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For me, this beautiful, rich and energetic country of ours can become a model of the just society in which every citizen will enjoy his fundamental rights.

—Pierre Elliott Trudeau, 1968

Introduction

The Canadian Nurses Association Code of Ethics is meant to guide Canadian nurses throughout their nursing practice. According to that code, “Nursing ethics is concerned with how broad societal issues affect health and well-being. This means that nurses endeavour to maintain an awareness of aspects of social justice that affect the social determinants of health and well-being and to advocate for improvements” (CNA, 2017, p. 3). The first part of the Code of Ethics describes the core ethical responsibilities central to nursing practice. The Code of Ethics is grounded in nurses’ professional relationships with persons receiving care as well as with students, nursing colleagues, and other health care providers. The seven primary values are:

1. Providing safe, compassionate, competent, and ethical care
2. Promoting health and well-being
3. Promoting and respecting informed decision making
4. Honouring dignity
5. Maintaining privacy and confidentiality
6. Promoting justice
7. Being accountable

The second part of the CNA Code of Ethics “describes activities nurses can undertake to address social inequities. Ethical nursing practice involves endeavouring to address broad aspects of social justice that are associated with health and well-being” (CNA, 2017, p. 3). A brief overview of the ethical responsibilities of a nurse leader will then lead to a focus on the advocacy—driven by the CNA Code of Ethics—required to promote the optimal health of citizens throughout the world.

10.1 Integrating Ethics into Nurse Leadership

It is the nurse leader’s responsibility to integrate professional guidelines (e.g., CNA Code of Ethics) with the ethics of their health care organization (e.g., mission, vision, values) in order to offer ethical guidance to care providers. Simultaneously, the nurse leader is required to critically analyze situations and take appropriate action with regards to practices that may threaten a patient’s health and safety. Nurse leaders model the just and caring behaviours that promote the common good for care recipients as well as students, nursing colleagues, and other health care providers. The following quote stresses the link between ethics and patients: “The ultimate goal of nursing ethics is to promote the wellbeing of patients through the delivery of good nursing care” (Johnstone, 2017, p. 19). Ethical nursing care and good nursing care are, by definition, similar terms that describe the actions required to achieve quality health care outcomes.

Recent research conducted in Australia investigated the ethical principles that guide the leadership practices of clinical nurse leaders (Mannix, Wilkes, & Daly, 2015). This research revealed three main principles that shape day-to-day clinical practices. These principles are relevant for nurses and nursing practice around the world. The principles discussed in the research are:

1. Nurses remain true to their beliefs, by embodying principled practice;
2. Nurses recognize that not all practices fit every patient, offering ethical leadership in ambiguous situations;
3. Nurses are open to people’s concerns and provide fair and just solutions. (Mannix et al., p. 1605)

These principles convey a sense of pride in nursing practice, a willingness to advocate for practices that meet the needs of patients, and an understanding of how to facilitate change by listening to people and empowering them to engage in change. Nurse leaders, by virtue of their Code of Ethics and the ethical principles that shape their daily practice, are obliged to advocate on behalf of their professional colleagues and the general public for healthy living conditions within healthy communities.

10.2 Advocacy

Advocacy is defined in the online Merriam–Webster dictionary as “the act or process of supporting a cause or proposal [or] the act or process of advocating something.” For a deeper understanding of the professional nurse’s responsibility to advocate, we need to look at how the CNA describes advocacy:

Advocacy involves engaging others, exercising voice and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality. It involves participating directly and indirectly in political processes and acknowledges the important roles of evidence, power and politics in advancing policy options. (CNA, 2018)

For more on advocacy, see the CNA’s webpage Policy and Advocacy.

Awareness

The short but comprehensive description of advocacy by the CNA requires the professional nurse to be aware of inequity and inequality within patient practice, among professional colleagues, and within local, national, and international communities. A simple example of inequity or unfair treatment within patient practice may include violations of best practice. For example, care of a complicated chronic ulcer demands a specialized dressing; however, a health care institution may not have the required dressing due to cost restrictions. Consequently, a less costly dressing is used and the healing of the patient’s wound is delayed. The knowledgeable and ethical nurse leader understands the consequences of inappropriate wound care and is prepared to take appropriate actions to foster best practice.

The nurse leader is aware of the need for positive staff morale and spirit at work in the health care workplace. Contrary to the actions described in the phrase “nurses eat their young,” a successful nurse leader mentors new graduates, by including them as part of the team and working with other team members to support new team members in developing their full potential as professional nurses.

The nurse leader’s awareness of health, well-being, and social justice extends beyond the health care workplace to his or her local, national, and global communities. The leader works to support healthy lives and well-being for people of all ages as stated in the United Nations sustainable development goals (WHO, 2015). The nurse leader may not work directly with every community; however, she or he can impact all communities indirectly through health-focused actions and communications within the local community.

Community, Communication, and Evidence-Informed Action

Advocacy requires the engagement or participation of multiple people. It is not a solitary act. It requires the nurse leader to communicate with others and involve the community in the development of plans and potential solutions to health-related problems. The nurse leader’s skills in accessing relevant research ensure that advocacy initiatives are constructed upon a foundation of evidence that provides strength to the community action.

 

10.3 Client Care Advocacy: The Thin Line Between Advocacy and Paternalism

Advocacy and change are irrevocably linked. In fact, the term advocacy suggests that individuals and communities are working to promote change. Additional insights into patient care advocacy can be obtained from the patient advocacy literature.

Virginia Henderson described advocacy as providing health care for people that they would do for themselves, if they had the “strength, will or knowledge to care for themselves” (Halloran, 1996, p. 18). However, other theorists such as Kohnke (1982) suggested that the nurse advocate’s primary role is to inform and support the patient in making decisions. Gadow (1980) and Curtin (1979) cautioned care providers, stating that professionals cannot decide what is in the best interests of the patient unless they understand the individual patient’s values. Zomorodi and Foley (2009) further advised that the “thin line between advocacy and paternalism may be crossed” (p. 1748) when patients are unable to communicate or practice autonomy due to illness or intimidation.

Paternalism is defined as “intentional overriding of one person’s known preferences or actions by another person, where that person justifies the action with the goal of benefiting or avoiding harm to the person whose will is over written” (Johnson, as cited in Zomorodi & Foley, 2009, p. 1747). Paternalism is contrary to the values expressed by the World Health Organization in the Ottawa Charter for Health Promotion (WHO, 1986), including that which affirms that every person has the right to control all factors that contribute to his or her health. Recent authors stress that patients have the right to make their own decisions, even when professional caregivers believe that the decisions are wrong (McKinnon, 2014; Zomorodi & Foley, 2009; Griffith, 2015; Risjord, 2013). This debate between autonomy and paternalism has raged over the centuries, with John Stuart Mill voicing clear support for autonomy almost two centuries ago:

The only purpose for which power can be rightfully exercised over any member of a civilized community against his will is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. (as cited in McKinnon, 2014, p. 677)

10.4 Social Justice and Advocacy

The CNA Code of Ethics supports the principle of social justice, requiring that all peoples, without discrimination, “have the right to live in dignity and freedom and to enjoy the fruits of social progress and should, on their part, contribute to it” (Office of the United Nations High Commissioner for Human Rights, 1969, Part 1, Article 1).

Ethical nursing addresses aspects of social justice that are considered essential for the health and well-being of individuals, communities, and populations throughout the world. According to the CNA,

Advocacy refers to the act of supporting or recommending a cause or course of action, undertaken on behalf of persons or issues. It relates to the need to improve systems and societal structures to create greater equity and better health for all. Nurses endeavor, individually and collectively, to advocate for and work toward eliminating social inequities. (CNA, 2017, p. 5)

Nurse leaders working to ensure the health of all, will advocate for the presence of the fundamental resources essential for health, regardless of the dominant social, cultural, or economic system. Fundamental resources required by all people include: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity (Government of South Australia and World Health Organization, 2017).

It is important to remember that healthy people contribute to the social and economic development of the community or nation. Advocacy for health encourages political, economic, social, cultural, environmental, behavioural, and biological factors that favour health rather than suppress health. The control of factors that determine the individual’s health will support all people to reach their fullest health potential (WHO, 2017).

 

10.5 Power and Advocacy

What is Power?

Academics from many disciplines have studied the elusive concept of power. Hokanson Hawks (1991) provided two different meanings for power: (1) power to, or the ability to get things done, and (2) power over, or the ability to influence the behaviour or decisions of others. The definition of power, commonly found in leadership research, is “the ability to get things done, to mobilize resources, to get and use whatever it is that a person needs for the goals he or she is attempting to meet” (Kanter, 1993, p. 166). Power is a force that is inherent and personal and it comes into play when clinicians are influencing the health care decision making of others (Milton, 2016). When power is defined as the ability to get things done, it is a significant resource for nurses, and as such, warrants further in-depth discussion.

Sullivan (2013) adapted the classical description of social power to fit the nursing perspective. The five types of nursing social power, as described by MacPhee (2015) are: (1) “personal power based on one’s reputation and credibility; (2) expert power [referring to the possession of skills and knowledge] that are needed by others” (p. 188); (3) position power that is a result of your position in the organization or group; (4) perceived power resulting from your status as a powerful person; and (5) connection power ensuing from your association with, or links to, powerful people. Understanding these versions of social power, which have been adapted for nursing, will provide the nurse leader with a basic understanding of the power dynamics that influence decision making within the workplace.

However, the increasing complexity of our health care organizations requires the nurse leader to look at power from additional perspectives. Some authors look at power as situated within a relationship (Davidson, 2015). Davidson states that, by the very nature of being human, people are always in relationships where power dynamics are at play. Stacey (2006, as cited in Davidson, 2015) stresses the importance of relationships as both an enabling and a constraining power:

In order to form and stay in a relationship with someone else, one cannot do whatever one wants. As soon as we enter into relationships, therefore we constrain and are constrained by others . . . we also enable and are enabled by others. (p. 134)

Udod (2008) uses the work of Michel Foucault in her research exploring empowerment for staff nurses. Foucault’s work also emphasizes that power is not owned, but rather is a “relation or situation. . . . When power is exercised in relation to others, it causes reactions and effects” (cited in Udod, p. 81). Power is regarded as a strategy, suggesting that nurses develop tactics on how to comply with power, rather than fight it. Finally, power is not present solely in the actions of leaders; it is also present in the actions of people who resist (e.g., whistle-blowers). In summary,

nurses need to work with power rather than against it, recognizing that their task is not to overcome more powerful others . . . but to understand how power and its effects operate in order to enhance their sense of empowerment and hence, their practice. (Udod, 2008, p. 88)

 

Power and Health Care for Indigenous People

Recognition of the impact of colonization and residential schools on the health and well-being of Indigenous people requires the nurse leader to take a closer look at the relationship between power and diverse populations and, more specifically, at the relationship between power and the Indigenous population. Foucault’s work demands that we acknowledge “how power relations shape the production of truth” (Macias, 2015, p. 225) and how “discourse defines and limits the subject’s freedom” (p. 231). Foucault also suggests that changing discourse can produce freedom.

Madeleine Dion Stout (2015), a Cree speaker from Alberta who became an RN approximately 46 years ago, worked to improve the health of Indigenous people by changing the discourse of power in just such a way. She addressed the need for Indigenous people to develop their own determinants of health, rather than accept the values of the colonizer society. She stated very eloquently in both Cree and English how the Indigenous people will move forward to reclaim their health and well-being. In her words:

kaskitamasowin miýw-āyāwin is health and wellness we have conjured up and created for ourselves. kaskitamasowin miýw-āyāwin means achieving health status that we wish upon ourselves and for our families, communities and nations. We achieve kaskitamasowin miýw-āyāwin with our own will and abilities and with the resources we have at our immediate disposal. kaskitamasowin miýw-āyāwin comes from our inner strength, inner forces, and inner voices. (p. 145)

Changes in ownership of Indigenous health and well-being are rapidly becoming evident in the relationship between Health Canada and the Indigenous population. In accordance with the wishes of the Canadian Indigenous people for a health plan that meets their needs, the Government of Canada developed the First Nations and Inuit Home and Community Care (FNIHCC) 10-Year Plan (2013–2023) (Health Canada, 2015). This plan provides a template for collaboration with First Nations and Inuit partners in health care. It will be updated yearly or as needed. The plan is envisioned as responsive to the unique needs of the Indigenous people, representing “a continuum of home and community care services that are comprehensive, culturally safe, accessible, effective, and equitable to that of other Canadians and which respond to the unique health and social needs of First Nations and Inuit” (Health Canada, 2015, p. 1).

 

10.6 Empowerment and Advocacy

Discussion of nurse empowerment within the health care workplace is evident throughout worldwide nursing literature. Empower is defined as “to give official authority or legal power to [or] to promote the self-actualization or influence of” (Merriam-Webster, n.d.). To understand empowerment further we turn to the definition by Conger and Kanungo (1988): “a process of enhancing feelings of self-efficacy among organizational members through the identification of conditions that foster powerlessness and through their removal by both formal organizational practices and informal techniques of providing efficacy information” (p. 474). Many nurse researchers have investigated empowerment in an attempt to further understand this relationship between empowerment, the workers, and the workplace.

 

Structural Empowerment

Considerable research on empowerment in recent nursing literature has focused on Kanter’s ethnographic work (1993) on structural empowerment. This work focuses on the contextual or social-structural aspects of the organization that facilitate empowerment. Structural empowerment involves the sharing of power and the eventual transference of pertinent decision-making power from managers to lower levels of the organizational hierarchy. The applicability of the shared power to the needs of the employees is the key to the success of structural empowerment, enabling employees to make decisions related to their job or role (Spreitzer, 2008).

Structural empowerment consists of four dimensions (Havens & Laschinger, 1997). Employees of an organization have structural empowerment when they have access to: (1) opportunities (advancement or new experiences); (2) information (knowledge about the organization required to be effective); (3) resources such as equipment, supplies, and staffing required to carry out their daily work; and (4) support (from colleagues and superiors as required to complete their work and make decisions). Access to structural empowerment is gained through formal power (one’s position in the organization) and informal power (networks and alliances with supervisors, peers, and colleagues, both within and without the organization). Presence of the structural dimensions of opportunity, information, resources, and support leads to an empowered workforce with increased job satisfaction and retention (Wagner et al., 2010).

Psychological Empowerment

Psychological empowerment is another perspective on empowerment found in the recent literature. It is more micro in nature than structural empowerment, focusing on the individual’s psychological empowerment or perceptions of power; Spreitzer (2008) refers to the “individual’s reactions to the structures, policies, and practices they are embedded in” (p. 55). Psychological empowerment does not focus on sharing a manager’s organizational power, but rather concentrates on how employees experience their work. Components of psychological empowerment include: (1) meaning (a fit between job requirements and the individual’s own ideals or standards); (2) competence (individual’s confidence in his or her ability to do a good job of the required work); (3) self-determination (sense of control over work); and (4) impact (the sense of being able to influence important outcomes at work) (Spreitzer, 2008).

 

Critical Social Theory and Empowerment

Nursing leaders are also aware of the importance of critical social theory to empowerment in nursing. Critical social theory strives to create an awareness of how culture and the norms of everyday life constrain or disempower people. It strives to remove oppressive barriers, which are revealed in exchanges that contain hidden values and norms; these values and norms change, depending on the situation and the participants (Sumner & Danielson, 2007). According to Clune and Gregory, “A person who challenges the status quo in the social world is taking a critical social approach” (2015, p. 202).

Manias and Street (2000) describe four main theoretical areas of critical social theory:

1. Theory of false consciousness shows how a group of people may have a common set of false beliefs (e.g., people with non-white skin are inferior to white people).
2. Theory of crisis requires people to look at how their dissatisfaction threatens the cohesion of a society (e.g., ISIS terrorist actions).
3. Theory of education in which individuals receive benefit from education (e.g., information regarding the impact of terrorism upon the well-being of individuals).
4. Theory of transformative action, which involves making plans for change (e.g., the WHO’s development of sustainable development goals).

Critical social theory is important to nurses who are involved in caring relationships with patients where the communication is from the nurse to the patient. Much of the nursing literature speaks about the patient’s expectations of the nurse; however “what is rarely, if ever examined, are the human needs of the nurse that need to be met in the patient–nurse relationship” (Sumner & Danielson, 2007, p. 30). Perhaps it is time to look at the power structure of these unidirectional relationships between nurse and patient. In a similar manner, as aspiring nurse leaders, it is necessary to look critically at the nurse leader’s relationships with followers and with the overall health care organization. Critical social theory provides the opportunity to look at the nurse’s needs and think about how these needs may be met, while reflecting on the inherent asymmetry of the relationships (Sumner & Danielson, 2007).

Critical race theory, queer theory, and feminist theory are examples of well-known critical social theories. Another important critical social theory that is crucial to the profession of nursing is associated with oppressed groups. MacPhee (2015) states that nurses are considered by sociologists to be an oppressed group, or a group “whose freedoms and rights are restricted by socially imposed inequalities” (p. 189). MacPhee stresses that members of an oppressed group do not realize that their powerlessness is a socially constructed situation and can be challenged. Not surprisingly, members of oppressed groups tend to dominate or oppress others (bullying and horizontal violence). However critical social theory can assist members of oppressed groups, such as nurses, to gain insight into their behaviour through reflection and education. This new understanding may motivate them to engage in transformative action that challenges their socially conditioned powerlessness.

10.7 Whistle-Blowing as Advocacy

Whistle-blowing refers to “a conscious act of disclosure about organizational or individual practices and behaviours to those who could achieve possible change” (Jackson et al., 2011, p. 656). The CNA Code of Ethics supports the act of whistle-blowing when there are ethical violations, stating, “Nurses support a climate of trust that sponsors openness, encourages the act of questioning the status quo and supports those who set out in good faith to address concerns (e.g., whistle-blowing)” (2017, p. 16). However, whistle-blowing can be very difficult for the individual nurse since it involves a public accusation, which can cause the nurse to be perceived as disloyal to the organization. Despite these difficulties, nurses have a responsibility to speak up and report to their leaders when patients are at risk of harm or when they observe a poor-quality experience due to an inadequate patient care environment.

How organizational leaders respond to the concerns about ethical violations is often dependent on the organization. Nurses may be concerned that employment contracts with confidentiality clauses prioritize organizational issues over the concerns of staff and patients (Jackson et al., 2011). These confidentiality clauses sometimes lead to secrecy and the withholding of risky, or potentially stigmatizing, disclosures (Ellenchild Pinch, 2000). Perceived lack of response to client concerns by organization leaders and managers can force the nurse to take the issues to individuals in positions of power outside the organization. The employee who takes the issues outside the organization may violate confidentiality and risk negative consequences in order to address concerns of patient and staff well-being. Whistle-blowing is always a last resort (Reid, 2013).

 

Advocating for the individual patient is an important part of ensuring quality health care. Nurses may respond to the social, political, and economic context of their environment to advocate for their patients and families through invisible political activism. This invisible activism is linked to strong partnerships with the public, local residents, government, and other power structures. Ongoing communication with community groups, including the government and media, is required to maintain these partnerships (Paterson, Duffet-Leger, & Cruttenden, 2009). This work of maintaining positive relationships with the community can remove the individual nurse from client-centred health care responsibilities. Therefore, it is important to consider that collective advocacy, through the auspices of professional associations and unions, can “extend the reach of individual nurses in order to address systemic problems in health care institutions and bureaucracies” (Mahlin, 2010, p. 247). Mahlin stresses that many of the difficulties faced by individual patients are the direct result of system-wide issues and problems related to inappropriate health resource allocation—such as costly medications that patients cannot afford after discharge from hospital—and inadequate and unsuitable levels of health care provider staffing. Taking action and finding solutions to these system issues are frequently beyond the reach of the individual nurse, but definitely within the scope of health care professional groups.

Summary

This chapter focuses on the ethical responsibilities of nurse leaders to advocate for health. A leader who understands how to use power is more likely to be a successful advocate. Building on Foucault’s work, we know that we must look at the relationship between health, power, and diverse populations. In Canada a focus on the Indigenous populations is required if we are to make a difference.

Nurse leaders must also look at the workplace and examine how the presence or absence of structural empowerment and psychological empowerment for care providers impacts patient care. Critical social theory suggests that reflection upon the roles of nurses in health care systems empowers nurses to be effective advocates. Nurse leaders, intent on advocating for health, can join other nurses in political action directed at changing existing health care practices. When no other solution is available to advocate for the health of vulnerable people, whistle-blowing may be employed as a last resort.

 

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