Tendency of Nurses to Undertake the Role of Patient Advocate

- Nermin Ersoy, PhD*, Ynsaf Altun, MScN, Ayse Beser, MScN.
Department of Medical Ethics and Medical History,
Faculty of Medicine, University of Kocaeli, Turkey
*Kocaeli Üniversitesi Týp Fakültesi,
Deontoloji Anabilim Dalý, 41900 Derince, Kocaeli, Turkey
Fax: +0262.239 44 63

Eubios Journal of Asian and International Bioethics 7 (1997), 167-70.


This study was designed to evaluate nurses' understanding of implementation of patient rights and their tendency to patient advocacy and to test the adequacy of nursing training on ethics. A questionnaire was developed in the light of the literature data and administered to nurses working as bedside care givers at four hospitals in Kocaeli district (a nearby city of Istanbul). 90% (n=277) of nurses working in these four hospitals responded to the questionnaire. A considerable percentage of nurses believe that patients should have the right to receive health care, the right to self-determination, the right to refuse treatment, the right to know everything about him/herself, the right to have access to medical records, and the right to choose to die. This demonstrates that nurses in our country have considerable insight into contemporary nursing issues and are ready to play a role in patient advocacy.

Key words: Patient advocacy, ethics, nursing, nursing care.

Nursing which is regarded as a moral enterprise has undergone changes in its meaning and structure since the early nineteenth century, which saw changes in medical ethics and widening of the nursing field. These changes occurred in the structure and goals of nursing resulted in a contemporary nursing model and led to the concept that care, which is the core of nursing, should be carried out through supporting and protecting the patient's dignity (1-6). Thus, the aim of nursing has been settled as "to improve health and quality of life and to provide a safe and humane care". The primary goal of the nurse-client relationship has been recognized as to promote the well-being and safety of the person (7-12).

With care being the core of nursing, with the main purpose of nursing to provide a humanitarian care by establishing safe environment as well as to improve health and quality of life, the patient is now placed at the center of nursing profession. This dictates providing treatment and care by preserving patient integrity and esteem (7-9,12-17).

With the nursing values and goals established in the mid-1900s, the traditional nursing understanding of nursing as encompassing a physician-centered attitude showing respect to, and obeying the physician has been superseded by a contemporary patient-centered notion consisting of developing a respectful, honest, fair, loyal, brave, conscientious and compassionate attitude to the patient. This innovative nursing understanding has lead to alterations in the structure of nurse-patient relations and to a general agreement that the nurse's primary responsibility is to those people who require nursing care. This contemporary nursing understanding entails ethical responsibility to advocate and protect the rights of patients (7,9,11,18,19).

In addition, compassion which is inherent in care regarded as moral ideal of nursing, has been of help in the transfer of duty to advocate and protect patients' rights to the nurses (2,7,8,13,20). Moreover, anticipated mutual responsibility between a nurse and a patient is regarded as a valid reason for a nurse to undertake patient advocacy. This role has been defined as helping the patient obtain information which will facilitate his/her ability to decide, enabling the patient to reach information sources, and supporting the patient in his/her decisions about him/herself (14-16, 21-24).

From a nursing standpoint, patient advocacy not only involves helping the patient, who has the ability to decide for him/herself, utilize his/her rights, but, in the case of a patient lacking the ability to behave independently, also encompasses communicating, making appropriate decisions, and performing a wide range of duties one of which is having to derive a decision on behalf of the patient without necessarily getting the patient's wishes or participation. In these circumstances, it is important that nurses consider the patient's real needs and wishes and that the patients not be abused (5,9,19,25-27). In making decisions, reliance should be placed not on the nurse's individual opinions and values, but on the patient's values and expectations. It should always be kept in mind that the right to assume responsibility to decide belongs to the patient and his/her family and that it is the responsibility of the nurse to become involved only in supporting the decisions and in helping the patient exercise his/her rights (5,19,20,28). In order that nurses can fulfill this duty imposed by contemporary nursing principles, they should be very well aware of the significance and necessity of patients' rights.

We planned this study to evaluate the extent of implementation of this duty-oriented ethics as to the patient rights and to document the tendency of nurses who are in charge of providing care. We believe that valuable information will be derived concerning nurses' understanding of implementation of patient rights and their tendency to patient advocacy. Thus, we will be able to test the adequacy of nursing training on ethics.

From a functional standpoint, nursing education has not been standardized in many areas in Turkey. Considerable attempts are being made which inevitably will offer a fruitful way forward. At present, nurses are given nursing deontology at all levels of nursing education; however, nursing ethics is given only during postgraduate education. Unfortunately, ethics, philosophy, anthropology, and sociology are not included as independent subjects in the Turkish nursing education system.


This descriptive study was designed to determine the tendency of nurses to implement their roles to advocate patient rights. A questionnaire was developed in the light of data in the literature.

The first part of the questionnaire included descriptive data about nurses including age, levels of education, marital and family status, duration of occupation, and place of work. The second part consisted of 12 statements regarding the nurses' attitude towards the understanding that the patients should exercise rights which are defined in the Patient Bill of Rights (11,28,29) and about their opinions on some professional issues. In order to find out the extent of nurses' agreement with these statements, multiple choices were put forward including "strongly agree with the statement", "agree with the statement", "undecided about the statement", "disagree with the statement", and "strongly disagree with the statement".

In order for the content validity to be determined and the cognitive assessment to be made, the questionnaire first underwent specialist audit; thereafter, a preliminary study was carried out with 20 nurses with various education levels. The questionnaire was then improved in the light of the results obtained and was administered, in February-June 1996, to nurses working as bedside care givers at four hospitals in Kocaeli district (a nearby city of Istanbul). Ninety percent (n=277) of nurses working in these four hospitals responded to the questionnaire. After being enlightened about the study, the nurses were left alone to fill the questionnaire. Data were evaluated by chi-square and Fisher's exact tests using the SPSS statistical package. Individual attitudes of the nurses towards some questions were used as independent variables.

Results and Discussion

We derived information as to the nurses' opinions regarding the issue which rights the patients should be given. We also obtained information about the values to which the nurses gave priority and what ethical issues were intensified in nursing practice. Thus, we provided insight into the maternalistic attitudes and tendency of nurses to implement their roles of patient advocacy.

Most of the respondents (n=107) were at the age group of 20-25 years; nearly half of them (50.7%) were graduated from vocational high school of health; 51.8 percent of nurses were married; 128 (46.2%) of them had children and 41.5 percent of the nurses were in their first years of their profession (Table 1).

Table 1: Nurses' Demographic Profiles (n=277)

Age n %
- 19 26 9.2
20 - 25 107 37.9
26 - 31 53 18.8
32 - 37 48 17.0
38 - 43 38 13.5
44 + 10 3.5

Lysée of Health (Practical nurse) 143 50.7
Under graduate (Practical nurse) 129 45.7
Graduate (Registered nurse) 8 2.8
Post graduate (MSN) 2 0.8

Family status
Married 146 51.8
Unmarried 129 45.7
With children 128 45.4
Without children 154 54.6

Experience (years)
1 - 5 117 41.5
6 - 10 46 16.3
11 - 15 42 14.9
16 - 20 47 16.7
21 - 25 30 10.6
Work place
Izmit State Hospital 125 44.3
Izmit Social Insurance Hospital 92 32.6
Kocaeli Social Insurance Hospital 33 11.7
Kocaeli University Hospital 32 11.3

Table 2 shows the opinions and attitudes of respondents concerning the patients' rights. The majority of nurses (91.7%) believed that health care should be a right for all individuals. This concept depends on showing respect to every individual and encompasses a variety of ethics-laden nursing issues including equality and justice.

85% of respondents believe that the patients should have the right to participate in the decision-making process about their treatment. This finding indicates that nurses are inclined to implement their ethical duty of respecting and protecting the patients' autonomy. Another finding supporting this comment is that 46% of the respondents believe that the patients have the right to refuse treatment. Taking our country's circumstances into account, this rate is of particular relevance. Evaluation of the professional values of respondents who support the patient's right to refuse treatment shows that these nurses give priority to person's autonomy and human dignity.

However, when children are the case, only 12% of the nurses believe that children have the right to participate in the decision-making process. This particular attitude which is mainly determined by the principle of protection from harm appears to be influenced by the nurses' self-sacrifice. We did not find significant relationship between this attitude and the nurses' motherhood, suggesting that nurses have more intense maternalistic attitudes towards children. A study by Pek and Bahçecik also shows evidence of maternalistic attitudes of nurses towards children (23).

Two thirds of the respondents stated that patients should have access to their own medical records. At a time considerable controversy arises as to the patients' access to medical records, this finding reflects that nursing attitudes comply with the contemporary moral principles of medicine. This attitude of respondents was supported by another finding that nearly the same number of nurses (64%) shared the opinion that the patients should always be told the truth. These may have considerable implications in our country because studies performed in the early 90s indicated that only 25% of nurses and 32% of physicians supported the patients' right to be informed about their actual condition (25). Another study performed in the same period revealed that only 15% of surgeons regarded this issue as the patients' right (30). In contrast, 44% of patients in the same study stated that they wanted to be informed about everything about themselves.

Nearly half of the respondents (43%) were in favor of taking quality of life as the basis of maintaining treatment; this reflects the influence of esthetic judgments as well as the nurses' opinion that the patient should have the right to die with dignity. Similarly, 44% (n=122) of respondents stated that an individual has the right to self-determination. We feel that this attitude reflects nursing implications focusing on showing respect to the patient and is influenced by nursing values of protecting the patient's dignity. In addition, nurses in our country seem to give special thought to the principle of "nursing care that promotes human respect and dignity" (27), which is accepted as the first item of the ethical codes of nursing. Thus, these findings suggest that nurses may play a considerable role in helping the patients exercise their rights.

Table 2: Nurses' Attitudes towards Patient Rights (n/% ) (n=277)
Questions ++ + = - --
Do you believe that ............
1. Patients have the right to die?
44 78 88 43 23
(15.9) (28.3) (31.9) (15.6) (8.3)
2. A person has the right to refuse treatment, even if it will hasten his or her death?
43 84 95 43 12
(15.5) (30.3) (34.3) (15.5) (4.3)
3. Patients should always be told the truth?
75 102 72 12 16
(27.1) (36.8) (26.0) (4.3) (5.8)
4. People have the right to participate in all decisions related to their health?
128 106 26 9 8
(46.2) (38.3) (9.4) (3.2) (2.9)
5. Proposals to allow members of the health professions to actively end an imminently dying person's life on his/her request should be opposed by nurses and physicians?
57 79 84 44 13
(20.6) (28.5) (30.3) (15.9) (4.7)
6. You will donate your organs after death?
43 90 70 23 51
(15.5) (32.5) (25.3) (8.3) (18.4)
7. Severely impaired newborns should be allowed to die?
42 65 81 61 28
(15.2) (23.5) (29.2) (22.0) (10.1)
8. Children should be allowed to make their own treatment decisions after the age of seven?
10 24 128 107 8
(3.6) (8.7) (46.2) (38.6) (2.9)
9. Health care is a right?
174 80 6 10 7
(62.8) (28.9) (2.2) (3.6) (2.5)
10. Quality of life should be the criterion for making a decision concerning discontinuing treatment?
52 68 67 71 19
(18.8) (24.5) (24.2) (25.6) (6.9)
11. Patients have a right to examine their health record?
63 119 62 18 15
(22.7) (43.0) (22.4) (6.5) (5.4)
12. Nurses are independent professionals?
125 53 51 41 7
(45.1) (19.1) (18.4) (14.8) (2.5)
++ Strongly agree with the statement
+ Agree with the statement
= Undecided about the statement
- Disagree with the statement
-- Strongly disagree with the statement
Another striking finding is that almost half of the respondents (49%) stated that physicians and nurses should be allowed to implement the management of euthanasia in accordance with the patient's wishes. This is in sharp contrast with the common public opinion that, on moral and religious grounds, every one of the health care professionals in Turkey would be reluctant to perform active euthanasia, even if they receive requests from patients to hasten their deaths. These findings suggest that nurses give particular importance to the principle of showing respect to the patient and to the value of protecting the patient's dignity. They have a tendency to recognize and carry out the duty of patient advocacy, which is regarded as one of the requisites of contemporary nursing.

Another controversial issue in our country is as to whether newborns with severe disability should be given intensive care or not. This attitude, which is in potential conflict with public opinion, was regarded as convenient by 39% of respondents, whereas 29% of respondents abstained on the subject. Like nurses who stated that quality of life should be taken as a basis for the maintenance of treatment, these nurses supporting the death of severely disabled newborns accept an esthetic and dignified life as the fundamental value.

The finding which lead us to conclude that nurses consider the benefits of the community is that 48 percent of the respondents wished their organs to be used after their death. We feel that both the principle of usefulness and the value of self-sacrifice play a role in this determination. Although we could not find a significant difference between being in favor of patient rights and the respondents' personal features, we noted significant difference between the belief that nursing is an independent profession and the institution in which she worked (p<0.01).

Most of the respondents (64%; n=178) stated that nursing is an independent profession. This finding can be considered somewhat unfavorable as regards the remaining responses and it shows us that nursing education on ethics should be reconsidered. In addition, our observation that the belief that nursing is an independent profession varied from institution to institution is important in that it reveals the differences in nursing understanding and in providing nursing care between the hospital types.


It is our expectation that the results of this study will contribute to one of the most discussion-bearing issue of how patients' rights will be put into practice in Turkey. It also demonstrates the positive role of nurses in acknowledging patients' rights. Our study revealed that a considerable percentage of nurses, which is more than that anticipated, believe that patients should have the right to receive health care, the right to self-determination, the right to refuse treatment, the right to know everything about him/herself, the right to have access to medical records, and the right to choose to die. This demonstrates that nurses in our country have considerable insight into contemporary nursing issues and are ready to play a role in patient advocacy. However, a smaller percentage of nurses still pursue some maternalistic attitudes, especially when children are the case, as regards giving full support to patients' rights.

Wide acceptance (n=122) of the patient's right to die prompts us to develop a personal and moral/ethical stance and policy in relation to euthanasia and to establish some ethical values. The results of this study is promising in that Turkish nurses will continue to provide nursing care which, at the same time, complies with contemporary nursing understanding; however, they also show that nursing training on ethics needs to be restructured and reconstructed.


The authors wish to thank members of Ekin Ltd. for secretarial work of this manuscript.

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