Patient Advocacy

Vol. 7 •Issue 15 • Page 19
The Learning Scope

Patient Advocacy

Nurses can use their influence and authority to make a difference in the lives of patients and the community

This offering expires in 2 years: July 4, 2007

The goal of this article is to learn how to be an effective patient advocate. After reading this article, you will be able to:

1. Identify three perceived barriers to advocacy.

2. Define indirect and direct advocacy actions.

3. Describe three rules that apply to all advocacy activities.

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

As nurses, we have long accepted that part of our professional role is to act as a patient advocate. Considering the fact we are the only professionals who are with patients 24 hours a day, 7 days a week, we obviously are well-suited for this role. In addition, our knowledge and skills in patient education allow us to effectively “translate” information about medical diagnoses, procedures and medications into language patients can understand and use.

Nurses are well-informed and well-educated, and we are passionate about the well-being of our patients. All of these factors drive us to advocate for our patients. But for many nurses, their concept of advocacy ends at the bedside of an individual patient — and that’s too bad. Those same skills that serve us well as patient advocates at an individual level also can be used at the community or public health level. When nurses can go to that level, real change can occur.

As a patient advocate, you have an individual responsibility, but you may have more clout if you approach an issue as a group. Being effective, however, requires more than just passion and knowledge. Specific strategies and organizational and communication skills will enhance your effectiveness and opportunities for success. This article reviews the role of the nurse as an advocate beyond the bedside, and provides suggestions for techniques you can put to work in your expanded role of patient and health advocate.

Why Be an Advocate?

Advocacy, whether at an individual or broad level, involves one person or group speaking on behalf of a patient or cause. Why do nurses get involved in advocacy activities? In general, people become advocates because they believe in an issue and see a need for change — whether it be for a family, school, community or state. Health advocacy involves issues relating to public health, such as smoking, domestic violence or air pollution. By being advocates, nurses can effect change that, in the long run, will make it easier for people to be healthy.

When nurses take on public health advocacy roles, it benefits the profession, too. Many people do not understand and appreciate the vast knowledge and skills nurses possess. By taking a leadership role in a visible way — as part of a public health campaign, for example — nurses do more than “talk the talk.” Nurses are held in high esteem and trusted by the public. In an advocacy role, nurses are seen as active and constructive, which in turn can help improve nursing’s image. Given the ongoing nursing shortage, every action that shines a positive light on our profession is beneficial.1

Barriers to Advocacy

Many people shy away from advocacy activities because they believe participation requires a great deal of time and energy. While that may be true in some cases, it is easy to start small. If your time is limited, you still can be involved. Advocacy can be something as quick as sending an e-mail to a legislator. When written effectively, a two-sentence e-mail can make an impact and the time investment is minimal.

Another common barrier is believing it is impossible to make a difference. To counter that, remember this quote from Margaret Mead: “Never believe that a few caring people can’t change the world. For, indeed, that’s all who ever have.” There is evidence advocacy initiatives have had tremendous influence on policies related to tobacco control and lead poisoning, to name just two.2,3 Your efforts are important and taking action can make a difference. This bit of insight from the staff at the Health Advocacy ToolBox speaks volumes: “Three or four calls to a state senator on an issue is an avalanche.”4

Another fear — and this one is realistic — is employment-related repercussions. You need to carefully draw the line between what you can do as a private citizen and what you can and cannot do as an employee of an agency.

As a citizen, you have the right to vote, lobby and campaign, whether it be for an individual running for office or a policy or law you hope to see passed. However, keep in mind you run the risk of displeasing an employer if you publicly advocate for a position not congruent with your employer’s interests.

To minimize risks, make it clear you are advocating for your personal opinion. Do not use your official title from your job when you are advocating for yourself; that is unethical and foolish.5 Do not use work resources to advocate. Instead, make phone calls from home and use a personal e-mail account and computer to send messages.

To share contact information with others, create a set of personal business cards. While you may opt to have them professionally printed, you also can make a perfectly acceptable set with a computer, printer and package of pre-perforated business card stock. If campaigning for a candidate or issue, check with your employer to see if they have any policies against wearing campaign buttons while on the job. If so, leave them at home.

Depending on the group with which you are affiliated, there may be more stringent rules you should follow. For example, government employees are prohibited from engaging in advocacy activities during work time and using government equipment and materials, including all government-owned communication channels. Likewise, federal law has restrictions on lobbying initiatives by nonprofit organizations; nonprofits also are banned from electioneering activities.

Keep in mind many professional associations, such as the Oncology Nursing Society and the Hospice and Palliative Nurses Association, are nonprofit organizations. If you are a member of such a group, whether at the local or national level, you need to be very clear about your advocacy efforts as an individual versus a member of a professional association.

Only use an association’s logo or letterhead when acting in an authorized role as a representative of the association. There have been cases where an individual’s actions on behalf of a nonprofit crossed the line on lobbying and, as a result, jeopardized the nonprofit status of the organization. Make sure to keep the executive director informed about your activities, both verbally and by providing copies of letters, e-mails and all other relevant documents.

Along the same lines, many nurses wonder if they should use “RN” after their name, for example, in a letter to the editor of a newspaper. My take is that it is your credential — you have earned it — so it is yours to include or not. Personally, I include RN when writing about health and nursing issues; I leave it off for other topics.

Taking the Steps to Advocacy

As noted earlier, being an advocate does not always require large investments of time and energy. At the most basic level, being an informed citizen and voting in elections are advocacy activities. However, for the purpose of this discussion, we are taking a broader view. With that in mind, how do you get started?

In general, most advocacy efforts begin with an issue. The issue usually presents itself to you, rather than you searching for it.

• Ruth Malone, PhD, RN, founded the Nightingales (see sidebar) after she read hundreds of letters sent to tobacco companies from dying customers and their grieving families. She said, “I cried, sitting at my computer. I felt these letters must be heard.”6

• The Susan G. Komen Breast Cancer Foundation has raised more than $740 million for breast cancer research and community outreach since its founding in 1982 by Nancy Goodman Brinker, Susan Komen’s sister, after Komen died of breast cancer at age 36.

• I became an advocate in 2000, when I spent time and money to oppose the citizen-initiated Death With Dignity Act on the ballot in Maine. This referendum, which would have legalized physician-assisted suicide, was in opposition to my beliefs as a private citizen and a nurse. In the months leading up to the election, I wrote letters and editorials, spoke on call-in radio and television shows, and testified before the legislature. It definitely was a crash course in advocacy!

With an issue clarified, you might be wise to check if a group has been formed to advocate for the cause. While it certainly is possible to engage in individual advocacy efforts, the strength of a group or coalition will do more to bring the issue to the forefront of attention. “Working in coalition” was cited by Grace Damio, an advocate and director of maternal and child health and nutrition at the Hispanic Health Council, a community clinic in Hartford, CT, as key to her effectiveness.7

Of course, a group may not exist, and that may be where you need to begin. For example, the Center for Nursing Advocacy ( was founded by a group of graduate students at Johns Hopkins University School of Nursing in April 2001. They came together after a member suggested they form a group to help address the growing nursing shortage, which they felt was caused in part by inadequate understanding of and support for the profession. From that simple start, close to 500 nurses have signed on and provided financial support and have engaged in advocacy activities including several letter-writing campaigns and boycotts.

Keep your focus in mind. Some issues are time-limited, such as a referendum on a ballot that will be decided at election. Put your time and energy to the activities that will make the most difference, both in the short- and long-term.

Advocacy Actions

Advocacy strategies have been described as indirect and direct. Indirect activities are methods that influence the public and media perceptions about issues. They include letters to the editor, guest editorials and petitions. Direct activities speak directly to the people making the policy decisions. In addition to letters, direct activities include calls, visits, legislative testimony and protests. Successful advocacy campaigns usually include a mix of both.

No matter what the approach, there are a few rules that apply to every situation. First, keep your message clear, simple and concise. Whether delivering your message in the form of a letter, an editorial, a fact sheet or testimony, focus on the issue and address a single point. Most letters to the editor have length limits (usually 250 words); if you are presenting testimony, your time likely will be limited to 2 minutes. If you have several points to make, use the power of the group: have one person write a letter on point A, a second person on point B and so on.

Second, be clear about your audience. A direct message written to legislators or corporate executives will be different from an indirect message targeted to the mass media. While you certainly can reuse and revise a variety of letters and fact sheets, make sure each one is targeted specifically for your audience.

Third, identify the best way to communicate and then use the proper channels. Is e-mail or a phone call best? Verbal communication is immediate, and you have the opportunity to answer questions and clarify your message, but there is no written record. For a written message, find out the preferred way to send it: e-mail, fax or traditional mail.

Interestingly, the Web site of U.S. Sen. Olympia J. Snowe of Maine outlines the path a letter currently must follow to reach her office. Due to the anthrax scare and security concerns, a letter from a constituent in Maine would take 2-3 weeks to reach the senator. She makes it clear on her Web site that e-mail and telephone are the preferred methods of communication.

Fourth, be accurate. Do your research so facts and statistics are correct. You do not need a mountain of data, but the data you do present needs to be iron-clad in its accuracy. The corollary to this is to never make up an answer. “I don’t know” is an acceptable answer. “Let me find out and I’ll get back to you” is even better.8

Last, but certainly not least, don’t forget your manners. Be polite. Introduce yourself by name. When meeting with people, thank them for their time and attention. Remember your paths may cross again, so work to build relationships, even when the issue is adversarial. Remember the expression, “you catch more flies with honey than with vinegar.”

Be Prepared

In the coming months, the 2005 election season will be heating up. Are there issues in your state that are of concern to you? Are there specific candidates known to be “nurse-friendly” whom you would like to support? Take the time now to become prepared. Think about how you could become involved and make a difference. Use your advocacy skills to inform others about the issues that matter to you.

As a nurse, you have influence and authority in the eyes of the public. Use these assets to your advantage to make a difference in the lives of your patients and your community — and have fun in the process!


1. Summers, S. Create nurse-run patient advocacy organizations to establish nurses as premier advocates for patient health. Retrieved May 24, 2005 from the World Wide Web:

2. Freudenberg, N., & Golub, M. (1987). Health education, public policy and disease prevention: A case history of the New York City Coalition to End Lead Poisoning. Health Education Quarterly, 14(4), 387-401.

3. Tencati, E., et al. (2002). Teens as advocates for substance use prevention: Strategies for implementation. Health Promotion Practice, 3(1), 18-29.

4. The Health Advocacy ToolBox. Advocacy explained. Retrieved May 24, 2005 from the World Wide Web:

5. Galer-Unti, R.A., Tappe, M.K., & Lachenmayr, S. (2004). Advocacy 101: Getting started in health education advocacy. Health Promotion Practice, 5(3), 280-288.

6. Malone, R. (2004). Telling the truth about big tobacco. Journal of Addictions Nursing, 15(3), 107-109.

7. The Health Advocacy ToolBox. Profiles in advocacy: Grace Damio. Retrieved May 24, 2005 from the World Wide Web:

8. The Health Advocacy ToolBox. Tips no advocate should forget. Retrieved May 24, 2005 from the World Wide Web:

Leslie H. Nicoll is president and owner of Maine Desk, an editorial consulting business located in Portland, ME.

Nurses Take On Tobacco Industry

The Nightingales are a group of nurses actively working to focus public attention on the behavior of the tobacco industry and its contribution to the preventable epidemic of tobacco-caused disease and death. They believe it is not socially responsible for the tobacco industry to actively market cigarettes and other tobacco products. The Nightingales have a goal that the industry will voluntarily end active marketing and promotion of these products.

The Nightingales were founded by Ruth Malone, PhD, RN, associate professor in the School of Nursing, University of California, San Francisco. Malone, herself a former smoker (it took her 16 years to quit), was inspired after studying millions of pages of previously secret internal tobacco company documents released in legal cases. She came across an internal memo, written more than a decade earlier, that noted if nurses ever became activists on tobacco they “could easily become formidable opponents.”

In addition to the voluntary end to tobacco marketing, other goals of the Nightingales include 100 percent smoke-free workplaces, an “R” rating for tobacco use in movies and full coverage for tobacco cessation treatment programs as part of every health insurance plan.

The group’s Web site ( identifies several ways for nurses to become involved and join their cause. These strategies include tried-and-true advocacy methods, such as letters to the editor of your local paper and letters to tobacco companies expressing your view.

Other suggestions for action, which can be applied to this and other causes, include:

• Conduct a public reading of letters from the industry’s secret files, sent to tobacco companies from dying customers and their grieving families. Sample PowerPoint files and excerpts of the letters are available at the Web site.

• Buy a share of tobacco company stock and write a letter to the company as a concerned shareholder. As a shareholder, you also can attend the shareholders’ meeting, which Malone and 11 other nurses did in 2003, 2004 and 2005.

• Encourage professional organizations to endorse the campaign and get involved in ending tobacco marketing.

• Make a financial donation to allow the Nightingales to continue their voluntary advocacy efforts.


Malone, R. (2004). Telling the truth about big tobacco. Journal of Addictions Nursing, 15(3), 107-109.