Patient advocacy:
a concept analysis
art&science
nursing standard: clinical · research · education
33-39
Post-exposure rabies vaccine 41-42
Patient advocacy:
a concept analysis
Baldwin MA (2003) Patient advocacy: a concept analysis. Nursing Standard.
17, 21, 33-39. Date of acceptance: October 8 2002.
Abstract
Aim To clarify the ill-defined concept of
patient advocacy and develop a model.
Method An eclectic concept analysis was
used in the study.
Results Results of the analysis reveal that
advocacy has three essential attributes:
valuing, apprising and interceding.
Antecedents to advocacy include a
vulnerable population and a nurse willing to
take on the responsibility for advocacy. The
consequences of acting as a patient
advocate can be potentially negative or
positive for patient and nurse. On their own,
the attributes are one of a number of
helping strategies.
Conclusion Advocacy is a contemporary
nursing issue comprising three essential
attributes. Individually, each of the attributes is
a helping strategy used in nursing. Only when
all three attributes are present can advocacy
be said to be realised.
T
HE TERM advocacy has appeared in nursing
literature for almost two decades (Hewitt
2002, Mallik 1997). Much of the literature
has attempted to legitimise and encompass patient
advocacy in the role of the nurse. However, reser-
vations about the suitability of the nurse to act as
patient advocate have also been expressed (Allmark
and Klarzynski 1992, Copp 1986, Walsh 1985).
Advocacy first appeared in the Project 2000 nurs-
ing curriculum (UKCC 1988). Codes of conduct
and guidelines for professional practice provide evi-
dence that advocacy is a condition of contempo-
rary professional nursing practice (NMC 2002, UKCC
1992, 1996).
Continuing professional development
The management of prostate cancer 45-53
Author guidelines
Guidelines on writing for
56
Nursing Standard’s art&science section
Multiple-choice self-assessment 54
Practice profile assessment 55
Moyra A Baldwin RGN, RCNT,
RNT, Cert Ed, Diploma in
Advanced Nursing Studies, DipN,
BSc(Hons), MMedSci, Member of
Institute for Learning and
Literature review Teaching in Higher Education, is
Concepts are labels to describe phenomena that Senior Lecturer, Chester College
provide a ‘concise summary of thoughts’ (Meleis of Higher Education, School of
1991). A problem with advocacy, however, is the Nursing and Midwifery, Arrowe
myriad of definitions and explanations. Descriptions Park Hospital, Wirral.
range from counsellor, watchdog and representa- Email: m.baldwin@chester.ac.uk
tive (Abrams 1978) to potential whistleblower (Ahern
and McDonald 2002, Andersen 1990). There does
appear to be a consensus that advocacy involves
one person representing another (Allmark and
Klarzynski 1992, Konke 1982a, 1982b, Morrison
1991). However, for Copp (1986), it means more
than speaking for another as it involves interven-
tion for ‘vulnerable’ people who require it.
There are a number of models of advocacy. Fowler Online archive
(1989) has suggested four:
■ Guardian of patients’ rights. For related articles visit our
■ Preservation of patient values. online archive at:
■ Champion of social justice in the provision of www.nursing-standard.co.uk
health care. and search using the key
■ Conservator of patients’ best interests. words below.
The first and second models are concerned with
patients’ legal rights to health care and treatment,
with the second also encompassing individual val- Key words
ues. The third model is based on inequalities and
inconsistencies in healthcare provision. The final ■ Patients: empowerment
model demands that the nurse has autonomy to
empower patients. It is with this model that the ■ Research methods
codes of professional conduct (NMC 2002, UKCC
1992) are concerned. Conservator of patients’ best
interests is particularly evident in clause 2.4 of the These key words are based
NMC (2002) code, which states that the nurse ‘must on the subject headings from
promote the interests of patients and clients’. the British Nursing Index. This
Mallik (1997), however, states that advocacy mod- article has been subject to
els are inconclusive and that there is a need for clar- double-blind review.
ification. Indeed, the increasing literature advancing
february 5/vol17/no21/2003 nursing standard 33
art&scienceresearch
Box 1. Concept analysis
methods
■ Concept development
■ Concept delineation
■ Concept comparison
■ Concept clarification
■ Concept correction
■ Concept identification
(Morse 1995)
34 nursing standard february 5/vol17/no21/2003
advocacy as a nursing activity led Snowball (1996)
to suggest that advocacy is just a buzzword: a ‘con-
venient label for diverse activities’ (Snowball 1996).
Conceptual clarity is required to provide the evi-
dence base for advocacy in nursing.
Aim
The aim of this research was to clarify the concept
of advocacy and to develop a model of advocacy.
Method
Concept analysis is a method of enquiry that elicits
clarification, identification and meaning of words
(Norris 1982, Walker and Avant 1988, 1995). Several
methods of concept analysis exist to aid clarifica-
tion and there is considerable reference to Wilson’s
logical positivist approach (1971). Logical positivism,
in philosophy, is concerned with analysis of propo-
sitions in an attempt to show that it is possible to
‘know’ something for certain (Russell 1984). Walker
and Avant (1983) adapted this method for the
study of nursing concepts and much of the litera-
ture in which the purpose of the study is to exam-
ine a specific concept has used this approach.
Burnside and Haight (1992) elucidated the differ-
ence between the concepts of reminiscence and
life review. Gilje (1992) clarified the concept of
‘presence’ as a phenomenon in nursing, and Jacobs
(1993) and Mairis (1994) clarified grief and dignity,
respectively. Holcomb et al’s (2002) report on the
concept of nursing productivity used this method.
Wilson’s (1971) and Walker and Avant’s (1983)
approaches to conceptual analysis have been crit-
Table 1. The stages for concept analysis
Stages for concept analysis
Identify the concept of interest
Determine the aims or purpose
of the analysis
Identify and select an appropriate realm
or sample for data collection
Identify attributes, antecedents
and consequences of the concept
Identify a model case of the concept,
if appropriate
Identify implications for further
development of the concept
icised, however, for simplifying complex concepts
(Morse 1995). Rodgers (1989) considered that
Wilson’s (1971) method represented a static view
of concepts and was a reductionist approach. Her
philosophical examination of the foundations of con-
cept analysis revealed two distinct views of concepts,
namely entity and dispositional (Rodgers 1989). The
first focuses on the concept as an entity in itself, and
therefore removes the meaning of the concept from
context. Both Wilson’s (1971) and Walker and Avant’s
(1983) approaches provide an entity view. In con-
trast the dispositional view emphasises an individ-
ual’s ability to perform specific behaviours as a result
of being clear about the concept in question. Here
the concern is with the use of concepts in reality and
it can be seen to be relevant to exploration of con-
cepts relating to the practice of nursing.
In an attempt to address her criticism of Wilson’s
(1971) approach, Rodgers (1994) advanced an evo-
lutionary cycle of concept development, which
acknowledged that concepts are influenced by ‘sig-
nificance’, ‘use’ and ‘application’. Her method
brought about analysis that is practice related, as it
focused on application of a concept in practice. This
hybrid model, along with that of Wilson (1971) and
that of Walker and Avant (1983), however, was
rejected by Morse (1995) in favour of an alterna-
tive: an interpretative approach that used qualita-
tive research methods to establish a concept’s maturity.
Using qualitative methodology and drawing on
Bolton’s (1977) ‘rules of relation’, Morse (1995)
proposed analysis of primary and secondary data
to determine whether the object of enquiry could
be considered a concept. The rules of relation are
fivefold, concepts are:
Authors supporting
Walker and Avant (1983)
Rodgers (1994)
(implied by Wilson 1971)
Walker and Avant (1983)
Rodgers (1993)
Rodgers (1993, 1994)
Walker and Avant (1983)
Rodgers (1989, 1993)
Morse (1995) – concept development
Wilson (1971)
Rodgers (1994)
Rodgers (1993)

Table 2. Attributes of advocacy
Attributes Valuing
Definition A therapeutic relationship
in which to secure patients’
freedom and self-determination
Evidence Curtin 1979, 1983
Gadow 1980
Konke 1982a, 1982b, 1982c
Robinson 1985
Salladay and McDonnell 1989
Smith 1979
■ The expressions of the ways in which an indi-
vidual’s experience are organised.
■ The result of particular experiences becoming
general.
■ The result of co-ordination of elements.
■ Used to organise events and must be capable of
being applied to new ones.
■ Formed by examining the correlation between
application of a rule to a particular situation and
its results.
Having identified that a concept exists, application
of the ‘rules of relation’ clarifies which of Morse’s
(1995) six concept analysis approaches is the best
framework for a particular concept analysis (Box 1).
While Morse’s (1995) approach is comprehensive,
it is also more complex to a novice concept ana-
lyst. The method for the analysis and clarification
of the concept advocacy used in the author’s study
was an eclectic one based on Wilson’s (1971),
Walker and Avant’s (1983) and Rodgers’s (1989)
methods. Morse’s (1995) work on concept devel-
opment and qualitative thematic analysis has also
influenced the approach to this study. The stages
and evidence to support their inclusion are shown
in Table 1. Data sources include nursing, research
and scholarly literature.
Results
Attributes of patient advocacy The defining
attributes, that is, those consistently occurring char-
acteristics throughout the literature included the
following:
■ A therapeutic nurse-patient relationship in which
to secure patients’ freedom and self-determination.
■ Promoting and protecting patients’ rights to be
involved in decision-making and informed consent.
■ Acting as an intermediary between patients and
their families or significant others, and between
them and healthcare providers.
The attributes identified are summarised as valuing,
art&scienceresearch
Apprising Interceding
Promoting and protecting Acting as an intermediary
patients’ rights to be involved between patients and:
in decision-making and – family
informed consent – significant others
– healthcare providers
Barton 1991 Conway-Rutkowski 1982
Chamorro and Applebaum 1988 Copp 1986
Konke 1982b Curtin 1979
Marshall 1991
Sines 1993
Winslow 1984
apprising and interceding, and inherent in each is
the nurse who is proactive as well as reactive.
Evidence to support the defining attributes and
their definition is shown in Table 2.
Valuing Analysis of the literature demonstrates that
valuing is one attribute of advocacy. It is an essen-
tial attribute of a therapeutic nurse-patient rela-
tionship that secures patients’ freedom and
self-determination. Valuing is that which the advo-
cate holds dear, prizes or cherishes. Valuing has
two components: valuing patients’ individuality and
valuing self. The patient advocate is one who, while
providing expert care, maintains ‘individualization
and humanity’ (Smith 1979). Gadow (1980)
expressed valuing as: ‘the nurse is in the ideal posi-
tion among healthcare providers to experience the
patient as a unique human being with individual
strengths and complexities’.
Similarly, Curtin’s (1979) concept of advocacy is
based on the common humanity between nurse
and patient for she maintained that: ‘we are human
beings, our patients or clients are human beings,
and it is this shared humanity that should form the
basis of the relationship between us’.
Gadow (1980) placed valuing the patient’s indi-
viduality at the core of her philosophical founda-
tion for nursing. She contended that the right to
determine meaning for oneself was the most
supreme human freedom, a freedom subsumed
within the right to self-determination. Gadow (1980)
wrote of the nurse advocate helping patients to
‘authentically’ exercise their freedom of self-deter-
mination. By this she meant a way in which one
reaches decisions that are absolutely one’s own.
Valuing self - Konke (1982a) claimed that the advo-
cacy role was action filled and suggested that it
had risks. While supporting patients’ decisions the
nurse risks being labelled an informer and precip-
itating anger in others. The best antidote to these
risks and ‘hidden hazards’ was open-mindedness,
which included knowledge of oneself and an
february 5/vol17/no21/2003 nursing standard 35
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understanding of one’s own attitudes, values and
beliefs. She believed that knowledge dispelled the
myths of advocacy and, like advocacy, began with
the self. Knowledge affords the advocate the infor-
mation necessary to inform patients, and self-know-
ledge enables the advocate to support patients in
their decisions.
Robinson (1985) argued that advocacy involved
enabling patients to make decisions freely without
pressure and encouraging patients to make informed
decisions. The advocate takes responsibility for
ensuring goals and priorities are client-centred. A
successful patient advocate is a nurse ‘who is first
able and willing to set aside personal agendas and
unit politics’ (Salladay and McDonnell 1989). To do
this the nurse needs to know his or her own val-
ues, beliefs and opinions.
Apprising The second attribute is apprising, which
is a combination of informing, advising and edu-
cating. Konke (1982b) claimed that informing and
supporting were at the heart of patient advocacy.
Advocacy involves enabling patients to make their
own decisions regarding health care, which will
encourage the likelihood of them obtaining the
health care of their choice. However, advocacy goes
beyond merely assisting patients with their decisions.
It involves helping them to reason and deliberate
(Barton 1991). This requires that the patient is knowl-
edgeable, before making the decision, about the impli-
cations, consequences and alternative options on offer.
Thus the advocate acts as a ‘sounding board’ so that
patients can arrive at the right decision aware of the
ramifications of their decisions.
Chamorro and Applebaum (1988) enriched the
apprising component by arguing that advocacy
involved not only disclosing the consequences of
proposed treatment plans but also the conse-
quences of foregoing the treatment. This second
attribute demands the skills of informing and advis-
ing so that the advocate can promote and protect
patients’ rights to be involved in decision-making
and informed consent.
Interceding The final attribute is interceding. It
means coming between parties and intervening or
mediating where necessary. Patient advocacy
demands that the nurse helps patients to overcome
barriers to meeting their needs (Curtin 1979, Winslow
1984). Reference to transcending barriers is sup-
ported in the literature, which recognises nursing’s
role in re-humanising and re-personalising patients’
experiences of healthcare services.
Bureaucratic hospital systems and the power
ascribed to healthcare professionals render the
patient population vulnerable and impotent, as
does the disease process (Curtin 1979). Kahn et al
(1972) asserted that: ‘advocacy has existed for as
long as there have been powerless groups in need
of a champion’. In their position of powerlessness,
patients require someone to speak for them, and
in some cases mediate on their behalf. Interceding
36 nursing standard february 5/vol17/no21/2003
was identified by Marshall (1991) and Sines (1993)
as an advocate’s role. Both authors included medi-
ating between parties as one of the advocate’s
functions. Copp (1986) identified interceding in
respect of vulnerable people. As hospitalisation ren-
ders patients vulnerable, there is a need for an
advocate who is able and willing to intercede on
their behalf.
Most literature pertains to interceding between
patients and healthcare providers. Some identifies
that the patient’s advocate intercedes between
patients and family or significant others (Conway-
Rutkowski 1982).
Antecedents and consequences
Antecedents and consequences are stages of con-
cept analysis that are often ignored (Walker and
Avant 1995), yet they enrich an analysis by plac-
ing the concept in context. The analysis reveals that
there are two parties involved in patient advocacy
– the nurse and the patient. Therefore, there are
antecedents and consequences for both parties
(Figure 1).
Antecedents Antecedents are events that must
occur before the concept (Walker and Avant 1995).
The analysis has shown that the nature of the sit-
uation preceding patient advocacy is twofold. First
there is the context of vulnerability whereby the
patient, simply by being a patient, is vulnerable.
The patient in his or her vulnerable state might be
facing conflict or in a situation that requires a deci-
sion. Second, there is a need for the nurse, who is
to act as the patient’s advocate, to take responsi-
bility for assisting the patient.
Patient – Much of the literature analysed referred
to patient vulnerability. Abrams (1978) clearly
described how on becoming a patient there was
a need for an advocate. On entering hospital the
patient experiences loss of control over his or her
life, and loss of identity and initiative. Being hos-
pitalised removes one from the family and the
natural supportive network families provide. The
patient faces a strange environment with potential
worries about health problems as well as concerns
about separation from family (Abrams 1978, Jenny
1979). Recent government publications provide
evidence that patient vulnerability remains an issue
in the 21st century, for example, publications guid-
ing patients through the network of health services
(DoH 2001).
In addition to being vulnerable, patients face con-
flicts and situations demanding decision-making.
Barton (1991) identified this antecedent when she
claimed that advocacy was a vehicle for enabling
patients to refuse treatment. Citing a case study
of a patient who refused chemotherapy twice, on
the grounds of wishing to secure herself a ‘quality
of life’, Barton (1991) demonstrated how a vul-
nerable patient faced conflict. The case study
 art&scienceresearch

Figure 1. Attributes, antecedents and consequences of patient advocacy

Antecedents

Patient – vulnerability Nurse – willingness

– conflict – responsibility

Attributes

Valuing

Advocacy

Apprising Interceding

Consequences
Positive Negative
Patient – self-determination Patient – discomfort
Nurse – satisfaction Nurse – risk

demonstrated the first antecedent of vulnerability
in that the patient (who had a cancer diagnosis)
was experiencing a certain degree of persuasion
from medical personnel as well as her family. There
is evidence also that in this vulnerable state the
patient was in a situation causing her conflict as
she was refusing treatment. Brett (1998) likewise
noted how conflict and vulnerability were inherent
in the experience of the hospitalised older person.
The strange environment and protocols may make
older patients adopt a subordinate role where they
find themselves agreeing with powerful healthcare
professionals and feel a need to comply with rather
than refuse treatment (Brett 1998).
Nurse – Willingness and responsibility are the two
antecedents pertaining to the nurse. Fay (1978),
recognising that education would promote the
advocacy role, assigned students course work that
explicitly encouraged them to take responsibility
for, and to become, patient advocates during clin-
ical experience. In Barton’s (1991) case study, the
patient did not benefit from the services of an
advocate. There was no nurse willing to take
responsibility to continue to assist her with her deci-
sion and she was persuaded on the third occasion
to consent to chemotherapy. Ahern and McDonald’s
(2002) survey of nurses’ beliefs relating to whistle-
blowing and advocacy supported the existence of
the two antecedents: nurses who reported mis-
conduct believed in patient advocacy and felt they
had a responsibility to patients.
Consequences Consequences are those events that
occur as a result of the concept (Walker and Avant
1995). As with antecedents there are positive and
negative consequences for both patient and nurse.
Patient – A positive consequence for the patient is that
his or her autonomy is secured (Barton 1991, Graham
1992, Konke 1982a). Literature addressing nursing
ethics also notes that patient advocacy is supported
by the principle of autonomy because the nurse is
obliged to enable patients to be self-determining.
Teasdale’s (1998) advocacy flow chart, based on an
analysis of 150 critical incidents, ended with patient
empowerment which supports self-determination.

february 5/vol17/no21/2003 nursing standard 37

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Box 2. Advocacy: a model case
A 55-year-old woman with a diagnosis of inoperable pancreatic cancer was offered
the opportunity of participating in a randomised controlled trial (RCT) involving
cytotoxic chemotherapy. The patient confided to the nurse involved in her care that
she was having difficulty deciding whether or not to participate in the trial. The GP
and the patient’s family were supportive of the trial. Participating in an RCT meant
that she had no control over whether she would have to remain in hospital: one of
the treatments involved being an inpatient. The patient asked the nurse to help her
find out more information about the specific drug.
The nurse, with the support of the patient’s family, contacted a national
organisation’s helpline and obtained written information about the nature of the
cancer and the drug to be trialled. She also contacted the oncologist who provided
additional information about the drug. Stating that the patient had a poor prognosis,
the oncologist hoped that the trial might be able to offer some ‘quality of life’,
although what this involved could not be specified.
The patient, in possession of the information the nurse had provided, decided not
to enter the trial.
Table 3. Advocacy
Implications for practice
Assessment Antecedents
Consequences
Own advocacy skills
Planning Patient participation
Decision-making strategies
Advocating Using relationship building skills
Promoting and protecting patients’ rights to be
involved in decision-making and informed consent
Mediating, informing and supporting
Evaluating Criteria of effectiveness – consequences
A negative consequence that was implied in the
literature, however, is patient discomfort. Discomfort
appears more apparent when there is competition
for the role of advocacy between professionals
(Copp 1986). Konke (1982b) provided the most
tangible evidence for the less desirable aspect of
advocacy from the patient’s perspective. She claimed
that it was a human trait to want to blame others
in situations where the decision made turns out
not to be the best one.
Nurse – A positive consequence for the nurse is job
satisfaction; however, the negative aspect relates
to perceived and actual risk in terms of career.
Literature pertaining to the nurse’s role clearly
identifies advocacy as an ideal which, in turn, is a
means to self-actualisation and a positive conse-
quence of advocacy (Henderson 1961, NMC 2002).
From Henderson’s early writing to current codes of
professional conduct, being an advocate can help
the nurse to fulfil his or her role and is thus a pos-
itive influence. It is grounded in the caring ethic
(Curtin 1979).
A negative consequence, however, is advanced
38 nursing standard february 5/vol17/no21/2003
explicitly by Andersen (1990), namely whistle-
blowing. Other authors less forthright than
Andersen (1990) also support the notion that
advocacy is a risky business (Abrams 1978, Copp
1986, Fay 1978). Graham Pink was a charge nurse
working in care of the older person’s wards on
night duty at Stockport. After unsuccessfully rais-
ing concerns with his managers over a period
of two years, he decided to publicly report how
understaffing was causing inadequate care. Pink
was dismissed. However, his employers said that
it was not because of whistleblowing. They took
action when a patient’s relatives complained that
the information supplied to the press had been
sufficient for them to identify who was being
written about and this had caused them distress.
Further examples of these risks are evident in
Hunt’s (1995) whistleblowing survey results.
Model case
A model case taken from practice rather than cre-
ated, as Wilson (1971) suggested, follows Walker
and Avant’s (1995) next stage of concept analysis.
This is shown in Box 2.
The attributes of advocacy have been identified
as valuing, apprising and interceding. For this prac-
tice incident to qualify as a model case then all three
needed to be present. The nurse demonstrated valu-
ing in that her actions were aimed at gaining more
information for the patient so that she could make
an informed decision. Apprising and interceding
were also present through the nurse’s use of vari-
ous sources to inform the patient. She was engaged
in interceding when she took responsibility for ‘com-
ing between’ two parties: the patient and oncolo-
gist, and the patient and national helpline.
Discussion
The attributes of advocacy elicited from analysis of
nursing, research and scholarly literature are valu-
ing, apprising and interceding. While each has been
addressed individually, in reality they overlap. Concept
analysis reveals that patient advocacy is a combina-
tion of three essential helping strategies. Only when
all three attributes are combined is advocacy realised.
The deliberate, logical and systematic approach
of assessment (Table 3) is required to determine
those situations in which advocacy is appropriate
and possible. Identifying patients who are vul-
nerable and who require an advocate is essential.
Additionally the potential advocate needs to observe
for other situations in which to advocate for
patients. The advocate needs to be aware of the
antecedents so as not to miss opportunities that
may be less apparent than merely being a mem-
ber of, or stereotyped into, a vulnerable group.
While assessing for situations of advocacy the
advocate needs also to consider the consequences.
 art&scienceresearch
This will include weighing the benefits against the
Conclusion
costs to the nurse and patient. It is possible fol-
lowing one negative experience that an advocate The results from the analysis of the concept of
may assess the consequences in novel situations to advocacy reveal that it is a combination of three
be too great to implement advocacy. essential helping strategies. Only when valuing,
Patient participation is required. The fact that the apprising and interceding are combined can advo-
antecedents for advocacy include vulnerable patients cacy be realised. From the discussion, exploring
who may also be experiencing conflict in making implications for practice, along with the identifi-
decisions serves to illustrate the importance of their cation of antecedents and consequences, it can Smith J (Ed) Models, Theories and
involvement in the process. As the purpose of advo- be concluded that advocacy is an essential and Concepts. Oxford, Blackwell
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Rodgers B (1993) Concept analysis: an
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