Interventions in environmental health problems often require nurses and other health care professionals to assume the roles of advocate, activist, and policy planner on behalf of a single patient or population of patients. Patient advocacy within the health care setting is familiar to most, if not all, nurses; for example, bringing a patient's concerns to the attention of the physician. However, advocacy that goes beyond the health care system is a new kind of activity for many nurses, who may feel ill equipped to translate research and practice issues into health policy terms.
Most nursing professionals are comfortable with the idea of case advocacy on behalf of an individual patient, even when it involves aggressive action in the interests of the patient. Where ambivalence occurs is over policy-level (class) advocacy aimed at changing environmental conditions that are detrimental to populations of patients. For some members of the profession, the latter kinds of activity will seem unprofessional, overly political, and inappropriate for nurses. Others will regard it as an expression of nursing's true mission, going back to the profession's origins as crusaders for social justice, as embodied in the practice Florence Nightingale and Lillian Wald. Nurses interested in advocacy practice will find many pressures and incentives encouraging them to define this activity around the needs of individual patients. Policy-level advocacy for structural change is not emphasized in nursing education, not fully legitimized by the field's professional associations (although it is popular among student members), and not welcomed by the majority of employers and hospital administrators. In the area of environmental health, however, nurses are likely to be drawn into a fuller range of advocacy activities whether they are prepared for these roles or not. Therefore, the issue is not whether to undertake policy advocacy, but rather how to do it in a way that is sophisticated, realistic, and constructive. Anxiety about advocacy roles can be lessened considerably by building familiarity with a wider range of advocacy techniques, not all of which are necessarily adversarial.
There are many ways to conceptualize and practice advocacy in health and human services, and there are many heated debates about what true advocacy means. Different starting premises are possible. For example, who determines what is needed: the professional or those directly affected? Should professionals acting as advocates aim simply to solve the current problem, or should they, in addition, try to empower patients and communities to solve similar problems for themselves in the future? Is public conflict something always to be avoided in advocacy efforts, or is it sometimes useful? In thinking about such questions, nurses can draw on literature from other professional fields with advocacy dimensions such as social work, city planning, education, public health, law, and mediation. Based on a review of advocacy literature, Appendix F presents some useful conceptual frameworks for understanding different forms of advocacy and different advocacy strategies.
Advocacy that goes beyond helping an individual patient and enters the realm of health policy is not yet acceptable and expected practice for all nurses. To prepare the profession for a broader range of advocacy activities, nursing curriculum and continuing education programs may come to include content on lobbying, use of media, mediation, expert testimony, community organizing, and the like. In the meantime, whether with institutional support or on their own, nurses who are stretching the definitional boundaries of advocacy practice will need to build skills that were likely not part of their basic nursing education. Appendix F lists some of the self-training and support resources available for health and human services professionals interested in advocacy practice at the policy level.
The goal of nursing staff development programs is safe, competent practice. Comprehensive programs provide the critical resources to support and promote practice. In addition, professional nursing standards of practice, health care laws, regulations, and accreditation requirements focus on the components of competent patient care to protect the health care consumer. The establishment of a staff development program that is linked to clinical practice is key to the success of professional nurse development.
Critical care staff development programs can be designed to educate staff nurses within the competencies of the synergy model.1 The program builds on the nurse’s prior education and professional nursing experience, which facilitates attainment and maintenance of competence. Concepts intrinsic to the educational process and to critical care nursing are used as a framework around which professional development opportunities are organized. Once defined on the basis of a unit’s patient population, the organizing framework serves as the structure within which all critical care nursing staff development programs are designed.
Technical training alone is no longer sufficient to meet the care delivery needs of the nurse in the critical care environment. Critical care nurses require broad knowledge and expertise in areas such as communication, critical thinking, and collaboration.9 They need to attain the diverse skills necessary to meet the complex needs of their patients and families.
The theory and science required to meet the synergy competencies includes topics such as disease processes, nursing procedures, cultural differences, moral and ethical principles and reasoning, research principles, and educational learning theories. This information can be presented through a variety of methods, including lectures, written information, posters, self-studies, or computer-based technology. However, it is essential that the information be related to realistic clinical situations. Clinical scenarios, case studies, and simulations that represent the dynamic and ambiguous clinical situations nurses encounter daily are most effective.25
Bedside teaching is particularly helpful in the development of clinical judgment and caring practice skills. Expert nurses are role models for many of the competencies delineated by the synergy model. Novice nurses learn by watching these expert nurses and emulating their behaviors. Clinical teaching also enables the novice practitioner to gain experience with unfamiliar interventions in a safe and protected environment. Communicating and validating clinical knowledge focuses learning, positively affects patient outcomes, and adds to the total body of nursing knowledge.25
Information about research and research utilization builds clinical inquiry and system thinking skills. Demystifying research, outcome, and quality processes contributes to the development of these key skills. Use of journal club formats and supporting staff involvement in research develop clinical inquiry skills. Building knowledge in the areas of health care trends and political action expand system thinking skills. Development of critical thinking skills and problem solving skills also assists with development of system thinking.
Nurses acquire facilitation of learning skills by incorporating communication development into their professional development plan. Presenting clinical teaching strategies and helping staff to determine learner readiness and assess understanding are included in the development of facilitation of learning. The importance of developing patience, flexibility, and a nonconfrontational style is reinforced.
Negotiation, conflict resolution, time management, communication, and team building are components of collaboration skills. Role playing, role modeling, and clinical narratives are methodologies that have been used to develop collaboration skills.
Nurses learn technical skills and scientific knowledge in many ways, but caring practices and advocacy are developed only through relationships that evolve over time.26 Nurturing professional relationships with experienced staff promotes the novice’s integration into practice. Expert nurses who share their clinical knowledge and coach other nurses have a tremendous impact on novice nurses. Nurses who coach are in their roles because they are able to clinically persuade and guide situations. They demonstrate expert skills and expedite the ongoing clinical development of others.
A variety of staff development programs exist, but most fall into three general categories: orientation, in-service education, and continuing education programs.
Orientation programs help acclimate new staff to unit-based policies, procedures, services, physical facilities, and role expectations in a work setting. A specific type of orientation program that has developed in response to the nursing shortage is the critical care internship program. These programs have been developed as a mechanism to recruit and train entry-level nurses. They are designed to integrate nurses with little or no nursing experience into the complex critical care environment. They provide extended clinical support for novice nurses and introduce new knowledge more deliberately than do traditional orientation programs. Basic information and skill acquisition are the core features of these programs. This foundation builds on the knowledge and skills that these nurses previously acquired in their nursing school programs. Teaching usually is under the direction of a hospital educator and generally involves less senior staff as preceptors. Typically, the novice nurse starts with providing care to the least complex patients. The program establishes a foundation on which the novice can develop into a competent clinician.25
AACN has recently released the Essentials of Pediatric Critical Care Orientation program. This program provides a bridge for the knowledge gap between what nurses learn in their basic education program and what they need to develop clinical competence with critically ill pediatric patients. The program consists of an interactive eight-module course that provides case scenarios and practice activities that augment knowledge and lead to improved job satisfaction. This program provides flexibility because it is a self-paced didactic e-learning course that can be incorporated into a blended learning environment, combining traditional educational activities such as preceptorships, discussion groups, workshops, or simulation experiences.
In-service education programs, which are the most frequent type of staff development activity, involve learning experiences that are provided in the workplace to assist staff in the performance of assigned functions and maintenance of competency.27 These programs usually are informal and narrow in scope. They often are spontaneous sessions resulting from new situations on the unit in settings such as patient rounds or staff meetings. Examples of planned in-service sessions are demonstrations of new equipment, procedure reviews, and patient care conferences.
Legislation, regulations, professional standards, and expectations of health care consumers help determine the need for continuing education. Continuing nursing education includes planned, organized learning experiences designed to expand knowledge and skills beyond the level of basic education.27 The focus is on knowledge and skills that are not specific to one institution and that build upon previously acquired knowledge and skills. Examples of continuing education programs include formal conferences, seminars, workshops, and courses.