Chapter 06: Patient, Subordinate, Workplace, and Professional Advocacy

1. When applying the principles of advocacy, a nurse-manager should:

a. defer to a leader whenever possible because advocacy is primarily a leadership function.

b. prioritize the needs of subordinates over the needs of the organization.

c. balance the need to advocate for several different individuals, groups, and organizations.

d. recognize that advocacy can only be provided for individuals, not groups or organizations.

Ans: C

Feedback:

Advocacy is helping others to grow and self-actualize. The manager must be an advocate for patients, subordinates, and the nursing profession. The remaining statements are not accurate descriptions of the manager's role as advocate.

The nurse-manager is overseeing the care of a client who is taking a passive role in his care. How should the nurse begin to act in the role of an advocate?

a. Inform the client of his rights and help him to understand them

b. Teach the client the benefits of taking an active and assertive role in his care

c. Assess the size and quality of the client's social support network

d. Role-play with the client in order to teach him assertiveness skills

ANS: A

Feedback: The advocate informs others of their rights and makes certain they have sufficient information to make decisions. This contextualizes any further teaching or dialogue, such as role modeling or educating him about the benefits of being more assertive. As well, not every client has the desire or skills necessary to be assertive and an active participant in care. It is important to assess clients' social support networks, but this is not directly related to advocacy.

Even after a lengthy discussion concerning the ramifications, a client wants to leave the hospital against medical advice (AMA). What should the nurse do in the role of client advocate?

a. Instruct the client to wait until morning to leave the hospital.

b. Ask family members to help talk the client out of the decision.

c. Encourage the client to leave and assist with the transition.

d. Make sure the client has appropriate follow-up appointments.

ANS: D

Feedback: As advocate for this client, it is important to make sure the client is informed of the ramifications of leaving AMA; however, it is a client's right to refuse treatment. However, this does not mean that the nurse is obliged to actively encourage the client to leave, which would be inappropriate. The nurse should dialogue with the client about the risks of leaving but avoid making the decision for the client or coercing the client to stay.

A nurse-manager is reviewing the provisions of the Consumer Bill of Rights and Responsibilities (Patient's Bill of Rights) with a group of new nurses. The manager should address what goals of this legislation? Select all that apply.

a. Ensuring every client has access to quality, affordable health care

b. Promoting strong relationships between clients and health-care providers

c. Promoting clear communication between members of the health-care team

d. Helping clients feel confident in the health-care system

e. Assisting clients with understanding the provisions of their health insurance

ANS: B, D

Feedback: The provisions of the Patient's Bill of Rights are threefold: (a) to help patients feel more confident in the US health-care system, (b) to stress the importance of a strong relationship between patients and their health-care providers, and (c) to stress the key role patients play in staying healthy by laying out rights and responsibilities for all patients and health-care providers. This legislation does not explicitly address access to health care, communication in the health-care team, or teaching clients about their insurance.

The nurse-manager can implement workplace advocacy and subordinate advocacy by performing what actions? Select all that apply.

a. Creating an atmosphere that is free of violence or the threat of violence

b. Providing education about injury prevention and safety

c. Making efforts to ensure that nurses have reasonable and predictable work schedules

d. Including nurses in the decisions that must be made at the facility

e. Encouraging clients to provide feedback about the care they provide when they are discharged

ANS: A, B, C, D

Feedback: Workplace and subordinate advocacy includes such actions as preventing violence, promoting safety, creating workable schedules, and including nurses in the decision-making process. Asking clients to provide feedback about their care may be helpful in promoting good practice, but this does not directly relate to subordinate advocacy or workplace advocacy.

A nurse has become dismayed at repeated instances of false documentation in the health-care organization. The nurse has become aware that documentation has been altered so that acts of negligence appear to be accidents. When preparing to blow the whistle on this behavior, the nurse should:

a. attempt to edit the false documentation so that it is more accurate.

b. resign from the health-care facility to reduce the risk of retaliation.

c. seek permission from the nurse's immediate supervisor and head of the organization.

d. carefully document any prior attempts to address the issue with supervisors.

ANS: D

Feedback: Before whistleblowing, the nurse should carefully document any prior attempts to resolve the situation. It is unrealistic to expect supervisors to support whistleblowing, which is only necessary when the normal chain of authority has failed to respond to an issue. The nurse may eventually be forced to resign, but this is not a precondition for whistleblowing in every situation. Attempting to edit documentation may set the nurse up for legal consequences.

Which statement is true regarding political action committees (PACs)?

a. They attempt to persuade legislators to vote in a particular way.

b. They are composed of volunteers who are interested in politics.

c. Their focus is usually on defeating specific pieces of legislature.

d. They appear to have less influence on lawmakers than in the past.

ANS: A

Feedback: PACs attempt to persuade legislators to vote in a particular way. Lobbyists of the PAC may be members of a group interested in a particular law or paid agents of the group that wants a specific bill passed or defeated. Currently, PACs appear to have a significant amount of influence on lawmakers and the legislative process. There is no evidence that their influence is waning.

A nurse is deeply concerned about a proposed piece of legislation. Which action will best influence a local legislator who will be voting on the legislation?

a. Signing an online petition

b. Phoning the legislator's office repeatedly

c. Writing a succinct, personalized letter to the legislator

d. Forwarding the legislator online articles that related to the legislation

ANS: C

Feedback: Personalized letters can have a significant influence on a legislator, likely more so than telephone calls. It is not normally possible to outline one's ideas in a telephone message and a nurse cannot provide any detail by signing a petition. E-mail forward is very likely to be ignored and not opened

A nurse is preparing for a television interview to address an aspect of health care. What actions should the nurse perform? Select all that apply.

a. Being focused on key points

b. Introducing statistics that support the key points

c. Repeating key points several times during the interview

d. Providing background material related to the key points

e. Using technical vocabulary to ensure precise communication

ANS: A, B, C, D

Feedback: The best strategies for a television interview are to be prepared and to stick to three or four key points that will drive home your message and repeat them during the interview. Concentrating on popular points is not necessarily where the focus should be directed. It is best to avoid technical jargon because it will be not be understood by most people.

Which statement is true concerning political action of nurses?

a. Political action is often contrary to codes of ethics.

b. Political action mainly takes place through the American Nurses Association (ANA).

c. Nurses' primary focus is to speak out on consumer health-related issues.

d. Nurses have not yet recognized the full potential of political activity.

ANS: D

Feedback: As a whole, the nursing profession has not yet recognized the full potential of collective political activity. Political action is not contrary to ethical practice and may in fact support it. The ANA is not the main venue for political action among nurses, which can take many forms. Nurses can speak to many aspects of health care and the nursing profession, not only consumer issues.

Which leadership role is most closely associated with advocacy?

a. Creating a climate where advocacy and its associated risk taking are valued

b. Giving subordinates and clients adequate information to make informed decisions

c. Ensuring that the workplace environment is safe

d. Seeking appropriate consultation when advocacy results in intrapersonal or interpersonal conflict

ANS: A

Feedback: A leadership role associated with advocacy is to create a climate where advocacy and its associated risk taking are valued. Management functions include giving subordinates and clients adequate information to make informed decisions and seeking appropriate consultation when advocacy results in intrapersonal or interpersonal conflict. Workplace safety is more closely aligned with a management role than a leadership role

The manager of a community health center is committed to acting as an advocate. What action by the manager best promotes this goal?

a. Taking prompt action when working conditions appear unsafe

b. Seeking formal and informal interactions with the media

c. Communicating a vision that advocacy is something highly valued in the organization

d. Pushing for the creation of a binding, national Bill of Rights for Patients

ANS: A

Feedback: A management function associated with advocacy is taking prompt action when there is a lack of safety in the workplace. Leaders generally interact with the media more than managers do, and communicating vision is more closely aligned with a leadership role. Similarly, advocating for a national Bill of Rights for Patients is more closely aligned with leadership than management.

The nurse is working with a client who has a terminal diagnosis and who is facing difficult decisions around end-of-life care? How can the nurse best advocate for this client?

a. Teach the client how to make an effective decision.

b. Offer to facilitate a referral to social work or spiritual care.

c. Arrange for the client to meet an individual who has faced the same decision.

d. Ensure the client receives all the necessary information to make an informed choice.

ANS: D

Feedback: The main advocacy role for nurses involves giving clients all they need to make informed decisions. Teaching the client how to make a decision is likely to be perceived as paternalistic. Referrals may be helpful for the client, but this does not advocate for the client's need to make a decision. Introducing a client to another client in similar circumstances can be ethically challenging and may or may not be perceived as helpful.

Which characteristics associated with being a client of the health-care system increase the need for advocacy? Select all that apply.

a. Loss of physical freedom as a result of extended hospitalizations

b. Decreased independence due to physical or psychosocial limitations c. Loss of legal rights due to being a client in a health-care facility

d. Physical or psychosocial limitations negatively impacting autonomy

e. Increased vulnerability due to impaired communication

ANS: A, B, D, E

Feedback: Patient advocacy is necessary because disease almost always results in decreased independence, loss of freedom, and interference with the ability to make choices autonomously. In addition, aging, as well as physical, mental, or social disability, may make individuals more vulnerable and in need of advocacy. Admission to a health-care facility does not result in a loss of legal rights.

Which are common areas requiring nurse-client advocacy? Select all that apply.

a. Maintaining current licensure

b. Securing client informed consents

c. Preventing medication errors

d. Facilitating access to health-care services

e. Promoting respect for client dignity and cultural values

ANS: B, C, D, E

Feedback: Common areas requiring nurse-client advocacy include inadequate client consents, medical errors, access to health care, and respect for client dignity and cultural values. Although nurses must maintain current licensure, this does not involve client advocacy.

The nurse-manager of a hospital unit has set a goal of increasing client advocacy. What activities are likely to help the manager attain this goal? Select all that apply.

a. Staffing the unit with a sufficient number of care providers

b. Orienting staff on the safe use of a new mechanical lift

c. Providing an in-service on culturally meeting clients' end-of-life needs

d. Arranging for a client to have a meeting with a member of the financial office

e. Organizing an equitable system for distributing vacation time to staff

ANS: A, B, C, D

Feedback: Common areas for managers to advocate for clients include distribution of resources, use of technology, end-of-life decisions, and health-care reimbursement. Issues around scheduling and vacation are areas where the manager could advocate for subordinates, but this matter has little direct impact on clients.

The nurse is reviewing the provisions of legislation that relates to nursing practice in the jurisdiction where the nurse provides care. The nurse should identify what primary purpose of this legislation?

a. Protecting clients' rights and safety

b. Organizing the overall structure of the health-care system

c. Promoting a unique role for nursing in promoting wellness

d. Ensuring nurses provide care that is ethical and moral

ANS: A

Feedback: The legislative controls of nursing practice primarily protect the rights of clients. Legislation is not primarily aimed at organizing the health system, which is an administrative role, not a legislative function. Legislation is not aimed at promoting the role of nursing. Ethical practice is addressed primarily by codes of ethics, not binding legislation.

A nurse feels strongly that a proposed piece of legislation would be contrary to the interests of clients. How can the nurse most effectively oppose this legislation?

a. Address the issue on social media sites as often as possible.

b. Send e-mails to legislators' offices expressing concerns.

c. Collaborate with a group of professionals who feel the same way.

d. Contact media outlets and ask to be interviewed

ANS: C

Feedback: Collective action is generally considered to be more effective than individual action. E-mails are easy to ignore and are less effective than personalized letters. Addressing the issue on social media may make more people aware of the issue, but it may or may not result in action change. Media outlets normally initiate interest in news interviews; they rarely respond to people's requests to be interviewed

The Genetic Information Nondiscrimination Act (GINA) protects which individual from discrimination?

a. A client who has chosen genetic testing for her child

b. A client who has received gene therapy

c. A client who has been diagnosed with a health disorder that has a genetic component

d. A client who is known to have a genetic predisposition to a disease

ANS: D

Feedback: Some legally binding legislation has been passed to safeguard vulnerable populations. One such legislation, the Genetic Information Nondiscrimination Act (GINA), is a federal law passed in 2008, making it illegal for health insurers or employers to discriminate against individuals based on their genetic information

A nurse is involved in a challenging clinical situation which requires the nurse to consider many people's interests. How can the nurse best implement Standard VII of the American Nurses Association (ANA) Scope and Standards of Practice?

a. Allow the client to read the documentation about the situation.

b. Seek legal advice promptly.

c. Advocate for the organization's interests above those of individuals.

d. Carefully consider the ethical aspects of the situation.

ANS: D

Feedback: Standard VII of the American Nurses Association (ANA) Scope and Standards of Practice (2015) states that the registered nurse practices ethically. Consequently, this standard is more closely related to issues around ethics than issues around documentation or legality. It is simplistic and inaccurate to presume that the organization's interests always supersede the individual's interests.

Which nursing intervention demonstrates attention to the nursing values central to client advocacy? Select all that apply.

a. Assuring clients that their wishes will be respected regarding the care they receive

b. Reassuring the client that he or she will always make the right decision

c. Identifying the client's religious dietary practices when discussing a prescribed diet

d. Answering the client's questions regarding the alternatives to a proposed procedure

e. Suggesting to a client that a social services consult would help with discharge needs

ANS: A, C, D, E

Feedback: The nursing values central to advocacy emphasize caring, autonomy, respect, and empowerment. Telling a client that she will certainly make the right decision is false reassurance, which is not a valid form of advocacy.

Which strategy best demonstrates an understanding of the managers role as an advocate for his or her subordinates?

a. Posting a copy of the code of ethics in the staff room

b. Addressing an employee's high rate of absenteeism

c. Establishing friendships with as many of the nurses as possible

d. Working with primary care providers to expand standing nursing orders

ANS: D

Feedback: Promoting nurse autonomy in the form of increased standing orders is an example of advocating for subordinates. Publicizing the code of ethics may be beneficial for nurses but does not advocate on their behalf. In the same way, a manager is being responsible by addressing absenteeism, but this is unlikely to entail an advocacy role. The manager should seek professional relationships, not friendships.

What action by the manager of a community health center best demonstrates workplace advocacy?

a. Phoning the home of a nurse who has called in sick to confirm that the nurse is genuinely ill

b. Asking clients to provide feedback on the care that they have received in their homes

c. Ensuring nurses have all the personal protective equipment they need to perform home visits

d. Assigning a different nurse to a client who had personality differences with his original nurse

ANS: C

Feedback: Ensuring the safety or workers is one of the major demonstrations of workplace advocacy. Checking on a nurse who states that he or she is sick is likely to be perceived as an act of mistrust, not of advocacy. Asking for clients' feedback and assigning a client a new nurse are suggestive of client advocacy, not workplace advocacy

A nurse is concerned about the implications of a new piece of legislation that is being debated by lawmakers. The nurse has decided to draft a letter to a legislator and should do what actions? Select all that apply.

a. Self-identify as a constituent in the first paragraph.

b. State the reason for writing in the second paragraph.

c. Sign the letter and include contact information.

d. Address the legislator by his or her title.

e. Hand deliver the letter to the legislator's office, if possible.

ANS: A,C,D

Feedback: The nurse should be sure to address the legislator properly by title and establish credibility early in the letter as both a constituent and a health-care expert. It is best to state your reason for writing the letter in the first paragraph and refer to the specific bill that you are writing about. Then, state your position on the issue and give personal examples as necessary to support your position. Personal letters are more effective than other formats, but there is no reason to hand delivery the letter to the legislator's office.

A nurse-manager has been asked to write an article for the newspaper addressing a health-care issue of local concern. Which statement demonstrates the nurse's understandings of the appropriate way to respond to such a request? Select all that apply.

a. "I'll include the latest data on the subject."

b. "When will you need to have the final draft of my article?"

c. "Are you comfortable with me focusing on three key points related to this topic?"

d. "That isn't my field of expertise but I will contact a peer with that knowledge."

e. "Working with the media is outside my scope of practice, but I'll recommend you to someone else."

ANS: A, B, C, D

Feedback: Tips for effective interaction with the media include respecting and meeting their deadlines, having key facts ready to include, limiting key points to two or three, and not being afraid to say you lack that specific expertise. Working with the media is not something that is beyond the nursing scope or practice

The nurse is admitting a new client who is facing a serious health problem. The nurse can best apply the skills of advocacy when working with this client by:

a. seeking opportunities to demonstrate professionalism.

b. engaging closely and genuinely with the client and family.

c. making decisions for the client and family in order to lessen their responsibilities.

d. providing evidence-based care.

ANS: B

Feedback: Engagement has been identified as a key factor in advocating for clients and families when they are in the health-care system. Demonstrating professionalism and providing evidence-based care support good outcomes and may put the client and family at ease, but these actions do not necessarily demonstrate or promote advocacy. The nurse should always support the family's decision-making process rather than taking on this role.

A client has been diagnosed with a degenerative neurologic disease and has expressed interest in physician-assisted suicide. How should the nurse best advocate in this situation?

a. Document the client's statements verbatim in the medical record as a resource for the care team.

b. Clearly explain the moral and ethical implications of physician-assisted suicide.

c. Implement interventions that directly address the client's fear and anxiety.

d. Ask the client and family questions that help them identify and explore their values and beliefs.

ANS: D

Feedback: Providing the client and family with the tools necessary to make an informed decision is the best demonstration of client advocacy. Documentation is important in this situation, but this action does not necessarily demonstrate advocacy. The moral implications of physician-assisted suicide must be identified by the family rather than provided by the nurse; these are subjective and this will be part of the family's decision-making process. The nurse should avoid presuming that the client is fearful and anxious. This may not necessarily be the motivation behind the client's request

For which client would right to die laws most likely apply?

a. An adult client with major depression

b. An adult client who has a terminal diagnosis

c. A client who lives with intractable pain

d. A client who has expressed suicidal ideation

ANS: B

Feedback: Typically, right to die laws apply only to patients who are at least 18 years old, with the capacity to make medical decisions, with a terminal disease expected to result in death within 6 months. Depression and pain are not normally considered to be terminal diseases, and suicidal ideation in and of itself does not mean that this legislation would apply.

A nurse has accepted a new position as the manager at an ambulatory clinic. The nurse can best model subordinate advocacy in this new position by:

a. abolishing formal performance reviews.

b. increasing the number of part-time employees and reducing the number of full-time employees.

c. adopting a laissez-faire leadership style.

d. encouraging employees to participate in decision making.

ANS: D

Feedback: Collaborative decision making is associated with subordinate advocacy. However, the manager does not need to abolish rigorous practices (such as performance reviews) or adopt a laissez-faire style of leadership in order to promote subordinate advocacy. Doing away with full-time positions in favor of part-time positions is unlikely to be accepted as an example of advocacy; this will likely be perceived as threatening.

A nurse is distressed by some of the examples of substandard care in the workplace and is considering whistleblowing. What is the nurse's best initial action?

a. Seek contacts in the local media.

b. Inform the manager of the nurse's intent.

c. Carefully consider the possible ramifications of whistleblowing.

d. Hire an attorney to assist with the whistleblowing process

ANS: C

Feedback: Before taking action, it is important for the nurse to consider the possible ramifications of whistleblowing, which could be serious. This must precede efforts such as hiring a lawyer or contacting the media. Depending on the circumstances, it may be inadvisable to dialogue with the manager before whistleblowing.