Registered Nurses' description of patient advocacy in the clinical setting.

AIM: To provide Registered Nurses description of patient advocacy in the clinical setting.
DESIGN: A qualitative approach with descriptive study design was used to meet the set objective.
METHODS: Purposive sampling was used to select the study participants. Through semi-structured interview, data were collected from 25 participants, transcribed and analysed using qualitative content analysis.
RESULTS: The Registered Nurses described patient advocacy as promoting patient safety and quality care which includes the following: protecting patients, being patients' voice, provision of quality care and interpersonal relationship as well as educating patients. The nurses had adequate understanding of patient advocacy and were willing to advocate for patients. There is, however, a need to research into barriers to patient advocacy in the clinical setting. This study made significant contribution to the understanding of patient advocacy and its positive effect on the provision of quality patient care.

INTRODUCTION

Current emphasis on patient safety has increased the awareness of the critical role advocacy plays in promoting safe clinical practice. Studies have indicated that the absence of patient advocacy has negative consequences (Amidei, 2010; Black, 2011). For instance, Black (2011) revealed an increased in hospital‐acquired infections due to the nurses' inability to advocate for their patients. Norman, Aikins, Binka, and Nyarko (2012) seem to suggest that patients suffer complications and die in some Ghanaian hospitals not because of their sickness but rather as results of physicians or health professionals' refusal to attend to the patients in time. Abekah‐Nkrumah et al., (2010) also noted complaints of impolite treatments and disrespectful attitude towards patients, by hospital staff including nurses, suggesting a need for patient advocacy. In addition, an exclusive interview a midwife from a Metropolitan Hospital granted the Ghana News Agency on 1 January 2015 disclosed that advocating for patients' rights and ensuring patient's safety and quality care was a challenge for nurses. Yet, there is limited documentation about how nurses understand and carry out their advocacy role in Ghanaian healthcare settings. The role of the nurse as patient advocate was not widely embraced in Ghana until 1992 when the Patient Charter Act was introduced by the Ghana Health Service (GHS, 1992). Nurses became both legally and ethically accountable to the patient. The Patient Charter (GHS, 1992) obliged nurses' practicing in Ghana to protect patients' rights to safety, competent and quality care. However, specific guidelines to direct practicing nurses in their patient advocacy role are unclear. There seem to be knowledge gaps with regard to what Registered Nurses perceive or understand to be the meaning of patient advocacy in clinical practice in Ghana. Meanwhile, evidence suggests that nurses' understanding of patient advocacy determine how and whether or not they will advocate for their patients (Kohnke, 1982). Therefore, there is the need to research into how Registered Nurses understand and describe patient advocacy in the clinical setting.

BACKGROUND

Advocacy is a concept that has been widely acknowledged in other professions besides nursing. For instance, the law firm describes advocacy as pleading the cause of a client in the court of justice, while supporting and protecting the interest and rights of individuals in constituency meant advocacy in politics (Graham, 2012). According to Graham (2012), advocacy in nursing in the clinical setting is unique from all other careers in that it strives on a giving off of one's self (the nurse) to an individual (the patient). Patient advocacy in clinical setting focuses on health conditions, healthcare resources, patient needs and that of the public as well.

However, the exact interpretation of what nurses perceive as advocacy differs in the literature. Abbaszadeh, Borhani, and Motamed‐Jahromi (2013) described patient advocacy in the clinical setting as an action taken to attain goals on behalf of one's self or others. On the other hand, Motamed‐Jahromi, Abbaszadeh, Borhani, and Zaher (2012) viewed the concept of advocacy as a philosophical principle in the nursing profession. Motamed‐Jahromi et al. (2012) also argued that the concept of advocacy is an embedded component of nursing practice. Hence, nurses are expected by their professional code of ethics to intercede on behalf of patients in situations of ethical dilemma in the clinical setting.

Bu and Jezewski (2007) to clarify the concepts of advocacy in the clinical setting concluded on three core attributes. These attributes were safeguarding patient's autonomy, acting on patients' behalf and championing social justice in the provision of health care. These attributes support the fact that advocacy enhances patients' safety and ensures quality of patient care (Kalaitzidis & Jewell, 2015). Historically, patient advocacy has been an ethical responsibility for nurses. Most nurses viewed their daily activities in the clinical setting and measures taken on behalf of a patient as being patient advocate. Choi (2015) revealed patient advocacy in terms of the nurse using his or her professional knowledge effectively to advocate for their patients, as well as challenging the traditional healthcare power structures. Other authors like Davoodvand, Abbaszadeh, and Ahmadi (2016) viewed patient advocacy from the perspective of empowering patients to advocate on their own behalf in the healthcare setting.

Thacker (2008) explored advocacy among nurses in end‐of‐life care and found communication to be a key support to nurses who advocate for patients. Davoodvand et al. (2016) commented that advocacy was more than providing good care. Rather, it included actions that enhanced patient safety and quality care. Hanks (2010) and Choi (2015) also identified unmet needs of vulnerable patients and the work environment as factors that could influence the nurse's ability to advocate. These authors further warned that the advocacy roles of nurses in the clinical setting were often accompanied by risks, and the implications of such risks include frustrations, feelings of anger and job loss. Besides, Thacker (2008) asserted that successful advocacy resides in the nurse–patient relationship. Thacker (2008) therefore referred to patient advocacy in the clinical setting as providing safe care and improving quality of life for patients and their families. Patient advocacy has been described by Jackson et al. (2010) as “whistle blowing,” meaning the act of exposing institutions or practices deemed unethical or negligent.

The need for nurses to advocate for patients cannot be over emphasized. Davoodvand et al. (2016) revealed that nurses are able to empower vulnerable patients, delivering them from discomforts, unnecessary treatment, as well as protecting them from actions of incompetent healthcare professionals through advocacy. Graham (2012) argued that even competent patients are also at risk of making wrong decisions due to insufficient information, making nursing advocacy very essential.

Many theorists in nursing tend to agree that patient advocacy by nurses is important and that all healthcare facilities must hold patient advocacy in high esteem (Curtin, 1979; Gadow, 1980; Peplau, 1992). Patients are usually vulnerable in the clinical setting due to either lack of education and severity of their illness or fear due to terminal conditions. Advocacy allows nurses to defend and promote patients' rights and interest in such situations (Black, 2011; Graham, 2012). Further benefits of patient advocacy included empowerment of patients, positive health outcome (Bu & Jezewski, 2007), preservation and protection of patient's rights and safety Davoodvand et al. (2016), changing inappropriate rules and enhancing the public image of the nursing profession (Motamed‐Jahromi et al., 2012).

Abbaszadeh et al. (2013) contend that the nurse is always placed in an exceptional position to advocate for the patient because of the strong nurse–patient relationship that exists in healthcare facilities. Abbaszadeh et al. (2013) further confirmed that nurses spend more working hours with patients which provide them the best opportunity to advocate for patients. According to Graham (2012), nurses have a long history of advocating for patients because of their concern about caring for the patient as a whole and not just their physical health condition. Nevertheless, critics are of the view that nurses should not be the ultimate patient advocate due to their conflicting loyalty to both the employer and the patient (Black, 2011). According to Black (2011), nurses may choose not to advocate if the advocacy process becomes very complex and also due to fear of losing their jobs.

The limited research and documentation about how nurses define and practice patient advocacy in Ghanaian healthcare settings reveal a knowledge gap and pose a threat to patients' safety and quality care. This study will create the awareness and increase the understanding of patient advocacy. It will also enhance improved advocacy strategies and optimal quality care in the Ghana Health Services. The research question for the study was “How do Registered Nurses describe patient advocacy in the clinical setting?”

THE STUDY

Design

Qualitative approach with descriptive study design was used since this allows the researcher to meet the set objectives. Qualitative approach was chosen because it is explorative. It enables researchers to gain an understanding of individuals' underlying reasons, opinions and motives, as well as insight into the problem (Creswell, 2014).

Setting and participants

This study was conducted a Ghanaian metropolitan hospital. The study population included all Registered Nurses currently practicing at the male and female wards made up of surgical and medical patients, the children wards and maternity ward. It also included the theatre, communicable disease, ophthalmological and psychiatric units, as well as outpatient department of the hospital. Most of the participants have had the opportunity to practice in almost all the units in the clinical setting since the facility's policy requires yearly rotation across different units. Participant's responses were therefore not limited to the specific unit where they were practicing, rather a collective experience of their practice across the various units in the clinical setting. Most themes were mentioned by more than one participant. Theoretical saturation was attained as mention of themes became increasingly redundant (Creswell, 2014). A total sample size of 25 was selected from the study population of 51 Registered Nurses. The sample size was determined after the 25th participant was interviewed, and saturation was achieved (Creswell, 2014; Neuman, 2011). Purposive sampling technique was used to enable the researchers select the specific Registered Nurses who had practiced for a minimum of 1 year in the facility where the study occurred and willing to participate in the study. Registered Nurses who fell outside the inclusion criteria were excluded. Purposive sampling was appropriate for this study because only practicing Registered Nurses (RN) who have had experiences relating to the phenomenon to be researched were recruited to respond to the issues that were raised to meet the set objectives (Burn & Grove, 2011; Creswell, 2014; Polit & Beck, 2014). Participants were selected by first obtaining work schedules of potential participants from the ward managers. The researchers then visited the units on daily bases, privately approached potential participants on duty and declared the intent of the study to them. The Registered Nurses were informed that participation in the study was purely voluntary. Finally, time and place of interview were arranged with Registered Nurses who fell within the inclusion criteria and were willing to participate in the study without any coercion, (Creswell, 2014; Polit & Beck, 2014).

Data collection

Data were collected through semi‐structured interview by the researchers between February 2016–May 2016 from Registered Nurses practicing in various units in the hospital. Interview guide was developed by the researchers to assist in the collection of appropriate and in‐depth information from the study participants (Polit & Beck, 2014). The interviews conducted were audiotaped and transcribed verbatim by the researchers. The interviews lasted between 30–45 min. On the contrary, the participants' demographic information collected during the interview was not audio recorded. This approach was necessary to maintain the participant's confidentiality. All participants were also assigned pseudonyms at the start of the interview. Five of the interviews occurred at the offices of the participants in the hospital on a day shift. These participants were Registered Nurses in‐charge of their wards. The remaining twenty interviews took place in special rooms arranged by the participants in the hospital. The interview guide used during the data collection included the following:

Tell me how you would you describe patient advocacy in the clinical setting.

What does patient advocacy mean to you as a Registered Nurse?

Tell me more about your views on patient advocacy in the clinical setting.

Ethical considerations

The study commenced after permission was granted by both Institutional Review Board (IRB) of the University and the authorities at the hospital where the study occurred. The interview was conducted by a Registered Nurse who is a worker at the department of nursing at the university. She had never worked in the facility where the study occurred at the time of the interview. The interviewer had no personal knowledge of the study participants prior to the study. An informed consent was obtained from all participants before data collection. Participants were assured that their rights to privacy and confidentiality would be protected. Participation was purely voluntary; therefore, participants could withdraw at any time without penalty or consequence. Finally, the study data were managed appropriately to prevent breach of confidentiality.

Data analysis

Data were collected through semi‐structured interview and analysed using an inductive method of qualitative content analysis. Therefore, themes identified were derived directly from the content of the data obtained from participant's responses during the interview (Creswell, 2014; Polit & Beck, 2014). The lead author bracketed her ideas by identifying her own values, personal believes and perceptions about the phenomenon under study and put those aside before engaging in the analysis. The authors were aware of their own ideas and did not allow their personal views to influence the analysis of the data (Creswell, 2014). The analysis process included data reduction, data display, drawing conclusion and verification (Creswell, 2014; Miles & Huberman, 1994). The aim was to get familiar with the content of the data, make sense of the raw data and to also enhance proper description, interpretation and discussion of the phenomenon of interest to meet the set objective (Creswell, 2014; Miles & Huberman, 1994). The analyses were done concurrently with the data collection. Theoretical saturation was attained as mention of themes became increasingly redundant (Creswell, 2014). Analysis of the scripts was also regularly reviewed separately by other researchers for confirmation, discussion and needed amendment to avoid research bias.

The steps below illustrate how the qualitative content analysis was carried out. First, was verbatim transcription of audiotape recordings followed by reading and listening to audiotaped recordings for accuracy. Second, reading through all the transcribed data for complete understanding. Third, identification of significant statements, key phrases, single words and sentences of each participant's transcript as the unit of analysis. Forth, reduction in the data into statements and grouping of similar statements and naming them with sub‐themes describing the phenomenon. Finally, combining of all related sub‐themes into main themes answering the study objectives (Creswell, 2014; Miles & Huberman, 1994).

Rigour

Trustworthiness in qualitative study is explained by Creswell (2014) as a means of ensuring the quality of a research. Several methods were used to improve trustworthiness in this study. First, to achieve credibility, detailed description of sampling method, data collection procedure and analysis were clearly documented. Participants in this study were purposefully selected to ensure that they could provide an in‐depth information on their experiences with patient advocacy. Credibility was further assured through member check and peer review (Creswell, 2014). Two expert supervisors, one professor in nursing and one doctorial nursing student reviewed the researchers' method of data analysis, study findings and its interpretations separately. Discrepancies were discussed, and necessary amendments were made to avoid researcher bias.

The member checks were done by verifying responses and interpretations with the participants at the end of each interview before drawing final conclusions from the data. The feedback obtained from the participants ensured correct and clear presentation of participants' experiences. Polit and Beck (2014) and Creswell (2014) are of the view that study sample must be adequate in size and sufficiently varied to enhance confirmability and transferability. Adequacy of sample size in this study was enhanced by selecting 25 participants from diverse units across the hospital. Vast range of views and experiences was captured. Most themes were mentioned by more than one participant. Theoretical saturation was attained as mention of themes became increasingly redundant (Creswell, 2014).

In addition, significant agreement of the themes identified in this study and those of nursing literature indicate that the research findings have been confirmed by other researchers. Detailed descriptions of participants' characteristics, demographic data and the study setting have been documented in this study. In ensuring authenticity, direct quotes from participants' narrations have been provided.

RESULTS

Description of study participants

A total of 25 Registered Nurses comprising three males and 22 females practicing in various units of hospital participated in the study. The age of participants ranged from 20–51 and above. Similar to the ages, the participant's years of work experiences as Registered Nurses also varied from each other. Out of the 25 participants, fifteen nurses had worked between 1–5 years, six nurses ranged from 6–10, and two had 1–15 work experience while the remaining two confirmed their years of work to 21 years and above. Beside their work experiences as Registered Nurses, the participants were not completely new in the health facility. Participants' work experiences in the facility ranged from 1–20 years. Nursing ranks of these participants ranged from staff nurse to principal nursing officer. These participants have had the opportunity to practice in almost all the units in the clinical setting. Participant's responses were therefore not limited to the specific unit where they were practicing. Rather, a collective experiences of their practice as Registered Nurses across the various units in the clinical setting since most themes were mentioned by more than one participant. Theoretical saturation was attained as mention of themes became increasingly redundant (Creswell, 2014). The nurses agreed to participate because they felt it was an important and timely study that could enhance the safety and quality care of patients in Ghanaian hospitals. A summary of participants' demographic data is presented in Table 1.

Table 1

Participants' demographic characteristics

	Frequency	Per cent
Age/years
20–30	16	64.0
31–40	6	24.0
41–50	1	4.0
51 and above	2	8.0
Total	25	100
Sex
Male	3	13.6
Female	22	86.4
Total	25	100.0
Years worked as Registered Nurse
1–5	15	60.0
6–10	6	24.0
11–15	2	8.0
21 and above	2	8.0
Total	25	100.0
Years worked at facility
1–5	17	68.0
6–10	5	20.0
11–15	2	8.0
16–20	1	4.0
Total	25	100.0
Nursing education
Diploma	17	68.0
Degree	7	28.0
Certificate	1	4.0
Total	25	100.0
Staff Nurse	9	36.0
Senior Staff Nurse	6	24.0
Nursing Officer	4	16.0
Senior Nursing Officer	3	12.0
Principal Nursing Officer	1	4.0
Rotation Midwife	1	4.0
Staff Midwife	1	4.0
Total	25	100.0

Main theme: Promoting patient safety and quality care

The objective of this study was to explore the Registered Nurses' description of patient advocacy based on their experiences. To address this objective, participants were asked to describe their understanding of patient advocacy in the clinical setting. The main theme defining patient advocacy was identified based on the participant's responses as indicated in Table 2.

Table 2

Analysis of study result

Promoting patient safety and quality care
Category	Sub‐themes	Themes
Acting as a mediator for the patient	Acting on behalf of patients	Protecting
Carry out certain activities for the patient
Sometimes you have to talk to the family
Stand and defend for your patient	Defending patients' right
Standing in for the patient
Standing in on behalf of the patient
To defend the patient
We as nurses stand in the gap and do the needed thing	Meeting patients' needs
Standing in for the patient need
You stand in the place of the patient
As a nurse you speak up for your patients	Speaking up for patients	Being patient's voice
Being the mouthpiece of the patient
Communicating their needs
Speak on their behalf
Speaking up for patients
Stand in and speak for her
Talk for the patient
Talk to the doctor about whatever the patient need	Commitment to voicing patients' needs
To speak to the doctor for patients
You talk on behalf of the patient
Best care	Ensuring quality care of patients	Provision of quality care
Care for the patient
Care that we need to render
Caring for their needs
Giving quality healthcare
Good care	Taking good care of the patient
Maximum care
Quality care
Quality personal care
The patient is in a better way taken care of
Help them with their care	Helping patients when needed
Helping in settling patient's bills
Helping our patients to recover
Helping patients to get well
Helping the unconscious
To help patients
Helping them to get the necessary help
The patient can come in and speak something that they think that is what will be better for the patient	Self‐determination	Interpersonal relationship
To educate the patient on their conditions	Educating patients
To get the patient to understand
Interpersonal relationship between the nurse and the patient	Interaction with patients
Our relationship with them and their relationship with us
Administering their medications on time	Being available
Being there for the patient
We try to calm and tell them that we are here for them
You being there for your patient

Protecting patients

The participants describe patient advocacy as protecting the patients. They believed that all patients are vulnerable and limited in knowledge about their health conditions compared with the nurse. Advocating for the patient, therefore, means defending patients' right, meeting patients' needs and protecting the patient from injuries both present and anticipated, negative actions and inactions of relatives, colleague nurses, physicians and other healthcare professional that might not promote safety and quick recovery of the patient. Below are direct statements of some participants:

…Sometimes when our clients come to the hospital sometimes they need somebody to stand in for them to help them with their care and speak sometimes on their behalf to the management or other people. So I think advocating as a nurse just means that I am standing in for the patient in time of need. So far as they come to the hospital, they are coming in for some sort of help. So we are there to help them to get the necessary help and needs… (Mrs. C1, 1‐5 yr of experience)

Patient advocacy in my view is the nurse being there for the patient or the nurse insisting on the rights of the patient. The nurse being able to insist on the rights of the patient to make sure that the patient is in a better way taken care of… (Mrs. C2, 6‐10 yr of experience)

Being patients' voice

A second theme that emerged was being patients' voice which was a major component of the participants' descriptions of patient advocacy. All the research participants described advocating for the patient as being patient's voice. This included speaking up, speaking for and speaking on behalf of the patient as well as commitment to voicing the patients' needs:

Patient advocacy is about how as a nurse you speak up for your patients to ensure that they get the best. …there are a times you have to speak up for the patients when it comes to taking critical decisions… (Mrs. T1, 6‐10 yr of experience)

…is being able to speak up for the patient in situations where I think the choices that they make may not favour them or the choices that other health care members make may not favour them. I can come in and then speak on their behalf. (Mr. P3, 6‐10 yr of experience)

Ok to me basically it is being the mouth piece of the patient in terms of you communicating their needs and concerns… (Mr. P 1, 1‐5 yr of experience)

Provision of quality care

The participants stated that the goal of the patient advocacy was to achieve quality care of patient which was the third theme. Participants described patient advocacy as providing quality patient care including taking good care of the patient and helping them when needed. Some participants expressed these sentiments:

As nurses we always advocate for the patient as part of giving quality health care…it means going out of your way to help patients get or achieve the best care they are supposed to have. (Mrs. O2, 1‐5 yr of experience)

…What I understand is that you take good care of them… (Mrs. O6, 21 & above yr of experience)

Supporting the patients was another major sub‐theme used by the participants to describe patient advocacy under the provision of quality care theme. This point covered the areas of giving physical, emotional and financial support for patients. According to the participants, advocating for the patients meant helping and/or supporting the patient to obtain the needed financial support that would enhance their patient's care in the hospital during hospitalization.

It also meant nurses were available to help whenever needed by their patients. The participants made the following comments:

Patient advocacy is basically about you being there for your patient, when your patient expresses any need… (Mrs. F2, 6‐10 yr of experience)

It means helping our patients to recover from their illness. Advocating for patients means help them financially in terms of management of their bills. Sometimes we even pay for the bill for them. We put our heads together, collect money to pay and discharge them after they are discharged by the doctor. (Mrs. M3, 6‐10 yr of experience)

Interpersonal relationship

The interpersonal relationship as described by all participants dealt with interaction with patients and establishing rapport with the patient and family member. It also involved getting to know the patients, their needs, respecting and valuing them as well as involving them in the entire care. For instance, two nurses made the following statements:

…Patient advocacy, I think is an interpersonal relationship between the nurse and the patient, how cordial it is between them… (Mrs. O1, 1‐5 yr of experience)

…It is  how we treat patients, our relationship with them and their relationship with us, whiles it include relationship, everything is included… (Mrs. OP1, 1‐5 yr of experience)

Valuing and respecting under the interpersonal relationship theme were important points raised when respondents were describing patent advocacy. The nurses viewed patients as human beings who unfortunately were ill. Thus, advocating for them meant respecting them, recognizing their individualities and giving them dignify care without any intimidation. For example, one participant in defining patient advocacy noted that:

As much as possible, when they come to the ward, we try to calm them and tell them that we are here for them. So they should feel free and ask whatever they need so that we can also give them the quality of care that is needed. So that at the end, they will have a quick recovery and they will go home. (Mrs. E1, 21 & above, yr of experience)

Self‐determination was another sub‐theme used by participants to describe patient advocacy in the clinical setting. Even though only two nurses mentioned self‐determination in their description of patient advocacy, the researchers saw it as a very important point to be noted. These nurses believed that it was not only the nurse who could advocate for patents. Instead, the patients could also advocate for themselves. The patient has the right to be assertive, speak and defend themselves when necessary. Two participants said that:

…Sometimes the patient can come in and speak something that they think that is what will be better for the patient… (Mrs. CH1, 6‐10 yr of experience)

…it means empowering the patient to speak out… (Mrs. F2, 6‐10 yr of experience)

Some participants described patient advocacy in the clinical setting as educating patients through interpersonal relationship. To those participants, education meant enlightening the patients on their health conditions and getting the patient to understand all that will be involved in their care process. Understanding the care process enhances cooperation and speedy recovery. For example, a participant mentioned that:

…advocating for the patient is when you try to educate the patient on their conditions when you want to get the patient to understand. In our case for instance when you want to admit a patient, then you need to get her to understand the reasons for the admission, the complications and get the family on board to help in the health care delivery. (Mrs. O7, 1‐5 yr of experience)

DISCUSSION

Registered nurses' description of patient advocacy

The participants' descriptions of patient advocacy were similar to those already mentioned in nursing literature. Several nursing theorists have described the diverse activities and actions taken by nurses on behalf of patients as being their patients' advocates (Curtin, 1979; Gadow, 1980; Kohnke, 1982). The study participants believed that patients were vulnerable and limited in knowledge about their health conditions and the best treatment options. Advocating for the patient therefore meant protecting the patient from both present and anticipated injuries. This finding implies that the nurses' role of patient advocacy is crucial to minimizing injury, enhancing safety and optimal care for patients and their family members. A similarly study by Davoodvand et al. (2016) revealed nurses' description of patient advocacy as protecting patients from harm and making sure that patients are being cared for safely.

In addition, this study data revealed patient advocacy as being the patients' voice. This result seems consistent with Abbaszadeh et al. (2013) definition of patient advocacy as an action taken to attain goals on behalf of patients. It is known from this study that the absence of patient advocacy means the patient's voice would most likely not be heard. This implies that without patient advocacy, nursing care of patients might not meet the actual needs of patients, resulting in limited quality care. This probably explains why the increased health complications and death rate in most Ghanaian hospitals. The study participants affirmed that the essence of advocating was to ensure quality care. Hence, patient advocacy is simply providing quality care for patients. This finding provided evidence to support Davoodvand and co‐workers (2016) and Thacker (2008) who ascertained that advocating for patients involved the nurse undertaking many actions that enhanced patient safety and quality care. Further description of patient advocacy by the study participants included supporting and self‐determination. This interpretation implies that advocating for the patients goes beyond caring for the physical needs of that person. Patients should be valued and respected as individuals with specific needs, giving them dignified care without any form of intimidation.

Moreover, the participants believed that patients must be allowed to participate in the decision‐making process by speaking up and advocating for themselves if they had the ability to do so. These assertions reflect the views of Kohnke (1982) and Motamed‐Jahromi et al. (2012) who described advocacy as an act of supporting persons to freely make decisions about their health as they wished. The participants also described the entire patient advocacy process as interpersonal relationship which involved establishing rapport with patients and family, getting to know the patients and their needs and involving them in the caring process. The view expressed here is in line with Gadow's model of existential advocacy (1980) which viewed advocacy as the ideal nature and purpose of the nurse–patient relationship. This finding implies that advocating for the patient involves a multifaceted activities and cannot be achieved effectively by the Registered Nurse in the absence of an empowering practice environment. Interpersonal relationship, patient involvement in decision‐making and care process are effective in promoting patient advocacy.

The result revealed that educating the patients as a form of advocacy meant enlightening the patients on their health conditions and getting them to understand their care process to enhance cooperation and speedy recovery. The finding revealed that patient advocacy is very beneficial, and it promotes patient‐centred care for an enhancement of positive patient outcome. Similarly, Thacker (2008) explored advocacy among nurses in end‐of‐life care and concluded that the foundation of successful advocacy resides in the nurse–patient relationship. The participants' description of patient advocacy was in agreement with the existing nursing theory (Peplau, 1992), nursing advocacy model (Kohnke, 1982) and existing nursing literature (Motamed‐Jahromi et al., 2012).

Finally, it can be deduced from the study result that the need for patient advocacy will continue to increase as the quest for safety and quality care of patients among the Ghanaian populate rises. The study will be relevant in other countries with similar setting as that of the one studied. This study findings will contribute to the body of knowledge of professional nursing across the globe. It will also enhance improved advocacy strategies and optimal quality care in the Ghana Health Services. It beholds on nursing educational institutional authorities to put in measures to ensure that the training of nursing students enhances their ability to undertake effective patient advocacy activities. Also, with most nurses who are yet to embrace patient advocacy, this study will serve as a baseline knowledge that will guide the patient advocacy activities of nursing staff in the Ghanaian healthcare system.

LIMITATIONS

The first limitation of this study was the limited scope of the study to one health facility. In addition, the study participants should have included both physicians and patients as well since nurses formed only part of the individuals involved in the patient advocacy activities. Notwithstanding, the goal of qualitative research was to discover rather than verification and generalization (Creswell, 2014). The purpose of this study was to provide a rich description of the phenomena understudy from the participant's perspective. Finally, getting participants to agree to audio recording of the interview was difficult. However, this challenge was overcame through establishment of interpersonal relationship with participants and reassuring them of the use of pseudonyms and confidentiality in reporting of study findings.

CONCLUSION

The nurses' description of patient advocacy showed that they had adequate understanding of patient advocacy and were willing to advocate for patients. Patient advocacy saved lives, helped to maintain good health, decreased the nurses' workload, ensured caring and quality care of patients, quick recovery and minimized burdens on the healthcare system. Nurses viewed patient advocacy as an important component in their daily practice, yet the advocacy role should not be professional obligation in the absence of required skills and resources. This study made significant contribution to the understanding of patient advocacy and its positive effect on the provision of quality care of patients in the Ghanaian context.

Implications for research, education and practice

This study has implications for an improvement in patient advocacy and quality care of patients. Hospital authorities and stakeholders should motivate nursing staff through establishment of patient advocacy team, creation of awareness and provision of the basic equipment needed to provide quality patient care. Secondly, possible challenge in advocating for patients in the clinical setting necessitates a need to research into barriers to patient advocacy in the healthcare setting to enhance quality care. Finally, nursing educational authorities should ensure that curriculum design for nursing education accounts for the qualities, knowledge and skills required in the training of nurses for effective patient advocacy.

AUTHOR CONTRIBUTIONS

All authors have agreed on the final version and meet at least one of the following criteria: [recommended by the ICMJE (http://www.icmje.org/recommendations/)]: Significant contributions to conception and design, data collection, or analysis and interpretation of data; Drafting the manuscripts or critical revision of the content.