Min farfar albert karlson, riksdagsman för liberalerna OCH BONDE OCH PASTOR
min främsta förebild
FARFAR SKREV PÅ EN BORGEN FÖR EN SKEPPSREDARE HAN MÖTTE I STOCKHOLM kanske en liberal politiker
ETT FARTYG GICK PÅ EN MINA OCH SJÖNK FARFAR OCH FARMOR FÖRLORADE GÅRDEN
redarfamiljens namn har aldrig nämnts i min familj - det var en hederssak
farfar och farmor HADE FYRA BARN 1-8 år gamla och farfars äldste son, prematurfödd
hederlighet var ett viktigt begrepp i min familj.... man står för det man gör, man är pålitlig
år 2008 förväxlade jag natriumlösningar - vad gjorde jag då? svar: jag anmälde mig själv
år 2009 och 2010 anmäldes jag av läkare för två andra händelser de läkarna hade påstått att jag orsakat en skada 2008, som jag inte tagit på mig ansvaret för. hade jag begått misstag 2009 och 2010? svar: om jag skulle ha gjort det skulle jag ha anmält mig själv...
FEATURE: NEW HORIZONS
Understanding the nurse's role
as a patient advocate
Gerber, Lois MPH, BSN, RN
Nursing2019: April 2018 - Volume 48 - Issue 4 - p 55–58
doi: 10.1097/01.NURSE.0000531007.02224.65
SINCE THE DAYS of Florence Nightingale, patient
advocacy has been an important nursing responsibility. Nightingale laid the
foundation for patient advocacy by consistently insisting on quality of care,
including a safe and clean environment, and basic human rights for all.1-4 Personal
attributes of effective nurse advocates include professional competence,
objectivity, flexibility, empathy, self-motivation, accountability, commitment,
a sense of responsibility, and strong coping skills.5
The American Nurses
Association (ANA) Code of Ethics for Nurses clearly identifies a professional
nursing responsibility to protect the rights of patients.6 State
nurse practice acts may also mandate that nurses act as patient advocates.
Nurses must understand and comply with these professional guidelines.6,7 Blurred
professional boundaries can be problematic in long-term nurse-patient
relationships. Patient advocates must work to keep the relationship therapeutic
and patient-centered.8
Despite a long history, the role of nurses as patient
advocates is poorly understood.2,5 While patient advocacy extends to the broader
social system, this article is limited to the advocacy responsibilities of
nurses providing direct care through hospital and home-care organizations or of
those self-employed as private patient advocates. See https://healthadvocatecode.org for more information on the role.9
The advocacy
role, defined
Advocates defend patients' rights and interests and assure
the safety of those who can't advocate for themselves. This includes patients
who are children, unconscious, mentally ill, illiterate, uninformed, or
intimidated and fearful of healthcare professionals.1,5
Advocates ensure that patients' autonomy and
self-determination are respected. Serving as the link between patients and the
healthcare system, they also contribute to the patient/family decision-making
process and speak up when problems go unnoticed or when the patient or family
can't or won't address them.2,5,7,10
While technology provides many benefits, it also poses
technical, ethical, and communication issues.11 Many patients receive care at various places and
from different providers with only brief contact with the professionals working
with them. Care has shifted from hospitals to ambulatory care facilities, so
patients and families bear more responsibility for their well-being. Many of
them have trouble comprehending information, navigating the healthcare system,
and making appropriate decisions.5,12,13
Patient advocacy extends to the patient's family and
support system, who should be included in the patient's care if done in a
positive way with the patient's consent. Nurse advocates support the patient's
best interests while respecting the family's important role. They attend
healthcare team meetings with the patient and family to clarify any
communication problems and ensure information from the healthcare team is
complete and correct.14
Advocates become facilitators when patients and family
members need to discuss uncomfortable information or explore its implications.
Nurses may sometimes need to advocate for patients against their families. With
conflict, efforts should be made to find a common goal. Communication should be
assertive but not aggressive.6,14
The advocacy process can be complicated and require
in-depth assessment and negotiation to develop a care plan in the patient's
best interests.5,10,12
Four stages
The advocacy process has four stages.
- First is the assessment of needs, which focuses
on the patient, situation, setting, risks, and available healthcare
resources.5 Establishing therapeutic relationships with
patients is essential to understanding their interests and personal
values, which includes what makes them unique and what they want and need
from their healthcare providers. This requires nurses to assess the
patient's level of awareness, cognitive function, and understanding of his
or her patient rights.5,9
Many questions can be included in the needs
assessment. Are the patients aware of their diagnoses, prognoses, and treatment
options? Do they want a second opinion, or do they wish to refuse treatment? Do
they want certain significant others involved in the decision-making process?
What are their cultural and spiritual needs? Have their rights and choices
regarding care been respected?5
- The second step is identifying the patients'
specific goals. Most goals of patient advocacy are aimed at fostering
partnerships between patients, families, and healthcare professionals
while empowering patients in the decision-making process.5 Nurses may need to
translate hospital policies and clinical information into layman's
language as well.11 Nurses can provide information on the
various options recommended by the healthcare team and help patients
practice assertiveness in expressing their wishes.5
Advocates follow the patient's directives, not their
own or the family's. Each patient is an individual with distinct needs; no
single approach fits all.9,11 When patients are ambivalent or reluctant to
explore options, motivational interviewing may help. Nurses using this
technique don't impose their own opinions on the patient; rather, they elicit
and explore the person's beliefs.15 When the nurse accepts a patient's informed
choices, the patient gains a sense of control and improved self-image.5
- The third step is implementing the advocacy plan.
Nurse advocates facilitate communication with all members of the
healthcare team regarding the patient's preferences. They incorporate
patient-identified goals into the plan of care and provide objective guidance.
They support patients by negotiating and compromising when conflicts of
interest arise, maintaining safety and care coordination throughout the
entire course of the illness.5,11
- In the fourth step, nurse advocates evaluate the
outcome of their advocacy behaviors. The ANA Scope and Standards of
Practice suggest evaluations be criterion-based, systematic, ongoing, and
focused on the attainment of expected outcomes. These evaluations should
include the patient, the family, his or her caregivers, and other members
of the healthcare team.6,16
Advocacy in
organizational settings
The healthcare organization's commitment to promoting
nurse-patient advocacy is of utmost importance. Healthcare administrators must
maintain an effective and efficient chain of command. Clinical nurses need to
know where to report concerns and how to access the chain of command. They must
be assured that they have the support of their supervisors and others in
leadership roles.5,7
Without this support in place, as in organizations
lacking a shared decision-making process, nurses may have limited opportunities
to advocate proactively. Nurses who defend patients' interests may be labeled
troublemakers, and their advocacy may be seen as disrespect or disloyalty to
coworkers. Feelings of anger and helplessness may emerge, causing a lack of
motivation and fear of retaliation.5,7
Another barrier is inadequate staffing, leaving
insufficient time for advocacy activities. Nurse advocates may be unsure how to
address an issue, lack knowledge about established advocacy processes, or
display weak assertive communication skills.7,17
Organizations can promote patient advocacy from
within. Experienced nurses can mentor those less comfortable with the role.
Working with physicians as colleagues instead of an
authoritarian presence is another important strategy. All nurses are
responsible to keep patients safe and participate in organizational advocacy
improvement efforts. Continuing-education programs will broaden the nurse's
perspective here.1,7
Private
independent patient advocacy
Private independent patient advocacy is a fast-growing
profession, one very suitable to nurses. These independent professionals are
usually paid directly by the patient or family. Private patient advocacy is an
upcoming business model. Nurses are prime candidates for this role because of
their professional training and focus on quality patient care.18
Information is available for those who want to enter
the practice. Educational resources can be found at www.patientadvocatetraining.com and http://cmsa.org.
Written service contracts with patients and families
are important considerations. Areas to cover include the expectations of both
parties with clear delineation of duties, written releases allowing access to
medical records, physician and patient consents, and payment structure.19
Patients can experience adverse outcomes and other
problems can occur. Therefore, purchasing quality malpractice insurance is a
must to protect nurses from possible legal action. It's relatively inexpensive
and available through many professional organizations. Documenting all
interventions in writing, including communications with physicians and other
healthcare providers, is a must.20,21
Be cautious about transporting clients in one's
personal car, which can be a legal risk. Case managers need proof that their
vehicles are legally licensed, liability insured, and well maintained. Private
patient advocates should contact their insurance companies to ascertain if
commercial auto insurance is needed. A written waiver from the client and
family is another possibility.22
Private patient advocates provide in-depth
personalized care to the patient and family throughout the treatment process.
For example, they help patients select treatment options that best meet their
needs—medically, financially, and practically—so they can comfortably navigate
the healthcare system. Private patient advocates may also do research to ensure
that patients are prepared, informed, and engaged in the treatment process and
have a voice in their care. These advocates may provide hospital bed monitoring
or accompany patients to healthcare appointments. In addition, they review and
negotiate medical bills.23 Their purpose is threefold: providing quality
care, preventing medical errors, and protecting patient rights.24
Independent case managers come from various
professional disciplines.25 Certification isn't currently required for
private patient advocates. However, the Patient Advocate Certification Board
has developed a certification process to board-certify healthcare professionals
working as case managers. Registration is now available for the 2018 exams;
access information at https://pacboard.org. This certification adds to the nurse case manager's
professional credibility.20
Membership in the Aging Life Care Organization,
formerly the National Association of Geriatric Care Managers, is a resource for
nurse case managers working with older adults. Membership in this group
validates the geriatric care manager's education and expertise and is highly
recommended.26
Private patient advocates work with case managers, who
also coordinate care between the patient and the healthcare team. Although
their roles overlap, case managers focus more on the clinical aspects of
treatment and care plan implementation and may have less interest in tasks such
as driving clients to medical appointments or being with them during a hospital
stay. Both work with patients and families to coordinate services and refer
patients to other disciplines and outside community resources, which is especially
important for insurance and financial concerns and complex social problems,
such as domestic violence.5,11,24
Supporting
patient autonomy
At its best, advocacy is proactive behavior that
improves or corrects a situation, rather than a report of something that's gone
wrong.7 Assuring
that patients maintain their autonomy in directing their healthcare is a
challenging nursing role that takes moral courage as well as clinical skill and
knowledge.11
Bonus content!
Head to www.nursing2018.com for more information on motivational
interviewing.
Motivational interviewing for
patients with mood disorders
Motivational interviewing: A
journey to improve health
REFERENCES
1. Walker DK, Barton-Burke M, Saria MG, et al Everyday advocates: nursing
advocacy is a full-time job. Am J Nurs. 2015;115(8):66–70.
2. Davoodvand S, Abbaszadeh A, Ahmadi F. Patient advocacy from the clinical
nurses' viewpoint: a qualitative study. J Med Ethics Hist Med. 2016;9:5.
3. Sanford K. Overview and summary: nurse advocates: past, present, and
future. Online J Issues Nurs. 2012;17(1).
4. Selanders LC, Crane PC. The voice of Florence Nightingale on
advocacy. Online J Issues Nurs. 2012;17(1):1.
5. Choi PP. Patient advocacy: the role of the nurse. Nurs Stand. 2015;29(41):52–58.
6. American Nurses Association. Nursing: Scope and Standards of
Practice. 2nd ed. Silver Spring, MD; 2010.
7. Zolnierek C. Speak to be heard: effective nurse advocacy. Am
Nurs Today. 2012. http://www.americannursetoday.com/speak-to-be-heard-effective-nurse-advocacy.
8. Hanna AF, Suplee PD. Don't cross the line: respecting professional
boundaries. Nursing. 2012;42(9):40–47.
9. Alliance of Professional Health Advocates. The Code of Conduct and
Professional Standards. 2018. https://healthadvocatecode.org.
10. Lampert L. How to advocate for your patient. 2016. http://www.ausmed.com/articles/how-to-advocate-for-your-patient.
11. Jansson BS. Improving Healthcare Through Advocacy: A Guide for
the Health and Helping Professions. Hoboken, NJ: John Wiley and Sons; 2011.
12. Grant V. Advocacy: who's really in charge here. AAACN Viewpoint. 2016;38(3):12.
13. Wolf JA. Patient experience: the new heart of healthcare
leadership. Front Health Serv Manage. 2017;33(3):3–16.
14. Fahlberg B, Dickmann C. Promoting family advocacy. Nursing. 2015;45(8):14–15.
15. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in
Healthcare: Helping Patients Change Behavior. New York, NY: Guilford
Press; 2008.
16. Case Management Society of America. CMSA's standards of practice for
case management. 2016. http://solutions.cmsa.org/acton/media/10442/standards-of-practice-for-case-management.
17. Negarandeh R,
Oskouie F, Ahmadi F, Nikravesh M, Hallberg IR. Patient advocacy: barriers and
facilitators. BMC Nurs. 2006;5:3.
18. Dreher T. The emerging role of patient health advocates. 2015. http://www.nursing.advanceweb.com/Features/Articles/The-Emerging-Role of-Patient-Health-Advocates.aspx.
19. Mullahy CM. Legal responsibilities of case management professionals.
In: Mullahy CM, ed. The Case Manager Handbook. 6th ed. Burlington, MA: Jones
& Bartlett; 2016.
20. Individual malpractice insurance can protect you in case of lawsuits.
Hospital Case Management. 2016. http://www.ncbi.nlm.nih.gov/pubmed/27434942.
21. NURSE.com. Legally speaking: case managers and liability. 2014. https://nurse.com/blog/2014/11/21/legally-speaking-case-managers-and-liability.
22. Insurance Information Institute. Insuring your business: small business
owners' guide to insurance. 2018. http://www.iii.org/publications/insuring-your-business-small-business-owners-guide-to-insurance.
23. Alliance of Professional Health Advocates. An overview of the
profession of patient advocacy. 2017. https://aphadvocates.org/profession-overview.
24. Torrey T. What's the difference between a patient advocate and a
geriatric care or case manager. Alliance of Professional Health Advocates.
2017. http://www.aphablog.com/2010/12/08/whats-the-difference-between-a-patient-advocate-and-a-geriatric-care-or-case-manager.
25. Baltimore County Department of Aging. Taking care of Mom and Dad. 2017. http://takingcareofmomanddad.net/independentliving/descriptionservices/casemgmt.html.
26. Aging Life Care Association. About Aging Life Care. 2018. http://www.aginglifecare.org/ALCA/About_Aging_Life_Care/ALCA/About_Aging_Life_Care/What_you_need_to_know.aspx.
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Copyright © 2018 Wolters
Kluwer Health, Inc. All rights reserved.
(r
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n)
(m
t
v)tv, m-t
v) A motif in art, literature, or music.- vi förväntar oss en belöning – t.ex beröm, erkännande, att må bättre.
- vi försöker undvika bestraffning
- vi hjälper för att andras nöd gör oss oroliga och lustiga och vi vill må bättre
- vi hjälper människor som liknar oss själva i syfte att stärka vår grupp, skapa vi-känsla
1. Raoul Wallenberg. It looked like his goal was to help other people, but in fact what he was trying to do was give himself a more meaningful life.
2. Mother Theresa. Yes, she was helping other people. But the reason she was doing it was to get a really big reward in heaven.
3. David Allsop. He lived modestly in order to send big checks to environmental causes. But he “previously worked as a campaigner . . . and . . . found it deeply satisfying . . . to be able to provide the financial support for others to campaign” (65).
We’ve considered three specific cases. The English philosopher Thomas Hobbes took a more systematic approach. He looked at the general motives people have, and tried to show how all of them can be understood in egoistic terms. Examples:
1. Charity. People who act charitably are doing so only to get the rush that comes from demonstrating their power. Charitable people are “powerful” in the sense that they can take care of themselves and other people.
2. Pity. Sometimes we feel bad for someone and try to help them. According to Hobbes, “the reason we are disturbed by other people’s misfortunes is that we are reminded that the same thing might happen to us” (66). In helping others who we pity, we are, in effect, attempting to help ourselves.
”I den mån vårdaren systematiskt prioriterar sina egna behov och intressen och vårdar för sin egen skull är handlandet själviskt och egoistiskt, även om det har positiva konsekvenser också för patienten. Dessa konsekvenser är då en irrelevant biprodukt i vårdandet.
Jag anser att ingen ska få skriva vårdplaner eller ställa omvårdnadsdiagnoser förrän de arbetat länge under en specialistsjuksköterska med motsvarande funktion som en överläkare/bakjour har.