but you can’t. Your morale is affected, and even the zeal to even work gets a bit dull. You don’t really feel the excitement or the real power to help the patients.” (Mrs. C2, 6 - 10 yr work experience)
“…I went off for two weeks due to inability to advocate and the negative outcome…” (Mrs. O 3, 1 - 5 yr work experience)
“…it makes the work very difficult. Sometimes I feel like leaving this institution for a different place. Because sometimes, you really need the client to undergo certain investigations, and you are not able to achieve it.” (Mrs. O 5, 1 - 5 yr work experience)
3.5. Qualities and Skills Nurses Require for Successful Patient Advocacy
From participants’ experiences, important qualities and skills nurses need for successful patient advocacy include therapeutic communication skills and nurses’ personal commitment to intervene for patients. Direct quotes are presented under each subtheme in the subsequent sections.
Therapeutic Communication Skills: This study’s participants revealed that establishing rapport, good interpersonal relationships, ability to communicate, and readiness to collaborate with both patients and the healthcare team are the key therapeutic communication skills nurses need to succeed in patient advocacy. Some comments from participants were noted as follows.
“…you know, there are issues that are very dicey and difficult, but the way you communicate it will minimize the negative effects that were expected initially…” (Mrs. T 1, 6 - 10 yr work experience)
“…without communication and better relationship and cordiality among the health team, nothing can be achieved. Our work is such that you can’t work for 24 hours. Somebody may have to come and take over from you, and you need to take over from somebody, and if there is no proper communication, you end up killing the patient that you were trained to take care of…” (Mr. P 2, 1 - 5 yr work experience)
Nurse’s Commitment to Intervene: Nurses’ personal commitment to intervene, such as having patience, assertiveness, good moral values, and being knowledgeable, were regarded as essential qualities needed for successful advocacy. Below are some of the participant’s direct statements:
“…As a nurse, apart from some of the qualities that we say a nurse must have, other skills include intelligence…you should be very firm in decision-making. You should be assertive…” (Mrs. M 4, 1 - 5 yr work experience)
“…for example, when you are trying to advocate, you should be a person who has patience because the results don’t just come like that. At times, you have to push and push and push, so you have to have the zeal. You have to be somebody who has that persistence…” (Mr. P 1, 1 - 5 yr work experience)
“…Hmm, having the courage and not sitting back…There was the willingness to sacrifice…” (Mrs. OP 1, 1 - 5 yr work experience)
“…I was willing to spend much time to discuss with the mother. It was a difficult task…” (Mrs. T 3, 11 - 15 yr work experience)
4. Discussion
First, the positive outcomes of successful patient advocacy activities reported by the nurses include increased quality of nursing care for patients, a positive change in the patient’s health condition, satisfaction, and fulfillment, as well as positive emotions such as feelings of joy, happiness, thankful, inner motivation to work, and smiles. This study’s findings are congruent with several authors who call for a healthcare culture that empowers healthcare professionals to advocate for their patients without fear or intimidation due to its potential for positive patient health outcomes [1] [6] [14] . Studies have shown that positive outcomes of patient advocacy contributed to a sense of control, hope, and satisfaction among patients and their relatives, as well as improved professional recognition and job satisfaction for practicing nurses in the healthcare context [10] [11] [13] . Nevertheless, the findings contradict the suggestion of Mamaril [14] that nurses may side with their employers and neglect their advocacy role of safeguarding their patients.
Secondly, the outcomes of unsuccessful patient advocacy activities experienced by nurses in this study included negative consequences such as increased health, complications, lack of quality care for patients, longer hospitalizations, loss of confidence in the healthcare system, and negative emotions such as bad feelings of helplessness, powerlessness, painful feelings, and unhappiness. This finding provided some evidence to support the idea that patient advocacy is beneficial [6] [27] . This study’s findings necessitate a need for an enhanced strategy for promoting patient advocacy activities in the healthcare setting. Thus, the consequences of limited patient advocacy in the hospital context could be detrimental not only to vulnerable patients and their relatives but also to the nurses’ well-being [3] [9] [28] . Consequently, our study findings do not seem to support the findings of Sundqvist et al. [12] that nurses are not necessarily mandated to advocate for patients.
Additionally, the nurses noted that their experiences of patient advocacy outcomes included a psychological effect, which involves persistent thinking and pondering over the patients’ unresolved problems after working hours and continuous negative thoughts of guilt. The findings suggest that nurses who advocate for their patients could have moral distress and psychosocial experiences [10] [11] [12] [14] . Our findings suggest a gap in nursing theory and practice concerning patient advocacy, which is worrying considering the numerous people seeking healthcare at their most vulnerable moments in life.
Moreover, the physical and professional experiences reported by the nurses involve loss of interest in the nursing profession, physical anger, occasional verbal exchanges among colleagues, and feeling physically tired from the advocacy process. Several studies have shown that the process involving patient advocacy in the healthcare setting can be complex and challenging for healthcare professionals, including the potential risks of job loss [9] [10] [12] [14] [27] [28] [29] [30] . On the other hand, unlike Tomaschewski-Barlem et al. [31] , who reported a loss of job among nurses as a consequence of advocating for their patients, our study participants mentioned a lack of zeal and decreased work output, yet none of them lost their jobs as an outcome of their patient advocacy activities. The difference in findings is probably because, unlike the nurses in the study of Tomaschewski-Barlem et al. [31] , our study participants were all regular full-time nurses who have worked in the hospital between one to twenty-one years and above, which may have made it difficult for those authorities to dismiss them.
Furthermore, the study found therapeutic communication skills, which include establishing rapport, good interpersonal relationships, ability to communicate, and readiness to collaborate. Moreover, nurses’ commitment to intervene for patients was noted as a vital quality nurses require for successful patient advocacy. These qualities include patience, assertiveness, good moral values, and adequate knowledge about the patient advocacy process. This finding agrees with Curtin’s model of human advocacy [32] , which suggests that close interactions between nurses and their patients enhance the advocacy process. Peplau [33] believed that therapeutic communication and good interpersonal relationship is necessary for success in all nursing interventions for patients. Moreover, several studies have shown a need for effective communication skills during patient advocacy activities. This study finding necessitates promoting and strengthening therapeutic communication and interpersonal relations within health facilities and nursing educational institutions [6] [34] [35] [36] . This finding suggests that nurses practicing in a different context may require similar skills and qualities to experience success in their advocacy actions.
Finally, this result has implications for nursing practice and patient safety. Thus, the possibility of a patient receiving the best care in the hospital setting depends on the individual nurse assigned to that patient and his or her ability and commitment to advocate for the patient. This study result has created awareness of the need for collaborative efforts by the multidisciplinary health team, nursing educational institutions, and hospital management to ensure that nurses are well-equipped with the required skills for patient advocacy.
4.1. Limitations and Strengths
This study was conducted in only one hospital in Ghana. Hence, it might not be generalized as a true reflection of nurses’ experiences across all hospitals in the country. Nevertheless, the findings and recommendations from the study could benefit all healthcare providers, including nurses who advocate for patients in a similar context. In addition, this study’s findings have added to the body of knowledge of the healthcare profession. Moreover, the in-depth exploration of nurses’ experiences can provide valuable insights for further research and potential quantitative investigations.
4.2. Implications for Positive Patient Advocacy Outcomes among Nurses in the Hospital Context
Strengthening Patient-Centered Care: Positive patient advocacy outcomes emphasize the significance of patient-centered care. Thus, nurses who actively advocate for their patient’s needs and rights contribute to a caring environment that prioritizes individualized care, shared decision-making, and respect for patient autonomy [6] . This approach fosters a therapeutic relationship between nurses and patients, improving patient satisfaction and overall outcomes.
Enhancing Patient Safety: Nurses who advocate for patients’ safety contribute to reducing medical errors and adverse events [1] . When nurses are alert and proactive in identifying potential risks, such as medication errors or inadequate infection control practices, they can effectively intervene and prevent harm to patients. Positive advocacy outcomes reinforce the need for vigilant monitoring, effective communication, and timely intervention to maintain patient safety.
Promoting Ethical Practice: Patient advocacy involves upholding ethical principles and respecting patients’ rights. Nurses who successfully advocate for their patients often encounter ethical dilemmas, such as balancing patient autonomy with beneficence or addressing conflicts between patients, families, and healthcare providers [9] [36] . Positive advocacy outcomes highlight the importance of ethical decision-making and encourage nurses to navigate these complex situations with integrity, sensitivity, and adherence to professional codes of conduct.
Empowering Patients and Families: Effective patient advocacy empowers patients and their families to get involved in their care and make informed decisions [27] . Nurses who facilitate shared decision-making and provide information and support enable patients to assert their preferences, voice concerns, and collaborate in their own healthcare [13] . Positive advocacy outcomes emphasize the significance of empowering patients to actively get involved in their care, promoting patient autonomy, and improving health outcomes.
Influencing Organizational Policies and Practices: Nurses who achieve positive patient advocacy outcomes can influence healthcare organizations to prioritize patient-centered care and address systemic issues [28] . Nurses’ experiences and insights can contribute to policy development, quality improvement initiatives, and changes in healthcare delivery models. Positive advocacy outcomes can thus drive organizational change and create environments that support nurses in their advocacy roles.
Inspiring Professional Growth and Collaboration: Nurses who experience positive patient advocacy outcomes gain confidence and a sense of professional fulfillment [10] . These experiences can encourage ongoing professional development, promoting a continuous learning and improvement culture among nurses. Furthermore, positive advocacy outcomes can inspire collaboration among healthcare team members, fostering interdisciplinary teamwork and a shared commitment to patient advocacy.
4.3. Implications for Negative Patient Advocacy Outcomes among Nurses in the Hospital Context
Ethical Dilemmas: When nurses experience negative patient advocacy outcomes, it can lead to ethical dilemmas [14] . Nurses may find themselves torn between their professional obligation to advocate for the patient and the constraints imposed by the healthcare system or organizational policies [14] . These dilemmas can create moral distress and affect the nurse-patient relationship.
Decreased Trust: Negative patient advocacy outcomes can erode trust between nurses and their patients [3] . If patients perceive that their needs and interests are not adequately addressed, they may lose confidence in the nursing profession as a whole. Trust is a crucial component of effective healthcare delivery, and when it is compromised, it can negatively impact patient outcomes [28] .
Professional Burnout: Nurses who repeatedly face negative patient advocacy outcomes may experience increased levels of stress and burnout. Thus, advocacy can be emotionally taxing, especially when efforts are not successful [12] . The frustration and emotional exhaustion associated with these experiences could contribute to decreased job satisfaction and a higher risk of burnout among nurses.
Quality of Care: When patient advocacy outcomes are negative, it can impact the overall quality of care provided [11] . If nurses are unable to effectively advocate for patients, their needs may go unaddressed, potentially leading to suboptimal outcomes. Additionally, when nurses feel disempowered or unsupported in their advocacy efforts, it can hinder their ability to provide patient-centered care.
Need for Systemic Change: Negative patient advocacy outcomes highlight the need for systemic change within healthcare organizations and policies. It may prompt nurses to critically evaluate the barriers and challenges they face in advocating for patients and improvements in the healthcare system. These steps could include changes in organizational culture, resource allocation, communication channels, and policies to support nurses in their advocacy roles better.
Professional Development: Negative patient advocacy outcomes can serve as learning opportunities for nurses. They can prompt self-reflection and encourage nurses to enhance communication, negotiation, and conflict-resolution skills [14] . It may also motivate them to seek additional education, training, or professional development opportunities to strengthen their advocacy skills.
4.4. Implications for Nursing Education
First, nursing education programs should emphasize the importance of patient advocacy and equip nursing students with the required knowledge and skills to effectively advocate for their patients. These skills can include training in communication, critical thinking, ethical decision-making, and conflict resolution. Secondly, integrating realistic patient scenarios into nursing education through clinical simulations can help students practice patient advocacy in a safe and controlled environment. These simulations can replicate challenging situations where advocacy may be required, allowing students to develop effective strategies. Besides, nursing education should emphasize the ethical dimensions of patient advocacy, including understanding legal and professional responsibilities, respecting patient autonomy, and navigating complex ethical dilemmas. This action can help nurses make informed decisions and mitigate negative outcomes. Finally, there is a need for collaborative efforts by nursing educational institutions, nursing organizations, and hospital management to ensure that nurses are well-equipped with the required skills for patient advocacy [37] .
4.5. Implications for Policy
Healthcare institutional authorities should create a supportive work environment that could foster a patient advocacy culture. This action includes providing resources, such as adequate staffing levels, continuing education opportunities, and access to ethical consultations, to empower nurses to advocate for their patients effectively. Moreover, policymakers should develop and implement policies prioritizing patient advocacy and protecting nurses who advocate for their patients. Clear guidelines should be established to ensure nurses feel confident and supported in their advocacy efforts. Additionally, interprofessional collaboration: Policies should encourage interprofessional collaboration and teamwork to enhance patient advocacy. Creating platforms for healthcare professionals to communicate, share information, and collaborate can lead to better patient outcomes and a more cohesive healthcare system.
4.6. Implications for Research and Quality Improvement
Future research involving patients, physicians, and other stakeholders is required to explore their perspectives and strategies for supporting and promoting positive patient advocacy outcomes in nursing practice. Besides, healthcare organizations should implement quality improvement initiatives focused on patient advocacy. This initiative can involve regular evaluation of advocacy practices, feedback mechanisms, and the integration of patient and family perspectives to improve patient-centered care [38] . Furthermore, the experiences of nurses encountering negative patient advocacy outcomes in clinical practice can influence the quality of care provided to patients and shape the overall healthcare system [9] [10] [14] [27] [29] [30] [39] . Hence, addressing the implications of negative patient advocacy outcomes in nursing education and policy can lead to improved patient outcomes, enhanced nurse job satisfaction, and a more effective and compassionate healthcare system.
5. Conclusion
This study explored how nurses experience patient advocacy outcomes in clinical practice. The study concluded that failure or success is possible when nurses advocate for patients in clinical practice. Patient advocacy has advantages; however, lack of success may yield outcomes that could negatively affect the nurses’ well-being as well as the quality of patient care. Hence, patient advocacy should be enhanced in healthcare facilities to promote patient safety and positive experiences of nurses. In addition, therapeutic communication skills and nurses’ commitment to intervene were key qualities and skills required to succeed in the advocacy process. Finally, it behooves all nurses to seek help, including physiological counseling, when necessary to enhance their optimal well-being and the quality of patient care.
Availability of Data
The data used to support this study are available from the corresponding author upon request.
Disclosure
It is important to note that a previous version of this article has been presented as a thesis Nsiah [40] and deposited at the University of Cape Coast Institutional Repository, which is available at https://ir.ucc.edu.gh/xmlui/.
Author’s Contributions
Conceptualization, study design, and data collection: CN; Data analysis and interpretation of data: CN; Supervision of data collection, analysis, and providing feedback during the research activities: JPKN and MS; A significant contributor in the original drafting and writing of the manuscript: FN and CN; Critical revision of the content, contribution to the manuscript, read and approved the final manuscript: All authors.
Acknowledgements
Many thanks to the participants for willingly consenting to participate in this study. Thanks to Professor Janet Gross and Dr. Joseph Agyenim Boateng for their support.