LEVELS OF ADVOCACY: CASE AND CLASS

In thinking about what advocacy means in the context of nursing practice, a clear distinction needs to be made between "case advocacy" directed at individual patients, and "class advocacy" directed at changing policies and social conditions.

Case advocacy is well known to nursing professionals, being part of the field's traditions and continuing professional values (Cary, 1992; Gadow and Schroeder, 1995; Nelson, 1988; Kohnke, 1982; Winslow, 1984; Marks, 1985). Nurses are accustomed to advocating for individual patients and families to secure needed services and solve problems related to the particular case. Over the years the concept of case advocacy has undergone an important evolution in nursing practice, gradually coming to include more emphasis on client empowerment. Shifting from its early meaning of interceding on behalf of those who could not or would not help themselves, advocacy for patients has now come to involve a more complex set of activities placing the nurse in mediator and promoter roles (Cary, 1992). These contemporary case advocacy roles emphasize client self-determination. They put a premium on informing and supporting clients, enabling them to define and act in terms of their own best interests (Kohnke, 1982). While in principle the "client" can be a community as well as an individual, the skills and objectives of case advocacy tend to stress better coping strategies, negotiation, and increasing access to existing resources in order to get health problems solved in the absence of major system change.

Class advocacy, a more overtly political approach, is quite different. Instead of focusing mainly on the client's opportunity choices, class advocacy focuses on changing the system of opportunities itself to further the interests of larger groups, organizations, or communities. The advocate acts as a catalyst to alter existing policies, institutional systems, laws, or patterns of resource allocation in ways that potentially benefit many individuals. This kind of advocacy can be done in ways that challenge the system directly, or it can be done indirectly behind the scenes (see Needleman and Needleman, 1974).

The following example, borrowed in part from Cary (1992), is a good illustration of how both case advocacy and class advocacy might be used by nurses faced with an environmental health problem:

A community health nurse doing immunizations at a homeless shelter encounters a resident with serious environmental health concerns. All three of the resident's children are asthmatics. From the time the family was forced to seek residence in the shelter, the children—particularly the youngest—have had multiple, acute episodes of asthma. The shelter manager is unwilling to correct the building's problems of dust, mold,



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