LEARNING OBJECTIVES

  • At the conclusion of this article you will be able to:
  • Identify the role of professional self-advocacy in addressing safe working conditions and improving job satisfaction
  • Identify some barriers that constrain effective nursing self-advocacy
  • Identify nursing strategies to improve advocacy for safe workloads.

Nursing roles and responsibilities are constantly evolving and being redefined in response to socio-economic, political, cultural, and professional demands1.

The constantly evolving health workplace – responding to budgetary pressure and ever-growing demand – can result in unsafe workloads while nursing responsibilities remain undiminished. Being constantly buffeted by changing professional demands amid expectations to still deliver safe and effective care is a challenge for many nurses.

Nurses who find themselves unable to say “no” or to assertively question the many demands made on them reveal a diminished nursing capacity to honour or self-advocate for their own needs. Why do many nurses put others demands above their own professional needs to practice safely? This article aims to identify some of the negative impacts of nursing exposure to consistently demanding workloads and associated responsibilities, as well as the role of self-advocacy in attempting to manage these.

Much has been written on the effects of heavy nursing workloads on care outcomes, professional relationships, role satisfaction, workplace stress, and nurse retention2,3. Unsafe workloads can lead to increased emotional and physical exhaustion4 high patient mortality, complications and medical errors5, as well as delays in patient treatment6.

So what is self-advocacy and what does it involve?

Self-advocacy defined

Advocacy is defined as the act or process of supporting a cause or proposal7 seeing a need and finding a way to address it8 and speaking up for oneself. Polifko-Harris (2010) states that:

Inherent in successful self-advocacy are effective communication and problem solving skills. With self-advocacy one must know one’s current state, one’s desired state, how to achieve it and how other person’s can assist.7

Self-advocacy then involves the skilful use of communication, influence, problem solving, collaboration and empowerment.

Communication involves the ability to articulate issues of concern clearly, professionally, and respectfully. Communication exerts a powerful influence on peoples’ attitudes, perceptions, and behaviours. Disgruntled nurses who speak negatively among peers about workplace issues can add to workplace tensions and conflict.

Disgruntled nurses who speak respectfully are usually better positioned to positively effect change. Influence means being able to talk to peers about issues of concern in ways that can positively alter individual and collective attitudes and garner greater commitment to seeking appropriate solutions.

Influence also assists nurses to recognise the right people to raise concerns with in order to effect meaningful change. Problem solving involves the ability to bring potential solutions to issues of concern raised, that can be robustly rationalised and support requests for change.

Collaboration involves working together with the relevant people to gain appropriate support to address issues of concern while ensuring the needs of all involved are being honoured equitably. This also means being able to appreciate and consider the wider perspectives and impacts of any change initiatives sought on the outcomes achieved for all involved.

Empowerment involves recognising when needs are not being met and feeling confident to positively speak about these in the appropriate forums to include relevant people. This may involve seeking or creating opportunities to honour one’s rights to be heard and have needs met.

One consequence of not advocating for what nurses need regarding safe and acceptable workloads is to risk losing the right to self-determination within their practice environments. By simply accommodating demands for them to do more with less sets a precedent that increasingly heavy workloads are an acceptable norm and empowers others to determine nursing needs.

To assist nurses to fulfill their professional responsibilities safely and appropriately, the Nursing Council not only regulates practice but also provides useful documentation aimed at guiding practice. Documents such as New Zealand nursing’s scopes of practice10, the Code of Conduct11 and the Code of Ethics12 are examples. Ultimately, accountability for practice rests fully with individuals and every nurse is responsible for monitoring his or her own practice and for managing everything that threatens their ability to practice safely.

Principal 9 of the Code of Conduct for Nurses in New Zealand makes reference to maintaining public trust and confidence in the nursing profession. Two standards are recommended to guide successful implementation of this principle; the first is to encourage nurses to document and report practice environment concerns that compromise consumer health and safety13 and the second is the responsibility for nurses to maintain their own health and wellbeing14. The Code goes onto describe, in a step-wise fashion, how nurses might address escalating issues of concern using both formal and informal methods of self-advocacy.

Despite nurses embracing patient advocacy as a valid part of their professional role, they appear less comfortable advocating for themselves. What then are some of the barriers that prevent nurses advocating effectively for their professional needs?

Barriers to nursing self-advocacy

Staples (2012) believes nurses have a compelling need to say “yes” to requests or demands made of them and therefore demonstrate a reduced ability to say “no”. She goes on to suggest that some of the reasons why nurses say “yes” is because they want to help people; tend to put others needs before their own; want people to like them; don’t want to encourage conflict; fear real and or imagined consequences of saying “no”; or think that no-one else can or will fulfill the request15.

Negative experiences for nurses who attempt to self advocate by saying “no” can also deter them from raising their ongoing or changing needs. Negative experiences can include critical comments expressed by colleagues or managers who undervalue or belittle the nurse’s attempts to self advocate against an increasing workload that could compromise the nurse and health consumer safety16 . Some nurses demonstrate poor communication and other challenging behaviours when trying to advocate for change resulting in negative engagement with colleagues and increased workplace tensions or conflict17. This can be counterproductive when seeking positive change and can result in negative outcomes.

What are some strategies for strengthening self-advocacy among nurses when attempting to address unmanageable workloads or other workplace demands that could compromise safe practice?

Recommended strategies for improving self-advocacy among nurses

Staples (2012) recommends the following strategies for nurses to consider.

On the spot self-advocacy

  • Pause and ask for time to think carefully about any requests made (this honours your need to truly consider all aspects of the request before making a decision).
  • Consideration might include the number of shifts already worked, days off and need for rest, time with family and friends, pre-planned events, etc.
  • When approached to undertake an increased workload, acknowledge the request (this demonstrates you have listened and do care).
  • Politely decline if unable to accommodate the request.
  • Say what you mean and mean what you say professionally and respectfully. There is no need to qualify or defend your answer unless you have safety concerns and then this is an important discussion to enter into.
  • Be brief and honest.
  • Negotiate only what you can contribute or offer at that time if you cannot commit fully to the request.
  • Ditch feelings of guilt and don’t waver if you have put your own needs first.

Bensing in a recent online article also recommends that nurses avoid making snap or impulsive decisions, when requests are made of them and especially if being pressured for a reply. She advises nurses to clarify their personal and professional priorities when considering their availability to undertake more work or before considering juggling their workload17.

Long-term self-advocacy strategies

  • Do not be uncomfortable to approach colleagues to discuss implications of requests and possible workload rearranging to safely accommodate the request where able.
  • Be mindful of individual capabilities to safely and thoroughly fulfill nursing duties to an acceptable standard.
  • Critically reflect on those aspects of practice that may benefit from strengthening and that could improve workload manageability – e.g. time management, ability to prioritise care.
  • Seek assistance from relevant colleagues to support professional development initiatives.
  • Review the workplace policy and procedure manual for the process required to raise and manage workplace concerns.
  • Identify what is on average a manageable workload for yourself. Ensure this allows for anticipated fluctuations in changing consumer acuity and staffing levels.
  • Negotiate with colleagues at the commencement of each shift allocation of workload and assistance required to meet this.
  • Discuss workplace concerns with peers, managers, and or employers to gauge if the issue is only problematic for the individual or a widely shared concern.
  • Bring some robust and well-rationalised solutions to the discussion to appropriately address issues raised.
  • Be open to hearing alternative perceptions and opinions shared during discussions but do not allow yourself to be ‘brow beaten’ into submission if your view and beliefs differ from the majority.
  • Remain focused on seeking an appropriate solution to the issue of concern you have raised.
  • Thank everyone involved for taking the time to listen and work collaboratively with you to seek a solution to your issue.

Nursing Council of New Zealand guidance and recommendations for managing escalating concerns include:

  • Remain mindful of the nurses’ ethical obligations to report issues, wrongdoing or risks that could endanger health consumers and others.
  • If uncertain about an issue and the need to report it, seek advice and guidance from a senior colleague.
  • Raise concerns with colleagues and other relevant team members if they are contributing to concerns.
  • Formally raise concerns with your manager and escalate concerns to higher levels if these are not addressed or resolved.
  • If unable to resolve workplace issues within that context then address your concerns to another body e.g. Ministry Of Health, Nursing Council, or other health professional regulatory body18.

Conclusion

The nursing profession is dynamic and continually being shaped by, and impacted on, by many different variables. These variables can lead to increased workloads for nurses without diminished responsibilities. Unsafe workloads can lead to higher mortality rates, medical errors, poor care, nurse dissatisfaction, stress, and burnout, which are some outcomes that have been directly linked to outcomes of increased nurse workloads. Despite high workloads nurses are still expected to provide safe and effective care for consumers. Nurses themselves are best able to determine what constitutes a safe and achievable workload but some are challenged to advocate for this.

Self-advocacy involves the effective use of skills to include communication, influence, problem solving, collaboration and empowerment. If nurses are reluctant to advocate for a safe and manageable workload they risk losing the right to self-determination in this regard and empower others to identify this for them.

The Nursing Council of New Zealand plays an important role in safeguarding nursing practice and promoting acceptable health consumer outcomes. The Council also provides documentation to assist nurses to maintain responsibility and accountability for their practice. The Code of Conduct for nurses includes a section on guiding nurses in the use of different types of self advocacy to address and resolve workplace issues of concern that threaten the safety of health consumers and others.

Barriers to self-advocacy among nurses have been influenced by what some perceive to be a compelling need to say “yes” to all requests made of them and a tendency to put the needs of others first. This can occur without consideration being given to the consequences or impacts of that decision by the nurse. Decisions made in haste can often be regretted later. Other barriers can involve previous negative experiences with self- advocacy that have resulted in less than desirable responses and outcomes from colleagues, managers, and employers. Such experiences can discourage further attempts to address issues if concern within the practice context.

There is a plethora of strategies to guide the implementation of effective self-advocacy, especially as this relates to achieving desirable and safe workloads. Responsibility for identifying and advocating for safely manageable and satisfying workloads ultimately remains with nurses themselves. Nurses would benefit from honouring themselves more by creating opportunities to ensure they advocate to get their needs met at every opportunity.


Safer workload initiatives being implemented in New Zealand

In the last five years, much work has been done by the Safe Staffing Healthy Workplace (SSHW) Unit, formed by the district heath boards (DHBs) and New Zealand Nurses Organisation (NZNO) in 2007, to try to address safe workloads and ensure adequate staffing levels. Electronic systems and software such as the Care Capacity Demand Management (CCDM) system and the Variance Response Management (VRM) tools are two examples of initiatives. The CCDM system aims to measures safe staffing levels using patient acuity rather than nurse to patient ratios to plan safe care. Combining staff feedback, electronic and historical data CCDM – using the electronic workload management tool TrendCare – establish base staff numbers and clinical skill mix requirement as well as forecast future demand and clinical resources needed for safe care provision19.

The VRM tool is an electronic tick box system that signals at a glance how busy any ward within the hospital setting is at any given time. Using a colour-coded system to denote busy-ness then allows for early intervention to move staff and divert patients to address deficits and assist with safe care planning. Despite being a nurse-led initiative, the whole hospital, not just nurses, can access this information and see the current state of busy-ness within any area. Patient and staff risk mitigation responses can then be implemented based on ‘real time’ need.

These tools are still being refined and evaluated to assess their efficacy for purpose, however early indicators are encouraging. While such initiatives will not suit every clinical context this does demonstrate the role nurses can play in assisting themselves and others to address these very critical practice issues.

Download learning activity here>>


About the author:

Noreen McLoughlin RN MA (Applied) Diploma Adult Education & Training, is an independent health auditor, was a self-employed professional development consultant for eight years and has been a registered nurse for 30 years.


 This article was peer reviewed by:

  • Barbara Stirling RN, Winton Home, Southland
  • Heather Hackett RGON Assessment Treatment and
  • Rehabilitation Unit, Southland Hospital

REFERENCES

1. CAMPHOR S. Literature Review: Safe Nurse Staffing www.rnjournal.com Retrieved February 2014.

2. HAYES B, BONNER A, & PRYOR J. Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature. Journal of Nursing Management 2010, 18 804-814.

3. MORGAN JC & LYNN MR. (2009) Satisfaction in nursing in the context of shortage. Journal of Nursing Management 17 (4), 401-410.

4. SHEWARD L, HUNT J, HAGEN S, MACLEOD M, & BALL J. (2005) The relationship between UK hospital nurse staff and emotional exhaustion and job dissatisfaction. Journal of Nursing Management 13 (1), 51-60.

5. AGENCY OF HEALTH, RESEARCH AND QUALITY (2012) State mandated nurse staffing levels alleviate workloads, leading to lower patient mortality and higher nurse satisfaction. AHRO Healthcare Innovations Exchange, USA.

6. WINTERS R, & NEVILLE S. (2012) Registered nurse perspectives on delayed or missed nursing cares in a New Zealand Hospital. Nursing Praxis in New Zealand, March 1, 2012.

7. TOMOJAN K (2012) “Advocacating for Nurses and Nursing” OJIN The Online Journal of Issues in Nursing Vol 17 No1.

8. AMIDEI N. (2010). So you want to make a difference: advocacy is the key. (16th edition). Washington DC: OMB Watch.

9. POLIFKO-HARRIS K.A. (2010) The practice environment of nursing: Issues and trends. DELMAR Cengage Learning, New York.

10. NURSING COUNCIL OF NEW ZEALAND (2010) Scopes of Practice

www.nursingcouncil.org.nz/Nurses/Scopes-of-practice  Retrieved January 2014.

11. NURSING COUNCIL OF NEW ZEALAND (2012) The Code of Conduct for nurses www.nursingcouncil.org.nz/Nurses/Code-of-conduct Retrieved January 2014.

12. NEW ZEALAND NURSES ORGANISATION (2010) Code of Ethics. New Zealand Nurses Organisation

www.nzno.org.nz/resouces_publications  Retrieved January 2014.

13. NURSING COUNCIL OF NEW ZEALAND (2012) The Nurses Code of Conduct, Principal 9, standard 8.4 Nursing Council of New Zealand.

14. Ibid, Principal 9, Standard 8.7 Nursing Council of New Zealand.

15. STAPLES S. (2012). Nurses, learn to say “No”. www.nursetogether.com Retrieved January 2014.

16. LONGO J. (2010). “Combating disruptive behaviours: strategies to promote a healthy work environment”. OJIN The Online Journal of Issues in Nursing Vol.15, No.1, Manuscript 5.

17. BENSING K Learning how to just say No.

www.nursing.advanceweb.com/article/learning-how-to-just-say-no-3.aspx.

18. NURSING COUNCIL OF NEW ZEALAND (2012) The Nurses Code of Conduct, Guidance: Escalating concerns pg 11. www.nursingcouncil.org.nz Retrieved January 2014.

19. CASSIE F (2012) Management tool shows hospital’s true colours Nursing Review Vol12 Issue 10 p.5.


THE HOUR OF POWER: Self-advocacy

Reading the article and undertaking this self advocacy learning activity is equivalent to 60 minutes of professional development

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