The Sphere of Advocacy Model

Patient advocacy is essential to the scope of nursing practice. When caring for different populations, knowledge about key issues can facilitate a better understanding of the importance of advocacy for all, but especially for the most vulnerable. It is therefore importiant to address the disparities that exist between different racial and ethnic groups—disparities that are a result of policies that discriminate against people of color indirectly. The purpose of this paper is to use the Sphere of Advocacy Nursing Model as a guide to explore the underlying causes of maternal health disparities as well as mental and behavior health disparities across racial and ethnic groups-differences that demand attention, accountability, and the advocacy that is greatly need, yet lacking, for disadvantaged populations on an institutional level.

The term “health disparity” refers to a higher burden of illness, injury, disability, or mortality experienced by on group relative to another (Artiga & Oregra, 2018) (Olden, 2011). Although disparities in health care arise due to several intertwined factors such as social determinants of health, issues of social justice and equity are believed to be the primary cause. According to the Centers for Disease Control and Prevention (CDC), black women are more than three times more likely than their counterparts to die from pregnancy-related causes, regardless of their income levels. (Monahan, 2012). Within the same collection of data, it highlights that only 54% of black babies have ever been fed breast milk compared to the 74% for white babies, 50% for Latino babies, and 81% of Asian American babes (Monahan, 2012). The broad issue at hand is that minorities tend to receive decreased quality care, as well as access to quality care when compared to their more privileged counterparts, even when access-related factors, such as insurance status and income, are controlled. The health care system as a whole continues to allow its past and present policies to perpetuate structural racism and inequality, and it is the lack of advocacy for a shift in these policies that have allowed these oppressive systems to continue.

Furthermore, reaserch states that racism exists at multiple levels, ranging from individual to structural, and the metaphor of the iceberg is used to describe these levels within the health care system (Carmichael & Hamilton, 1967) (Jones, 2000). The tip of the iceberg represents acts of racism that are mediated by individuals and are easy to see and recognize. The second section below the tip is underneath the water; this represents structural racism – which is easier to ignore and more dangerous and detrimental to black bodies in interactions with the system (this is because structural racism is hard to eliminate). The term “structural racism” refers to the levels of society that possess the most power to influence ethnic health inequities (Bonilla-Silva, 1997). Policies and interventions put in place to eradicate the tip of the iceberg do little to change what is hidden under the surface, that being the structural inequities that have remained intact throughout history. What makes it an irretractable force is that it is constantly reconstructing it’s the elements necissary to ensure its perpetuation (Link & Phelan, 1995). These problems call upon our professional obligation as nurses to protect the people vulnerable to harm, and expose the systems that perpetuate this structural oppression.

In addition to this obligation to protectm advocacy can be defined broadly as an integral part of care that strives to inform and support an individual’s health care decisions – more specifically, exercising your voice and power to influence policy and practice (CNA, 2010) (Kohnke, 1982). It seeks to ensure that individuals who are most vulnerable have their voices heard on issues of importance to them, and are given the oppurtunity to defend their rights and wishes about decisions being made on their behalf. The concept encourages that people have access to the information and services they may require to explore their health care options.

In regards to health care, nurses exist as forerunners in the defense of patient rights.  The primary need for advocacy stems from the vulnerability of the patient, which affects their power in the situation and control of their own health. This can be a result of a physical illness that renders them incapable of self-advocacy, or disparities in health care that were a result of inequity, or structural and institutional barriers such as prejudice and racism. It is the nurse’s responsibility to be aware of the implications that one’s culture and ethnicity have on their experiences as patients, as well as how to use advocacy to affect change against these potential barriers. This includes recognizing patterns such as inequity and inequality that threaten to undervalue the voices of populations most vulnerable.

Patient advocacy in the context of nursing theory is defined as  “A process or strategy consisting of a series of specific actions for preserving, representing and/or safeguarding patient’s rights, best interests and values in the health care system” (Jezewski & Bu, 2006). The Sphere of Nursing Advocacy (SNA) model stresses the importance of nursing advocacy on behalf of the client. The key concepts include the nurse and the external enviornment surrounding the patient or sphere. It stresses the importance of professional nursing values such as altruism, autonomy, human dignity, integrity, and social justice by placing the client at the center of the model, with the nurse as protection from the external enviornment in situations of vulnerability. In addition, this protective sphere is semipermeable, allowing the client to advocate for themselves when circumstances permit the physical and emotional ability to do so (Hanks R. C., 2005). It allows nurses to provide the support needed when interacting with the quietest voices, and at the same time, provides a safe space for individuals to express and embrace their wishes and values.

The practices of advocacy in professional setting do however come with its own challenges, especially in regards to speaking in favor of the client against the health care system. It breeds the oppurtunity for backlash from other health care providers, as well as from members within the hierarchy of the institution. The disparities in health care are a direct result of institutional racism (CPHA, 2018). With the basis of institutional racism being white supremacy, it is importiant to recognize the existence of white privilege; an unearned advantage due to race which threatens the value of black and brown individuals in the context of health care (CPHA, 2018). A nurse that recognizes this could advocate for efforts to remove the systems that inexplicitly support racism and white privilege, such as advocating for cultural training to exhibit new behaviors that are not detrimental to black bodies interacting with the health care system. This would all be in hope to eliminate previous damaging behaviors within their own institution. However, they may be subjected to criticism and be labeled as being insubordinate in nature rather than passionate in providing safe health care to disadvantaged populations (CPHA, 2018).

Consequently, this means that there is a certain expectation to be met by caregivers. Nurses have the responsibility to broaden their knowledge about health disparities across different populations. The elements of inequity and privilege we face today were bred by an oppressive institution. It is not enough anymore to practice advocacy at the bedside alone. Eliminating these differences in health status require nurses to advocate for the appropriate health initiatives, community support, and an increased access to quality health care. As a collective, we can start by advocating for a switch in focus with regards to nursing reaserch and curriculum. The health care system possesses the power with regards to delegation of knowledge and curriculum content in the scope of nursing practice. Consequently, the curriculum validates these same rules and regulations in its teachings to students. This includes which patterns in communication are acceptable and unacceptable, which attitudes towards authority are appropriate or inappropriate, and many other racially determined behaviors that are shared and encouraged in nursing practice and spaces of learning for students. Although some of these behavioral guidelines, modes of communication, and ways of thinking are useful, there are many that inexplicitly ignore, discount, or isolate individuals who do not fit within the characteristics of the dominant culture of “whiteness”.

To illustrate this in regards to pain management and delegation of medication for example, I have witnessed instances in a professional setting where a nurse had completely discredited the intensity of the experience of pain of a black woman in her care, because of the preconceived notion that her self advocacy for a stronger medication was due to addiction, a factor which the nurse believed to be common in “people that look like her”. Notions like these are extremely damaging to black people as a whole, as it completely retracts our oppurtunity to optimal health. Prejudices such as this are perpetuated by a system that disguises this mindset as “critical thinking and knowing as a practicing nurse.” These practices are taught to students as an essential part of nursing intuition. However, personal knowing and critical thinking have the potential to be affected by the biases that exist within us. Biases and ways of thinking are taught overtime. It is for this reason that we must advocate for more social justice focused education in the nursing curriculum in the area of pedagogy and practice. Building a culturally rich curriculum can improve academics for minority students who struggle to connect. Samantha Washington, contributor to The Century Foundation in social curriculum stated that evidence is overwelming to support the idea that students who received curriculum that has more diverse elements exhibited less racial prejudice and reported more confidence (Washington, 2018).

Nevertheless, it is the responsibility of all nurses to examine their biases for notions that would indicate possible discriminatory actions within their scope of practice. Moreover, it is importiant to recognize that advocacy is intended for all, however it does not look the same for all. Different racial and ethnic groups require different forms and degrees of advocacy within that community. Advocating for more inclusive reaserch on diverse populations and their health care needs would facilitate more discussion and a better understanding of the issues that exist. We are in need of a curriculum that is more inclusive to issues outside of normative topics. The curriculum must be able to use those same normative elements to connect the dots from these inequities to broader institutional influences—the same influences that have built segregated neighborhoods with fewer hospitals, and that continues to ignore the oppressive systems in place that result in higher incidence of chronic disease due to inadequate care, and unequal access to healthcare (Hanks, Solomon, & Weller, 2018). Similarly, nurses must advocate to include the voices of more black men and women in policy development. Sunshine Muse, founder of Reproductive Justice explained that “when policy development is led by black women, the likelihood that black women’s safety and care will be centered in its words and execution are high” (Muse, 2019). With regards to advocating for policy change, it is not uncommon to be met with resistance. As a black woman, and an aspiring nurse, I have been met with resistance. I am able to confidently recognize these behaviors as a tactic to discount the weight of personal narratives and label them cathartic or self-indulgent. The negativity associated with advocating against a system as powerfully oppressive as that of health care is that it breeds silent advocates who will restrain from speaking out against these issues due to fear of ostracization. A powerful assumption of The Sphere of Advocacy Nursing Model is that “nurses should not doubt their actions for advocating for clients” (Hanks R. C., 2005).

In summary, nurses and other health-care caregivers can no longer feign ignorance to the disproportionate disparities across populations – and a great portion of our responsibility as caregivers means that we must do the work to understand the burden faced by others so that we can provide appropriate care. The individual or institutions with them lost power influence things that matter. Nurses are prided for having a rare element of “caring” compared to other health care providers. The fact that nurses “care” may not be sufficient enough to eradicate disparities between dominant and subordinate populations (Barbee & Porter, 2005). We must start by admitting to unconscious biases, recognizing the privilege in being a white individual in health care, and what that means in terms of the power you hold to advocate for others. For nursing as a whole, this means striving to embrace complexity of advocacy, rather than unity in advocacy that benefits only those with privilege. This includes taking the time to research, understand and embrace the complexity and uncomfortable nature of what it means to be a black individual interacting with the health care system. One can do so through shared experience as well, such as engaging in meaningful conversations with individuals who have lived these burdens on an every day basis. Individuals like myself, whose experiences are often ignored because they are less profound. Yet, as a nursing student, I can admit to experiences of feelings of seclusion and isolation amongst my peers and teachers. The curriculum has never introduced anything explicit about race except that teachings about unity in nursing care is rooted in treating everyone alike. In the same way, when injustice is brought up in conversation, people are perplexed at the idea that racism is still a factor affecting the health care system. People pride themselves on not looking at elements such as the color of skin during interaction, when in reality, it is required to see the color of our skin, recognize what it means, and act accordingly. This is especially importiant in nursing practice. Before we can truly advocate, it is required that we understand which populations are most vulnerable and what they need advocating for. My role as a nursing student has never been clearer. Our activism and advocacy have the potential to directly save lives.

References

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